Author name: Richard Hurtig

Even if you value being able to effectively support patients’ ability to summon help and communicate with caregivers, getting institutional buy-in and establishing a “culture communication” can be challenging. Making the case to staff and administrators will be more effective if you can marshall evidence based on data and regulatory requirements.

Sadly, patients who face barriers to effective communication are more likely to experience preventable adverse events that negatively impact their medical outcomes and land up costing hospitals billions of dollars. Some of the communication barriers are due to the patient’s medical condition while others may be due to a patient’s limited proficiency in the language spoken by the medical staff.

The impact and magnitude of such barriers are documented in a number of peer-reviewed papers that you can use in making your evidence-based argument for getting institutional buy-in to implement programs and strategies that allow patients to overcome communication barriers.

Agency for Healthcare Research and Quality. (2013b). Annual hospital-acquired condition rate and estimates of cost savings and deaths averted from 2010 to 2013. Rockville, MD: Author. Retrieved from https://www.ahrq.gov/professionals/quality-patient-safety/pfp/index.html

Bartlett, G., Blais, R., Tamblyn, R., Clermont, R. J., & MacGibbon, B. (2008). Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Canadian MedicalAssociation Journal, 178(2), 1555–1562. https://doi.org/10.1503/cmaj.070690

Cohen, A. L., Rivara, F., Marcuse, E. K., McPhillips, H., & Davis, R. (2005). Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics, 116(3), 575–579. https://doi.org/10.1542/peds.2005-0521

Divi, C., Koss, R. G., Schmaltz, S. P., & Loeb, J. M. (2007). Language proficiency and adverse events in US hospitals: A pilot study. International Journal for Quality in Health Care Advance Access, 19, 60–67. https://doi.org/10.1093/intqhc/mzl069

Happ, M. B., Seaman, J. B., Nilsen, M. L., Sciulli, A., Tate, J. A., Saul, M., & Barnato, A. E. (2015). The number of mechanically ventilated ICU patients meeting communication criteria. Heart & Lung, 44, 45–49. https://doi.org/10.1016/j.hrtlng.2014.08.010

Hurtig, R., Alper, R. M, & Berkowitz, B., (2018) The Cost of Not Addressing the Communication Barriers Faced by Hospitalized Patients, Perspectives of the ASHA Special Interest Groups SIG 12, Vol. 3(3), 99-112. https://pubs.asha.org/doi/10.1044/persp3.SIG12.99

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patient-and family-centered care: A roadmap for hospitals. Oakbrook Terrace, IL: Author.

The Joint Commission. (2011). Summary data of sentinel events reviewed by the Joint Commission. Oakbrook Terrace, IL: Author.

Zubow, L., & Hurtig, R. (2013). A Demographic Study of AAC/AT Needs in Hospitalized Patients. Perspectives on Augmentative and Alternative Communication, 22(2), 79-90. https://pubs.asha.org/doi/abs/10.1044/aac22.2.79

It is also important to make clear that statutory and accreditation standards require hospitals to address the access and communication barriers faced by their patients

Costello, J. M., Santiago, R. M., & Blackstone, S. W. (2015). Pediatric acute and intensive care in hospitals. In S. Blackstone,

D. Beukelman, & K. Yorkston (Eds.), Patient–provider communication in healthcare settings: roles for speech-language pathologists and other professionals. Plural.

Hurtig, R. R., Nilsen, M., Happ, E. B., & Blackstone, S. (2015).

Acute care/hospital/ICU adults. In S. Blackstone, D. Beukelman, & K. Yorkston (Eds.), Patient–provider communication in healthcare settings: Roles for speech-language pathologists and other professionals. Plural.

You can find out more about how Voxello supports patient-provider communication by visiting www.voxello.com.

Human frailty and mortality are a fact of life. Living through the Covid19 pandemic over the last year with daily updates in the news on the number of critically ill and dying patients in our hospitals has just served as a painful reminder of that fact of life.

