Assignment Task

Tracheostomy patients receiving MV such as Tony depend on augmentative and alternative communication (AAC) methods to express their needs. AAC refers to any form of communication other than speech; from basic picture and letter boards to advanced computer-based systems (Aitken et al, 2019). Selecting the most effective form of AAC can be difficult as multiple methods exist and each are subject to the individual’s abilities and clinical condition. Some methods of AAC, such as lipreading, as used when communicating with Tony also rely on the nurse’s skill of interpretation. Although beneficial because no equipment was required, a report by Action on Hearing Loss (2013) found human lip-reading can be highly ineffective. The report studied the experiences and capabilities of 9 volunteers lip-reading video clips before and after attending 30 sessions of 2-hourly classes with a qualified tutor. To analyse the effectiveness of the lip-reading course, participants engaged in both qualitative and quantitative research methods in the form of semistructured interviews and lip-reading exercises Using multiple methods of data collection is identified as triangulation and is a method used by researchers to increase the validity of research (Noble and Heale, 2019). Triangulation of qualitative and quantitative data faces limitations as both methodologies have conflicting standards for accuracy (Brannen, 2016). Whilst a small sample size of 9 participants can be accepted in the qualitative semi-structured interviews to allow for complex information to be gathered and analysed (Vasileiou et al, 2018), limited quantitative results significantly reduce the power in which their findings can be generalised to the overall population. Following the lip-reading course, word success rates ranged from 8–88%. This huge disparity in individuals’ lip-reading skills necessitates further study with a larger sample size, and if representative of the population could explain some of Tony’s frustration.

To reconnect isolated non-verbal patients like Tony and reduce health inequalities in compliance to the Health and Social Care Act (2012), Meltzer et al (2012) argue lipreading interpreters should be routinely offered in medical settings. Funding this is likely to cause debate however as methods of cutting costs on translation services have already been questioned when a report by Gan (2012) found £23.3 million was spent by NHS Trusts in 2011 on translation. Perhaps the future for lip-reading communication lies in Artificial Intelligence (AI) such as ‘LipNet’ created by Google DeepMind which significantly out-preforms human lip-reading with a 95.2% success rate on sentence-level translation (Assael et al, 2016). Lip-reading AI requires more data collection prior to its use in a visually noisy ICU but offers an interesting possibility for the future.

The Intensive Care Society Standards (2014:53) advises communication aids are included in the patients ‘tracheostomy box’ which stores necessary bedside equipment. Against best-practice, the trust caring for Tony had no regulated protocol for communication with non-verbal patients. Communication aids were not routinely stored at the bedside. Pen and paper were easily accessible to nursing staff and Tony was encouraged with written communication. Written communication is highly beneficial as it allows patients to share unique messages and show character. However, many patients are unable to manipulate a pen to produce legitimate handwriting due to poor hand dexterity (Lloyd et al, 2018). This was the case for Tony. Doyle (2019) encourages trialling communication boards in patients such as Tony who have strength to lift limbs but insufficient fine motor skills to write. Unfortunately, other AAC methods were not explored, mirroring Happ et al’s (2015) findings that whilst 53.9% of mechanically ventilated patients meet the criteria to be served by AAC tools, they are rarely initiated by nurses. Perhaps because nurses working in busy environments feel pressure to continue with daily tasks due to a perceived lack of time (Norouzinia et al, 2016). Competing demands from other patients are also known to regularly interrupt nurse-patient communication (Ali, 2017a), making assessments for communication aids difficult for nurses in practice. To overcome these barriers, support from other members of the MDT is essential.

Unlike nurses, Speech and Language Therapists (SLTs) have dedicated time to assess the communication abilities of tracheostomy patients and produce clinical management plans. The Faculty of Intensive Care Medicine (2019) recommend a minimum staffing level of 0.1 whole time equivalent, equal to one SLT per ten critical care beds, to allow for an optimal service. This service includes providing all tracheostomy patients with a communication aid which is suitable to their individual ability. Evidently, the trust caring for Tony failed to provide this service. NCEPOD (2014) discovered poor SLT engagement to be an NHS-wide issue as only 26.9% of patients with a new tracheostomy on critical care were referred to SLTs in the 150 trusts studied. To provide high quality communication strategies and therefore improve QOL of tracheostomy patients, timely referrals to SLTs is essential. SLTs offer knowledge and skills of early voice restoration techniques such as above cuff vocalisation (ACV) (The Faculty of Intensive Care Medicine, 2019). ACV is an innovative technique which is not yet licenced for use in the UK but has shown to be effective in producing audible voice in tracheostomy patients receiving MV and may have been beneficial to Tony. Austin Health in Melbourne, Australia have been using ACV since 2014 under strict guidelines (Garbutt et al, 2014) which have since been revised (Tracheostomy Review and Management Service (TRAMS), 2017). The technique uses a specialised tracheostomy tube such as the Portex Blue Line Ultra Suctionaid (BLUS) (Smiths Medical, 2018) to deliver a low flow of gas backwards through the subglottic port. The gas flow passes over the vocal cords and out of the mouth with the intention of producing sound. 

