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Call to Action: Improving Care to Communication

Vulnerable Patients

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SpeakersAmy Wilson-Stronks, MPP, CPHQProject Director & Principal InvestigatorHospitals, Language, and Culture StudyDivision of Standards and Survey MethodsThe Joint Commission

John M. Costello, MA, SLPChildren’s Hospital BostonDirector, AugmentativeCommunication Program

Lance Patak, MD, MBADepartment of AnesthesiologyUniversity of MichiganPresident and Founder,Vidatak.LLC

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Many Patients are Vulnerable due toInhibited Communication AbilitiesAccess to direct communication can be

inhibited due to:– Hearing impairment– Visual impairment– Speech impairment– Cognitive limitation– Intubation– Disease (ALS, stroke)– Language– Culture– Health literacy– Health Care Proxy (patient non-responsive)

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The Need for AccurateInformation:

Practitioner PerspectiveAssess patient needsDetermine diagnosis/prognosisProvide TreatmentObtain consentEducate/informHand-off communications

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What Strategies Are Often UsedWhen a Patient Cannot Speak?

Rely on lip reading

Gestures

Hand drawn pictures

Ask yes/no questions

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What Strategies Are Often UsedWhen A Patient is Non-English

Speaking or Deaf?Rely on family member, friend, or “ad hoc”

interpreter to interpretRely on lip reading (for the deaf)Sign language (for non-English speaking)

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Why Are These Strategies Inadequate?

Potential for misunderstandingConfidentiality when a family member

or friend is used to interpretLimits patient ability to participate in

own care (if only respond Y/N)

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“First of all, I would probably use my little board ornotepad, and I would write in English to see if heunderstands the language. If that is not the case,what I usually do is maybe by some form of signlanguage try to explain to him that he has severepain in his abdomen and he probably needs anoperation. The other thing I could show him ismaybe pictures of a surgeon where he probablyhas to open up the abdomen to perform theprocedure.”

– Emergency Department Physician

Source : Hospitals, Language, and Culture Study. A.Wilson-Stronkset. al., 2008.

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Why Is This Important?

Patient safetyTrust between patient and health care

practitioner/teamRole in health care disparitiesPatient satisfactionLegal and regulatory requirementsPatient participation in care is vital to

quality and safety!

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Examples from the Field

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Video: Yvonne

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Poor Communication ImpactsPatient Safety

– Serious medical events (Cohen et al., 2005, Bartlettet al. 2008)

– Sentinel events (The Joint Commission, 2007)

– Poor medication compliance/ adherence(Andrulis et al., 2002; Flores et al., 2003)

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Bartlett, G. et al.CMAJ 2008;178:1555-1562

“The presence of physical communicationproblems was significantly associated with anincreased risk of experiencing a preventableadverse event”

“We found that patients with communicationproblems were three times more likely toexperience preventable adverse events thanpatients without such problems”

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Copyright ©2008 Canadian Medical Association or its licensors

Bartlett, G. et al. CMAJ 2008;178:1555-1562

Figure 1: Odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated withpreventable adverse events, adjusted for age, sex, Charlson Comorbidity Index score,

admission status and type of hospital

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Risk for Serious Medical Events

Communication-vulnerable patients are:– Twice more likely to experience medical physical

harm– Increased risk of nonadherence to medication– Misreported abuse– Decreased access to medical care– Decreased use of medical care– Increased diagnosis of psychopathology– More likely to leave hospital against medical

advice– Asthmatics more likely to receive intubation– Less likely to return for follow-up appointments

after Emergency Room visits

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Risk for Serious Medical Events

Communication-vulnerable patients are:– Higher rates of hospitalization– Higher rates of drug complications– Highest use of resources to provide care– Lowest levels of satisfaction with care– Increased risk of delayed care– Increased failure to treat and prevent devastating

disease states and death– Increased risk of malpractice– Increased length of hospital stay

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Health Care Systems WorkingAgainst Effective Communication

No standardized system in place to identifycommunication needs

Lack of supporting resources, training, andtime needed to effectively communicate

Limited evidence and awareness of bestpractice

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Impact of AddressingCommunication Needs

Patients taught to use communication tools such aspicture boards, word boards or simple communicationdevices, reported improved satisfaction and comfortwhen compared to care without communicationsupport. (Stovsky, Rudy & Dragonete, 1988; Costello, 2000)

Communication boards can also significantly reducepatient frustration.

(Patak et al. 2002, 2004)

Provision of professional interpreter services isassociated with improved clinical care and increasedquality of care to LEP patients.