End-of-life conversations are fraught with a mix of emotions. For the patient, family members, and friends, and talk about an impending death is too often avoided due to a combination of fear and denial. Modern medicine and the decline in multi-generational households have turned what had been a natural and expected event in the cycle of life into an unexpected aberration. As life expectancy has increased, we have pushed thinking about our mortality into the dark and by extension our discomfort when confronted by either our own death or that of someone close to us. This discomfort creates a barrier to the full expression of our physical and emotional needs.

From the perspective of the individual who will be dying it translates into being scared to ask questions about a dire prognosis. On the one hand, we want to be told the truth, but on the other, as patients, we are scared to directly ask “Am I going to die?” When family and friends come and ask how we are doing, we are more likely to respond, “I am doing Ok” rather than “I am dying.”

From the perspective of family and friends, there is also a reticence to directly reference the inevitability of a patient’s impending death. Part of that reticence is due to being uncertain whether the patient is aware of the dire prognosis, but it is also in part due to general discomfort in any direct discussion of death. We just don’t know what to say if someone told us they were in pain or that they were dying.

The avoidance of conversations about death and dying may reduce the discomfort of the moment but it will inevitably lead to regret that we did not say what needed to be said. Failing to confront an impending death can lead to a patient’s inability to be involved in medical decision-making about clinical interventions and the use of life-sustaining interventions. To support patients and their families deal with a terminal prognosis, clinicians must overcome their own fears of raising a difficult subject and also support their patients and families so that they can cope and manage the end-of-life crisis they are facing. Whether the patient is in a facility or at home, support from psychological counselors and pastoral care providers can reduce the anxiety about the impending death and provide guidance on how to make the most of end-of-life conversations.

Patients, whose medical condition renders them unable to speak or write, face the challenges we have just described and the added challenge of not being able to express themselves. The patient with ALS should have the same right to participate in medical decision-making and end-of-life conversations as a patient with end-stage cancer. Saying goodbye is hard enough when you can speak, we should not make it harder for those who cannot speak. Providing access to augmentative and alternative communication tools can enable patients to not only actively participate in their care but to also participate in end-of-life conversations with friends and loved ones.

Voxello’s noddle-chat communication tablet has been designed to support the wide range of communication needs of hospitalized patients including their ability to engage in end-of-life conversations. Being able to let one’s personality shine through even when using a speech-generating device can go a long way to breaking the ice needed to overcome our reticence to speak about death and dying.  Noddle-chat can be quickly implemented, so regardless of how imminent death is, the patient can engage with family at the end of life. For the patient being able to communicate reduces some of the stress of facing death and for the family, it eliminates the regrets of not having been able to truly say goodbye.

You can find out more about how Voxello supports patient-provider communication and end-pf life conversations by visiting www.voxello.com.

Effective patient-provider communication is critical to positive outcomes for hospitalized patients. When patients face barriers to communication, they are at a higher risk of experiencing a preventable adverse event.  They are more likely to experience higher stress and be less satisfied with their care. Hospitals can successfully reduce their patients’ communication barriers by promoting an institutional culture of communication.

The Joint Commission’s hospital accreditation standards require hospitals to establish a range of care standards that value patients’ ability to express themselves and to be able to be active participants in their care. Such care standards should lead hospital staff to continually assess their patient’s ability to summon help to effectively communicate and to be able to implement the appropriate communication strategies and tools. This dynamic assessment and intervention process can be built into care flowsheets that relate to a patient’s ability to summon help and communicate.

The hospital’s nursing staffs are the primary bedside caregivers and the most likely to be assessing whether the patient can independently use the nurse call and whether the patient is able to communicate with the staff. It is therefore important that nurses are able to order consults from the appropriate departments when their patients face access and communication barriers. 

To meet patients’ nurse call access needs, the hospital should have a range of assistive technology alternatives to the standard nurse call pendant and identify who in the organization is responsible for supporting the alternative nurse call technology. The decision process about what alternatives should be made available needs to be informed by an interdisciplinary team of nurses, occupational therapists, and speech-language pathologists. Voxello’s noddle switch can make accessing the nurse call system possible for patients who might only be able to produce a tiny intentional gesture with some part of their body.

