Half of Mechanically Ventilated ICU Patients Could be Served by Assistive Communication Tools

1. Half of Mechanically Ventilated ICU Patients Could be Served by Assistive Communication Tools Andrea M. Sciulli, BA Amber E. Barnato*, MD, MPH Jennifer B. Seaman, BSN, RN Melissa Saul, MS Judith A. Tate, PhD, RN Mary Beth Happ, PhD, RN, FAAN University of Pittsburgh School of Nursing and *Medicine

2. To meet basic communication criteria, ICU patients must be awake, aware, and responsive. • One study of 4 ICUs reported an 18.4% point-prevalence of patients meeting basic communication criteria*. • No studies have documented the proportion of MV patients who are awake, aware, and attempting to communicateusing daily assessments of wakefulness over an entire ICU stay. • BACKGROUND *Thomas LA, Rodriguez CS: Prevalence of sudden speechlessness in critical care units. Clin Nurs Res 2011, 20(4):439-447.

3. PURPOSE • To determine the longitudinal prevalence of communication ability for at least one 12-hour nursing shift among patients mechanically ventilated for 2 or more days.

4. SETTING • Stepped wedge crossover cluster randomized trial of nurse training in the use of assistive communication tools. • 6 ICUs in 2 UPMC-affiliated hospitals. • Neurology Neurotrauma • Transplant Trauma • General Medical Cardiovascular • August 1, 2009 – July 31, 2011 [ 24 mos.] • Abstraction occurred across an ICU stay beginning on day 1 and reaching a maximum on day 28. Day 1 was always a MV day.

5. UNIT SIZE & CASE MIX

6. DATA COLLECTION • Two-stage sampling of medical records and billing data. • Screening for clinical eligibility.

7. SCREENING/ELIGIBILITY • EMR screening • Medical Archival System billing records • Admissions to a study unit • No prior ICU admission during the current hospitalization • Charge for MV for ≥ 2 days • Random number generator used to number MARS eligibility list • Sequentially screened patients to identify 30 patients/unit/quarter for full EMR abstraction. • Goal of 30 patients/unit/quarter • Goal of 1440 patients upon conclusion of the study (July 2011). • UPMC PowerChart • Nursing note descriptions of alert, arousable, anxious, or awake for ≥ 12-hour period • A score of 6 (Obeys Verbal Commands) for their best motor response on the Glasgow Coma Scale • A score of 1-3 on the Modified Ramsay Scale for sedation • A score of 3-7 on the Riker Sedation-Agitation Scale • MARS eligibility • Clinical eligibility

8. ENROLLMENT DIAGRAM • *Exclusions: • n = 17 Protected Group • n = 43 Ventilation Location • n = 96 Not 1st ICU Admit • n = 275 Not MV ≥ 2 days, Never vented, On unit < 1 shift

9. RESULTS

10. INTERPRETATION • The Neurological ICU had the lowest proportion of MV patients meeting communication criteria  41% • Neuro ICU patients often have insults to the centers of the brain that control communication, comprehension, and/or expression. • Trauma/Cardiovascular ICU’s had the highest proportion 70% • younger patients • shorter periods of MV, post-op ventilations

11. LIMITATIONS • Sampling from a single region, single academic medical system. • Analysis is limited to MV patients of a 2-day duration, potentially leading to underestimation of longitudinal prevalence of communication ability.

12. CONCLUSION • Half (53.8%) of MV patients experienced sustained periods of wakefulness during which they were nonvocal, but likely able to communicate in some way.

13. IMPLICATIONS • A large population of MV patients could be served by assistive communication tools. • Given the large population of MV patients, even small impacts on patient frustration and agitation of assistive communication tools could be clinically significant.