Babies speak by crying. Artists speak with a paintbrush. Individuals with hearing impairment speak with their hands.
Trauma patients, on the other hand, are quite literally speechless.
Often lacking the ability to speak or use their hands, patients with traumatic injuries frequently suffer in silence.
Fortunately, at WellSpan York Hospital in York, PA, trauma patients now have a voice.
Intubated trauma patients at York's trauma-surgical ICU can "speak" by means of an innovative communication board.
The new board is the result of interdisciplinary collaboration between York's nurses, speech-language pathologists and patients.
"Communication is one of the most difficult and frustrating aspects of caring for intubated patients. It is very difficult to 'hear' what our patients are trying to say," said Kelli Eldredge, MSN, RN, CCRN, who serves as clinical nurse educator for York's trauma-surgical ICU.
Family Advisory Council
Eldredge is also a liaison to York Hospital's Trauma Patient and Family Advisory Council. As the title suggests, this council is composed largely of former patients and family members.
The council seeks to offer suggestions and advise healthcare staff on patient-centered care.
"During our first meeting we simply asked the council members to tell us some concerns about their hospital stay. Many of their concerns focused on communication," Eldredge said.
"All members had experienced the ICU during their stay and thought that communicating during intubation, whether patient or family, had been very frustrating," she said.
The advisory council was the crucible in which the communication board was formed.
By asking the council for communication suggestions, its creators were sure to receive ideas from individuals who had firsthand experience with the frustration of intubation communication.
"The Trauma Patient and Family Advisory Council was the driving force in the development of the communication board," Eldredge emphasized.
"The mission of our council is to facilitate the collaboration between patients, families and healthcare providers to deliver the highest standard of patient and family-centered care."
Keeping It Simple
Upon recognizing a communication dearth amongst intubated patients, Eldredge approached York Hospital speech-language pathologist Kelly Cousineau, MA, CCC-SLP, about the matter.
"We began looking for evidence-based practices through an extensive journal review. We came up with multiple communication methods that could work in a trauma care setting. With the information compiled, we took our findings to the Trauma Patient and Family Advisory council," said Cousineau.
The council reviewed and discussed the journal findings. Everyone was in agreement that trauma patient communication needed to be improved; the only question that remained was how to go about improving communication.
"Options ranged from very low tech all the way to a very high level of complexity," said Cousineau. "Ultimately, the advisory council thought that the easiest system was the way to go.
"Trauma units can be very noisy," she added. "With that in mind, it was decided that the more complex speech-generating systems might result in patient overstimulation," .
A more simplistic communication system offered many advantages: Ease of training, lower start-up costs and quicker implementation. These were among the factors that contributed to the council's decision to implement a picture board communication system.
"Ultimately, we decided that the picture-based communication board was the most viable system. Patients were allowed to pick all the pictures that we used," said Cousineau.
"As a result of this patient collaboration, an entire page was dedicated to emotions. Now we can actually ask intubated patients, 'How are you feeling?' That was something we probably would not have added without having patient suggestions."
The board allows for intubated patients, as well as immobilized patients, to communicate. Because the board was produced in-house, York Hospital was able to customize everything to fit their specific desires.
"Our trauma patient communication board is a flip book consisting of six different pages. All of the pages are printed in color on large paper. Each photo is surrounded with ample blank space. This allows individuals who have limited mobility but are cognitively intact to use eye gaze in order to communicate," said Cousineau.
A Wide Array of Content
The fairly simple communication board is able to cover an amazingly wide array of topics in only six short pages.
"The first sheet is a simple 'yes' or 'no' page. The second page contains basic wants and needs - hard to breathe, cold, hot, ice chips or pain. The third page helps the patient to communicate the location of the pain," said Cousineau.
The board functions sort of like a flow chart. For example, if on the second page the patient indicates pain then the nurse will direct him to the third page to help locate the pain. This allows for semi-complex messages to be conveyed in a relatively simple manner.
"The fourth page contains emotions. This allows the patient to express feelings of frustration, sadness, anger or contentment. Next is a general-purpose letter board allowing patients to point toward letters in order to actually spell out words. The final page is a pared down page consisting of three photos for patients with cognitive impairment," said Cousineau.
All parties involved - nurses, speech-language pathologists, patients and families - agree collaboration was vital to the communication board's success.
"Multidisciplinary collaboration was the key here. Input from our speech-language pathologist, Kelly Cousineau, was invaluable in the completion of this project. It is also essential to have a dedicated group of healthcare providers along with patient and family advisors to make such projects a success. We were blessed to have all of the above," said Eldredge.
Opportunities for Communication
Hearing patients, even when they cannot speak, is vitally important. Providing a way for intubated patients to speak decreases patient frustration and anxiety. Opportunity for communication also helps trauma patients maintain a level of self-determination.
"Every patient is different and it is important to consider what works best for each individual. It is also vital that we educate family members about what works best for their loved ones in regards to communication. The communication boards are an excellent option that we can add to our bag of tricks," said Eldredge.
Hearing patients, even long after care has been rendered, is also vitally important. The communication board project highlights the value of this sustained listening.
"We had a reunion meeting several months after our various projects were completed to share our outcomes. The group was so excited to see that we had paid attention to their concerns and made improvements that resulted in improved care for our trauma patients. They felt empowered by the work they had accomplished," said Eldredge.
Empathy is a powerful way to show patients you care. However, until one actually experiences the speechlessness of intubation, it is hard to fully empathize. Instead of guessing what it is like, York Hospital went straight to the source: Former patients who have themselves been intubated.
"The perspective and feedback from patients and families who have actually been in these situations are vital in the development of tools to help future patients. They are able to provide insight into specifics regarding communication that we may never have considered as professionals," said Cousineau.
A. Trevor Sutton is a frequent contributor to ADVANCE.