ACV was tested on 10 suitable patients receiving MV in Manchester University NHS Foundation Trust with the success of 8 patients achieving audible voice (McGrath et al, 2019). A larger sample size would have been preferable. However, the availability of resources determines the feasibility for sample sizes (Rakesh, 2016). Of the 74 patients managed with a tracheostomy over a 5-month period, only 13 patients met the inclusion criteria. This narrow inclusion criteria suggests few tracheostomy patients will be eligible to benefit from ACV since the technique requires good levels of consciousness and well managed secretions, qualities which are often lacking in ICU patients. Most patients tolerated 15 minutes of ACV before experiencing complications such as excessive oral secretions and general discomfort. Therefore, even ACV eligible patients will continue to rely on alternative methods of communication throughout the remainder of the day.

McGrath et al (2019) did not measure patient’s psychological response following ACV and this was later challenged. Pandian et al (2019) carried out a randomised control trial (RCT) measuring QOL scores in 25 patients pre and post ACV involvement, compared to 25 patients continuing with AAC methods over a two-week period. Randomly assigning participants into groups reduces bias by balancing known and unknown confounding variables (Hariton and Locascio, 2018). RCTs are considered as the gold-standard research method for examining the safety and efficiency of new treatments and clinical interventions. Practice decisions are often based on evidence from well-conducted RCTs (Bhide et al, 2018). The larger sample size used by Pandian et al (2019) also provides greater statistical power, therefore findings from this study can be used with confidence.

ACV proved to be effective in increasing QOL scores from 14.4% pre-intervention to 22.5% post intervention. 41.9% of participants felt some level of satisfaction using ACV and 72.7% reported some level of independence. Although benefits to QOL are evident, the study highlighted hospital and ICU length of stays (LOSs) were significantly higher in patients receiving ACV. The cost implications of increasing patient LOS and training large teams of ICU nurses to use ACV is unattractive to trusts, especially since only a small population of tracheostomy patients are eligible to use the technique. Potential harm to patients also deters trusts from employing the technique. ACV risks damage to laryngeal mucosa (McGrath et al, 2016) and sudden neck and facial emphysema (Calamai et al, 2018). However, for patients such as Tony where comfort has become a priority, offering him the opportunity to verbally communicate could have significantly improved his QOL whilst in ICU. The cost of implementation could be significantly reduced through training small teams of ICU nurses who share a keen interest in reducing communication barriers to support other members of the nursing team. This team could be labelled as ‘communication link nurses’ (cLNs).

Link nurses (LNs) are practicing nurses with good understanding of a clinical subject. They engage in formal discussions with specialist teams and disseminate information among nurses in the clinical area, acting as a role model for their region of interest (Legg et al, 2017). A literature review carried out by Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC) (2018) found LNs improve NHS services through sustainable change and improved access to specialist teams. Poor engagement with SLTs have been identified as a key issue throughout this assignment in the failure to meet Tony’s communication needs. Therefore, implementation of cLNs may benefit the development of critical care services through bridging the gap between SLTs and ICU nurses. LN models are highly encouraged resources to ward managers (NHS Improvement, 2018), though LNs are often frustrated by the lack of support and recognition they receive at organisational levels (NIPEC, 2018). LNs require relevant training and dedicated time to work safely and effectively in their roles (National Quality Board, 2018). In order to recruit and retain cLNs, an incentive is required. An easy and effective method of supporting and rewarding LNs as shown by Williams et al (2019) is through offering certificates and academic credits on completion of LN courses. 

Regular LN meetings offer the opportunity to formally case manage identified patients and devise individualised action plans with MDT input (NIPEC, 2018). The first stage of case management is case finding, this involves identifying patients in need (Ross et al, 2011). Since cLNs are also members of the general nursing team delivering direct care over the 24-hour period, they are likely to be more accessible to nursing staff than SLTs. A cLN folder could be used to document flagging patients and common queries which should be discussed at the next cLN meeting. The regularity of the meetings would depend on the acuity of the ICU unit and would be revised as needed.

Lack of time, knowledge and interruptions to nurse-patient engagement have also been identified as barriers to communication assessments. To overcome these barriers, a flow chart is proposed, flow charts are useful in processes which require analysis and management because they present complex workflow information clearly and concisely (Heher and Chen, 2017). Gathering a consensus of processes is particularly important when managing a large team of nurses with varied levels of experience as it limits room for error. A study by Wikjord et al (2017) found nursing practice in nutritional care to be improved through the implementation of a simple flowchart-based protocol when compared with comprehensive, electronically stored protocols on ICU. Although tested on a different nursing topic, this study indicates that easily accessible and user-friendly protocols are favourable to nurses and effective in practice. Beauvais (2019) states flowcharts encounter problems when the process is too complicated. To prevent confusion, the flowchart recommends specialist advise when communication needs become complex. For effective integration into practice, nurses will require updating on the new communication assessment protocol. Informal bedside teaching is a favourable form of education within ICU because nurses need to be nearby their patient to ensure safety. ‘Core’ topics require classroom-like environments, but bedside relevant topics, such as this, could be effectively taught on ICU by cLNs if management allowed the time (Joyce et al, 2017). 

Once an effective method of communication has been established, the personalised bedhead sign may be a useful tool to quickly and clearly identify patient’s individual communication needs. This idea was inspired by the National Tracheostomy Safety Project (2020) bedhead signs which display essential tracheostomy information so responders to airway emergencies can interpret information immediately. The use of these safety bedhead signs is acknowledged as a vital tool for any patient with a tracheostomy in hospital (Billington and Luckett, 2019). They are inexpensive, quick, and easy for nurses to complete. Having a clear display of a tracheostomy patient’s communication method is likely to benefit both patient and staff to enhance communication.