(Karliner et al. 2006)

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Call to Action

Improve clinical practice to incorporate asystematic & methodological approach topatient-provider communication

Optimize institutional availability and use ofauxiliary services and increase frequency ofreferrals to specialists for “COMMUNICATION”purposes

Educate health care providersRevise health care policy and standards to set

performance expectations for heath careproviders on patient-provider communication

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Formalize a Process to Manage Patient-Provider Communication at the Patient-Level

Patak, et.al, in review

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Low Information

High Uncertainty

Low PerceivedControl

High ThreatAppraisal

High EmotionalDistress

IneffectiveInformationProcessing CYCLE OF

STRESS RESPONSEACCH, 1985

UnfamiliarSituation

Don’t know howTo cope

FearAnxietyTension

MisunderstandingMisinterpretation

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Identify Communication Need

HearingVisionSpeechCognition IntubationAphasicPreferred language (if not English)Low Health LiteracyOther

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Introduce Intervention

Professional language or signlanguage interpreter

Communication boardAdaptive communication devicesSensory supports (glasses, hearing

aids, FM systems, etc.)Use of plain language, teach back, and

“Ask Me 3”

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Monitor InterventionEffectiveness

Is communication effective?– In order for communication to be effective,

the message must be complete, accurate,timely, unambiguous, and understood bythe communication partner.

Is a different intervention needed?Is referral to specialist needed?

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Considerations in Planning Care

Increased institutional support foraccess to tools and service providers atpoint of care

Increase support and utilization ofspecialty services as part of care team(Interpreter, Speech-LanguagePathologist with AugmentativeCommunication expertise, Audiologist,Chaplain, etc.)

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Given the broad contributions of aSpeech Language Pathologist withAugmentative Communicationexpertise…Let’s examine the impact of SLP inplanning care

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Goal of the Speech LanguagePathologist

To support immediate success byinsuring that “stop gap” tools andstrategies are within reach at point ofcare.

To provide a comprehensive and fluidassessment of patient needs andstrengths and match those to availableaugmentative communication tools andstrategies.

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Based on ongoing report ofpatient’s communication success

The “stop-gap” strategy may continueto be most efficient and effective overtime

Additional customized or moresophisticated strategies may berequired

Collaborate with other team membersincluding audiology, interpreterservices, ophthalmology, etc.

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AAC Assessment Considerations Whena Patient Is “Communication Vulnerable”

A well thought out ‘something’ is better thanNOTHING.

Try to support immediate success

You can learn a great deal very quickly byfollowing a thoughtful approach to ‘on thespot’ assessment.

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Cognitive Status

AlertnessAwarenessOrientationPre-morbid status

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Assessment Considerations

Often status is first reported by bedside careproviders

Patient’s wakefulness and fatigue (impactparticipation and length of assessment)

Patient’s ability to follow simple directions

Patient’s ability to respond to simplequestions

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Feature Match/InterventionConsiderations

May need to re-assess often and adjustrecommendations frequently

May need to keep interventions very brief andfocused

Will impact complexity of language used duringassessment

May initially focus on orientation through visuals,visual schedule, memory book for comfort.

Use of symbols versus written word

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Sensory Domain

Vision

Hearing

Changed status from beforeadmission?

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Assessment Considerations

Does s/he where glasses? If yes, are theyhere?

Does s/he have hearing aids? If yes, are theyhere?

If physical status will not support glasses orhearing aids (swelling, incision site, etc.),what accommodations can be made

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Intervention Considerations

Size of targetsColor contrastsComplexity of layoutUse of symbols versus text

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Size of targets

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Motor Domain

Use of gestures/pantomimeControl/accessDirect selection (hand, eyes, other?)Indirect selectionAbility to write/draw

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Assessment Considerations

Ability to write/draw

Ability to point with hand

Ability to point with eyes

Ability to point with head light

Use of splints to support pointing

Indirect access through scanning

Indirect access through partner assist

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Intervention Considerations

Inventory of natural gesturesBasic sign languageAdapted nurse call systemKeyboardPaper and penUse of keyguardSingle switch access to technologyPartner assisted scanningEye gaze/Etran

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Videos: Real life examples

Amy - Direct selectAndrew - single switch scanning

Lori - splint to help access

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Partner Assisted Scanning

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Partner Assisted ScanningSpelling Board

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Direct Selection Spelling Board

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Language Comprehension andLiteracy Screening

ComprehensionLiteracy skillsAble to answer yes/no/maybe

questionsNon-English speaking?

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THE WORD BEGINS WITH…..

Q W E R T Y U I O P

A S D F G H J K L

Z X C V B N M Start again

br cr fr gr tr pl str Next word

bl cl fl gl sw dw tw End

sl sc sk sm sn sp

sw squ spl spr scr

Letter Cue Board

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Topic Cue Board

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Speech Production

Reduced volume?

Moderately compromised intelligibility?

Severely compromised intelligibility?