To address the communication needs of patients who have limited English proficiency (LEP), hospitals must provide translations of written materials and ensure that interpreter services are available to support bedside conversations between patients and their care providers. Hospitals may either have certified medical interpreters on staff or use remote interpreter services via telephonic or video links. It is critical that everyone interacting with a patient with LEP be aware of the need to use the appropriate tools to ensure that the patient understands the caregivers and that the caregivers understand what the patient is trying to communicate. Having bilingual communication tools like Voxello’s bilingual noddle-chat or low-tech bilingual communication boards can be useful in supporting emergent communication at the bedside. Again, the key is that the entire care team, not just the patient’s nurse be aware of how to communicate with the patient.

When patients are unable to communicate because of a physical barrier that prevents them from speaking or being able to write, hospitals should be able to provide a range of alternative and augmentative communication tools. Low-tech communication boards are useful to assess pain and to allow patients to express a few basic needs but not much more. The hospital’s speech-language pathologists should be consulted to determine whether providing the patient with a speech prosthetic or a speech-generating device like Voxello’s noddle-chat tablet is appropriate.

Achieving a high-fidelity implementation of any care standard requires the training of all hospital personnel who will be caring for and interacting with patients. Clinical practice has shown that in addition to basic pre-service and in-service training it is important to make just-in-time training available. When individual nursing staff members and speech-language pathologists embrace the notion of a “culture of communication, they can serve as champions to support others on the care team to more effectively engage in bidirectional communication with their patients. Working with nurse educators and speech-language pathologists, Voxello has developed a range of training materials (https://voxello.com/education-training/).

You can find out more about how Voxello supports patient-provider communication by visiting www.voxello.com.

Imagine finding yourself in a hospital’s intensive care unit. Perhaps you were in an accident or perhaps you have contracted a disease like Covid19. If you are able to speak or write you would have lots of questions for the medical staff and you would want to have a role in deciding what treatment options should be considered. But if your admitting condition precludes your ability to effectively communicate or if you land up being intubated and on a ventilator, your ability to exercise some level of control over your care is severely constrained if not impossible.

An elderly patient was admitted to our surgical ICU with a severe cervical spine injury that left him unable to breathe and unable to move any part of his body. Because he was intubated and mechanically ventilated, he could not speak. His doctors had told his daughters about the gravity of the situation which led them to get into a heated discussion about whether their father should be kept on life support. One felt that since he was always strong and a fighter he would want to stay on life support. The other argued that because he was used to being active and vibrant that he would not want to be kept on life support. All this was going on right at his bedside. His nurse noticed that he was following their argument and becoming upset. She summoned the speech-language pathologist to help in assessing the patient’s competence to participate in medical decision-making and who could, if he was deemed to be competent, provide a communication tool that would allow him to express his wishes. Once he was given the means to communicate, he made it clear that he did not want to be kept on life support and was able to have important end-of-life conversations with his daughters. He was able to exercise his autonomy and diffuse what could have resulted in a life-long enmity between his daughters.

To meet the communication needs of such patients who face barriers to communication, Voxello developed the noddle-chat communication tablet. The noddle-chat communication tablet not only makes it easy for patients to talk about symptoms, but it also provides patients to ask general as well as more specific questions about their diagnosis, prognosis, and treatment options.

Imagine finding yourself in a hospital’s intensive care unit. Perhaps you were in an accident or perhaps you have contracted a disease like Covid19. If you are able to speak or write you would have lots of questions for the medical staff and you would want to have a role in deciding what treatment options should be considered. But if your admitting condition precludes your ability to effectively communicate or if you land up being intubated and on a ventilator, your ability to exercise some level of control over your care is severely constrained if not impossible.

To meet the communication needs of such patients who face barriers to communication, Voxello developed the noddle-chat communication tablet. The noddle-chat communication tablet not only makes it easy for patients to talk about symptoms, but it also provides patients to ask general as well as more specific questions about their diagnosis, prognosis, and treatment options.

