Intensive care, as thousands more American have experienced this year due to COVID-19, is an intense experience. It often involves life-saving equipment and complex treatment. To improve those patients’ outcomes and experiences, ICU staff ideally would operate under a protocol known as the “ABCDEF bundle.” Each letter refers to a type of care to promote liberation from mechanical ventilation and reduce the need for ICU level care. Adherence to this protocol, however, remains inconsistent, and many ICU patients suffer delirium – a state of confusion lasting hours or days – and clinical depression and anxiety that can last months to years.
In an editorial published June 19 in the journal Critical Care Medicine, Lance Patak, an assistant professor of anesthesiology and pain medicine at the University of Washington School of Medicine, and two faculty partners with The Ohio State University College of Nursing suggest that patient communications should not only be a key component of these bundled intervention, but also as standard and routine as any other vital sign.
“Empowering a patient to communicate should not be a random, situation- or provider-specific event, but something as common, expected and standardized as measuring and documenting blood pressure or heart rate. Perhaps communication should be a vital sign,” the authors argued.
Patak called poor patient communication with intubated patients and associated delirium “a silent healthcare crisis that needs immediate attention.” During the COVID-19 outbreak, he said, delirium rates have doubled and tripled, which he attributes, in part, to intubated patients not being able to communicate and because of increasing sedation.
“If we’re going to turn off sedation at 4 a.m., at the very least we should provide our nonverbal patients an effective means to communicate – otherwise we’re just re-exposing the patient to the terror and powerlessness that is their ICU experience,” he said in an interview.
The ABCDEF bundle is Assess, prevent, and manage pain; Both spontaneous awakening trials and spontaneous breathing trials; Choice of analgesia and sedation; Delirium: Assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment.
Patak, an anesthesiologist at Seattle Children’s Hospital, credits his time working as a nurse and nurse’s assistant to understanding the frustration of patients being unable to communicate.
He wrote the editorial with colleagues at The Ohio State University College of Nursing who believe so strongly in the need to elevate communications in care that they have created a toolkit for all healthcare staff. The toolkit contains six 10-minute modules on topics such as how to evaluate a patient’s communication needs and what tools are best for the patient, e.g., pen and paper, whiteboard, communication board, hand squeezes, eye movement, etc.
“There is a wide variability across the United States in how hospitals implement programs for patient communication support,” said co-author Mary Beth Happ, associate dean for research and innovation at The Ohio State University College of Nursing. She said communication has not always been a priority for intensive care units. ICU staff historically have relied on family members to help communicate. But with COVID-19, family members aren’t allowed in.
“In acute and critical care, many don’t think of a patient’s nonspeaking state as a disability but as a temporary condition of their illness,” Happ said.
During shift changes and patient handoffs, caregivers should be able to discuss how communication is being facilitated: what tool the patient is using, what their yes/no signal is, and whether they have glasses and/or hearing aids. She emphasized that a notebook and pen should be at every patient’s bedside. In the editorial, the authors said a communication plan should be next to a patient’s bed.
Thousands of hospitalized COVID-19 patients couldn’t communicate because of a ventilator and most of them reported experiencing delirium, said Patak. Their lives had shrunk to their bed and their world was turned upside down.
“Put yourself in their shoes. If you wake up in an ICU and your only access is strangers and you cannot speak because of a tube and you are too weak to write legibly, you experience terror, fear, anxiety, and eventually hopelessness,” said Patak.
Of the 6,100 U.S. hospitals, just a small fraction are systematically providing communication systems to patients who need them, he said. When providers don’t offer appropriate communication support, they rely on sedation as a substitute, he said. “What patients need are mobility and engagement to help them recover quicker.”
— Bobbi Nodell, UW Medicine media relations, bnodell@uw.edu, 206.543.7129
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