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Voice Amplification or use ofElectrolarynx

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Vocabulary Selection

Patient needsPatient personality ( j. thank you video)Patient interestAddress medical, personal and

pyschosocial needs

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Environmental Assessment

LightingNoiseMounting/access

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Communication Partners

Native languageLiteracy levelsSensory status

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Resources

AACTech Connect (selling a ‘kit’) www.aacTechConnect.comManufacturers of AAC devices:

http://www.ussaac.org/links.htmlBrookes Publishers:

Augmentative Communication Strategies forAdults with Acute or Chronic MedicalConditionsBeukelman, Garrett Yorkston 2007

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Resources

Hospitals, Language, and Culture study website:www.jointcommission.org/patientsafety/hlc/

Available:Downloadable reportsHLC study informationLinks to other websitesResources

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Importance of communication andpotential impact on patient outcomesis recognized by:American Association of Critical Care NursesSociety for Critical Care MedicineNational Institute of HealthAmerican Medical AssociationAmerican Hospital AssociationThe Joint Commission

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Developing Hospital Standards for CulturallyCompetent Patient-Centered Care

18-month standards development project (August 2008 through January 2010)

Project will explore how diversity, culture, language,and health literacy issues can be better incorporatedinto current Joint Commission standards or draftedinto new requirements

Standards will build upon previous studies andprojects, including the research framework from theHLC study and evidence from the current literature.

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Developing Hospital Standards for CulturallyCompetent Patient-Centered Care

A multidisciplinary Expert Advisory Panel will provideguidance regarding principles, measures, structures,and processes that will be the basis of standards

Collaboration with National Health Law Program(NHeLP) to develop an implementation guide toprepare organizations for new standards

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Questions?

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References

Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A.,Cox, J., et al. (2004). The canadian adverse events study:The incidence of adverse events among hospital patients incanada. CMAJ : Canadian Medical Association Journal =Journal De l'Association Medicale Canadienne, 170(11),1678-1686.

Bergbom-Engberg I, Haljame H. Assessment of the patient’sexperiences of discomforts during respirator therapy. CritCare Med. 1989;17:1068-1072.

Beukelman, D. R., Garrett, K. L., & Yorkston, K. M. (2007).Augmentive communication strategies for adults with acutechronic medical conditions. Baltimore, MD: Paul H BrookesPublishing Co

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References

Cohen AL, Rivara F, Marcuse EK, McPhillips H,Davis R. Are language barriers associated withserious medical events in hospitalized pediatricpatients? Pediatrics. 2005;116(3):575-9.

Costello, J. (2000). AAC intervention in theintensive care unit: The children's hospital bostonmodel. Augmentative and AlternativeCommunication, 16(3), 137.

Divi C, Koss R, Schmaltz SP, Loeb JM. Languageproficiency and adverse events in US hospitals: apilot study. Int J Qual Health Care. 2007;19(2):60-7.

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References

Elderkin-Thompson V, Silver RC, Waitzkin H.When nurses double as interpreters: a study ofSpanish-speaking patients in a U.S. primary caresetting. Soc Sci Med. 2001;52:1343-58.

Flores G. The impact of medical interpreterservices on the quality of health care: a systematicreview. Med Care Res Rev. 2005;62:255-99.

Flores G. Language barriers to health care in theUnited States. N Engl J Med. 2006;355(3):229-31.

Flores G, Laws MB, Mayo SJ, et al. Errors inmedical interpretation and their potential clinicalconsequences in pediatric encounters. Pediatrics.2003;111:6-14.

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References

Elderkin-Thompson V, Silver RC, Waitzkin H.When nurses double as interpreters: a study ofSpanish-speaking patients in a U.S. primary caresetting. Soc Sci Med. 2001;52:1343-58.

Flores G. The impact of medical interpreterservices on the quality of health care: a systematicreview. Med Care Res Rev. 2005;62:255-99.

Flores G. Language barriers to health care in theUnited States. N Engl J Med. 2006;355(3):229-31.

Flores G, Laws MB, Mayo SJ, et al. Errors inmedical interpretation and their potential clinicalconsequences in pediatric encounters. Pediatrics.2003;111:6-14.

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References

Jablonski RS. The experience of beingmechanically ventilated. Qual Health Res.1994;4:186-207.

John-Baptiste A, Naglie G, Tomlinson G, AlibhaiSMH, Etchells E, Cheung A, Kapral M, Gold WL,Abrams H, Bacchus M, Krahn M. The effect ofEnglish language proficiency on length of stay andin-hospital mortality. J Gen Intern Med.2004;19:221-8.

Nelson J, Meier DE, Litke A, Natale DA, SiegelRE, Morrison SR. The symptom burden of chronicillness. Crit Care Med. 2004;32(7):1527-1534.

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References

Patak, L., Gawlinski, A., Fung, N. I., Doering, L.,Berg, J., & Henneman, E. A. (2006).Communication boards in critical care: Patients'views. Applied Nursing Research : ANR, 19(4),182-190.

Patak, L., Gawlinski, A., Fung, N. I., Doering, L., &Berg, J. (2004). Patients' reports of health carepractitioner interventions that are related tocommunication during mechanical ventilation.Heart & Lung : The Journal of Critical Care, 33(5),308-320.