With noddle-chat patients can directly talk about what would happen if their heart were to stop or if they are unable to breathe. They would be able to ask about CPR and let the medical staff and their family know what their preferences are should their condition deteriorate. For specific interventions like mechanical ventilation, dialysis as well as nutrition and hydration, noddle-chat provides patients with both the critical questions that they might need to ask as well in statements to express their wishes about life preserving procedures.

You don’t have to give up your autonomy if you land up being hospitalized. Access to Voxello’s noddle-chat communication tablet will make it possible for you to be actively engaged and in control of your medical care.

You can find out more about how Voxello supports patient-provider communication by visiting www.voxello.com.

Physical trauma or a serious illness can render you temporarily “locked in”. Nevertheless, there are things that you want to know and things you want to communicate to others. Imagine waking up in an intensive care unit, hooked up to a ventilator, and unable to move.  You can make out that there are a number of people around you engaged in a range of activities and in conversations about you and about the interventions they are putting in place.  How would you get their attention and once you got their attention, how would you communicate with them to find out where you are and what is going on?  You want them to know that your mind is intact even if your body is not. You want them to treat you not just your body and most importantly you want to have some control over what kind of care you receive. The outcome of care is not just a function of the medical procedures and technical skills of our caregivers but of our ability to be active participants in our care. Without effective patient-provider communication, we cannot describe our symptoms and so run the risk of experiencing an adverse medical event that can lengthen our hospital stay or lead to a long-term disability or even death.

We all want and believe that we can exercise the autonomy we had before the accident or disease limited our ability to speak and move, If we hadn’t planned ahead and had not prepared an advanced medical directive, how would we let folks know what we wanted? Or if we did have an advance medical directive on file, how would we let people know that we wanted them to follow it or that we wanted to make some changes?

Without an effective channel of communication, it is difficult for our caregivers to assess us and determine whether we are competent to participate in medical decision-making and take an active role in our rehabilitation. The first and most rudimentary attempt at gauging our competence is to be able to somehow demonstrate that we can reliably respond to questions that only require a yes or no response. When you can’t speak, gauging your competence can be challenging. Good bedside practice should have caregivers try to identify a reliable way for their patients to indicate a yes and no response. Depending on how severely “locked in” you are, you could indicate yes and know with a thumbs up or down, one or two hand squeezes, or by looking up or down. To be effectively used everyone you interact with must be able to recognize which gesture you intended to produce. Sadly, producing two distinguishable gestures may be beyond what many ICU patients are capable of producing. But even if you can produce such yes/no gestures you still may have no effective way to summon your nurse if you are in pain or need something.

That is the depressing scenario that 30-50% of conscious mechanically ventilated patients face every day. They are trapped and unable to independently summon help or effectively communicate. To address the needs of these millions of patients, Voxello has taken the smart switch technology developed at the University of Iowa and produced the noddle switch that enables patients to summon help and control a speech-generating device even if they can only produce a tiny intentional gesture like a tongue click or a small low force and displacement gesture of some body part. Using patented gesture detection and counting algorithms the noddle can do much more than the conventional switches that have been on the market. The gesture detection algorithm can reliably detect intentional gestures like a tongue click and then count whether you produced one, two, or three gestures in a row. Based on the number of sequential gestures you produced, the noddle can either activate the nurse call system or allow you to navigate and select messages on the Voxello noddle-chat communication device.

You don’t have to be one of those “locked-in” patients if you land up being hospitalized. Even if you can only produce a single intentional gesture, Voxello’s noddle smart switch and the noddle-chat communication tablet make it possible for you to be able to summon help and effectively communicate with your caregivers.

You can find out more about how Voxello supports patient-provider communication by visiting www.voxello.com.

Experiencing a preventable adverse event while you are hospitalized can increase the length of your hospitalization, leading to a long-term disability and sometimes death. In addition to the pain and suffering that you might experience, the hospital will incur the financial pain associated with the costs they must absorb in treating you as well as the cost of any malpractice claim.

