COMMENTARY

The COVID ICU: Before You Sedate, Communicate

The Terror of Being Intubated With No Voice

Lance S. Patak, MD, MBA; Eileen Rubin, JD

Disclosures

September 30, 2020

A silent crisis is taking place in intensive care units (ICUs) across the country. Every day, thousands of adults with COVID-19 are experiencing the trauma of waking and finding themselves intubated on a ventilator. Panic comes in waves as they realize they are unable to speak or interact with the outside world. 

And to make this horrifying situation even worse, bans on hospital visitation have left COVID-19 patients without familiar faces at the bedside to reassure them and facilitate communication with the ICU staff. Isolated and muted, these patients can quickly lose their grip on reality and become terrified, anxious, and confused. As many as one third of patients hospitalized for COVID-19 show signs of delirium, which is associated with prolonged hospitalization and higher rates of complications, cognitive impairment (including dementia), and mortality.

Lance S. Patak, MD, MBA

Eileen Rubin, JD

The inability of the awake, intubated or tracheostomized patient to speak is a well-documented problem in the ICU. Forty years of research has exposed the terror experienced by these patients, yet hospitals have yet to adopt systematic processes that effectively address the need for patient communication in critical care. When communication assistance is offered, it's mostly ad hoc. It's essential that hospitals and clinicians across the country adopt a more consistent approach that restores patients with the dignity of being able to convey their needs to their caregivers.

Where Is "Communication" in ICU Care?

Many critical care healthcare professionals assume that facilitating communication is part of the ABCDEF bundle created by the Society of Critical Care Medicine and widely used in the ICU. Each letter refers to a type of care designed to promote liberation from mechanical ventilation and intensive care.

The ABCDEF bundle is as follows:

  • 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.

Within this bundle, interventions are delineated for holding sedation, waking the patient, performing spontaneous breathing trials, mobilizing the patient, and engaging family members to participate in care (when visitation is permitted). However, not only is adherence to this protocol inconsistent, but facilitating an intubated patient's ability to communicate is absent.

Rethinking the Critical Care Culture

Intubated patients cannot speak, yet no standard intervention is used to restore their ability to communicate. The iatrogenic loss of speech is viewed simply as an unavoidable consequence of intubation.

Yet helping mechanically ventilated patients with evidence-based communication tools has many potential benefits. Facilitating communication with these patients can reduce a patient's anxiety and frustration. This creates an enormous opportunity to reduce sedation exposure, which in turn can result in fewer mechanical ventilation days, shorter ICU and hospital stays, and lower healthcare costs.

Figure 1. Intubated patient using a communication tool in the ICU.

To change the culture of the ICU with respect to patient communication and foster more effective and humanistic care, we suggest four actions: 

  1. ICU rounds communication assessment. ICU staff should report whether the patient is communicating effectively and what modes of communication are being used. Considerations might include a sign posted in the patient's room denoting a communication difficulty, or referral to and recommendations of a speech language pathologist.

  2. Documentation: Nurses should systematically and routinely document the patient's communication function. How are they communicating overall, and specifically, the patient's ability to communicate "yes" and "no"? Has there been a change in status? Thorough documentation of communication status creates a chain of command and accountability.

  3. Communication plans: A plan should be posted by the patient's bed that explains how the patient conveys thoughts, needs, and symptoms to providers and how he or she understands what providers are communicating to them.

  4. Quality assurance: When entering a patient's hospital room and the patient is awake, the provider's first question should be, "Since the last time we spoke, is there anything you want to tell me?"

The ICU staff should also provide the patient's preferred communication aids (eg, pen/paper, communication board, picture board, communication app) The table below lists examples of currently available communication boards and apps for use in hospitals.

Table. Selection of Communication Boards and Apps

Communication boards Communication applications

Healthcare Communication Board

Vidatak EZ Board a

Vidatak Picture Board a

Spiritual Care Communication Board a

SmallTalk Intensive Care App

Patient Communicator App

VidaTalk App a

SpiritualCare Communication App[a]

aThese solutions have been tested with patients and shown to be effective in reducing patient anxiety and frustration with the inability to communicate.

Figure 2. The VidaTalk communication app.

A new approach is needed to help ICU patients communicate. It takes more than a good faith effort to understand what patients are trying to say. Sedating speechless patients as an alternative to empowering them to communicate effectively is the absolute worst option.

Lance S. Patak, MD, MBA, is an assistant professor of anesthesiology and pain medicine at the University of Washington School of Medicine and a pediatric anesthesiologist at Seattle Children's Hospital. He has researched communication problems with mechanically ventilated patients and helped develop an evidence-based communication tool for intubated, nonverbal, and non–English-speaking patients. With funding support from the National Institutes of Health, he developed and tested VidaTalk, the digital version of the EZ Board, and Eloquence, the first multilingual nurse call communication system.

Eileen Rubin, JD, is the CEO, president, and co-founder of the ARDS Foundation, a nonprofit dedicated to improving the lives of patients with acute respiratory distress and their family members. In 1995, she experienced ARDS and was hospitalized for 9 weeks, on a ventilator for 8 weeks, and in a drug-induced coma for 4 weeks. She has leadership positions in several committees with the American Thoracic Society and the Society of Critical Care Medicine.

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....