Over 20 years ago, the Institute of Medicine issued a report about the pervasiveness of preventable adverse events in healthcare, and the Joint Commission, which accredits hospitals in the United States, has promulgated a series of patient care standards in an attempt to reduce the incidence of preventable adverse events. In spite of a wide range of targeted changes to hospital procedures, the incidence of preventable adverse events continues to remain unacceptably high.

It turns out that the risk of experiencing a preventable adverse event is much higher if you are unable to communicate with hospital staff. Specifically, you are more likely to experience an adverse drug reaction, fall, develop pressure sores, or ventilator-associated pneumonia. If you can’t summon help and if you can’t let your caregivers know about pain and other symptoms, then they may not be able to promptly and properly treat you.

• If you are on mechanical ventilation, it is important that you be able to let your nurse know that you are having difficulty breathing and need to have your airway suctioned.  
• If you are being given a blood transfusion or a new medication, it is critical that you be able to let your nurse know if you are experiencing any novel sensations or symptoms that might indicate that you are having an allergic reaction that can result in serious injury and may even lead to death.  
• If you are bedridden and limited in your ability to move for even a short period of time, you can quickly develop a pressure sore that can become infected.

In the U.S. a little over 5% of patients experience one of these communication-related preventable adverse events, at a cost to hospitals of 17.5 billion dollars a year. For patients who face a communication barrier, the incidence rate for these preventable adverse events is nearly 8% with an added cost of over 9.5 billion dollars.

You don’t have to be one of those patients you land up being hospitalized. Even if you can only produce a single intentional gesture, Voxello’s noddle smart switch and the noddle-chat communication tablet make it possible for you to be able to summon help and effectively communicate with your caregivers.

Clinical trials have shown that patients who had access to Voxello’s noddle and noddle-chat had better outcomes and were more satisfied with their care. You can find out more about how Voxello supports patient-provider communication by visiting www.voxello.com.

Not feeling well and being hospitalized is never fun. For most of us, the hospital is an alien world where the routines associated with our care are different from our typical daily routines. We don’t get to decide what we will be doing; our schedules are set by a vast array of healthcare providers some of whom we have never met before. The challenges posed by acute hospitalization can be lessened if we can establish effective patient-provider communication so that we can let our caregivers know how we feel and what we need, and they can explain what they are going to do to treat us.

When the language we speak doesn’t match that of our care providers, we may face an insurmountable barrier to effective patient-provider communication. If you are a patient who faces a language barrier, you are at three times higher risk of experiencing an adverse medical outcome while you are hospitalized. Language interpreters can certainly help eliminate the communication barrier, but if I suddenly am experiencing a new symptom or am in pain I really can’t wait for an interpreter. Likewise, if my nurse needs to quickly take a blood sample or suction out my breathing tube there is no time to wait for a live or online interpreter. Voxello’s bilingual noddle-chat provides you and your care providers with a simple and easy way to overcome language-based communication barriers.

Bilingual noddle-chat supports bidirectional communication, enabling the patient and the caregiver to communicate directly. The patient’s message buttons are labeled in the patient’s language and produce messages in English. The nurse’s message buttons are labeled in English and produce messages in the patient’s language. The available messages support talking about vital signs, positioning care, feelings, food, care management, family, and entertainment options.  Bilingual noddle-chat is not meant to take the place of language interpreters and one of the built-in patient messages allows the patient to request that an interpreter be summoned.

 

Right now, bilingual noddle-chat is available for speakers of Arabic, Chinese, French, Hindi, Russian, Spanish & Tagalog. Voxello will expand the range of languages supported to address the needs of patients who use of sign language as well as for speakers of other spoken languages.

Clinical trials of Voxello’s noddle and noddle-chat have shown that when communication barriers are broken down patients have better outcomes and are more satisfied with their care. You can find out more about how Voxello supports patient-provider communication by visiting www.voxello.com.