Introduction
Over half of mechanically ventilated patients attempt to communicate, but many of these attempts are unsuccessful.1–3 Impaired communication during mechanical ventilation is frustrating for both patients and staff.4–6 Moreover, it has been linked to an increase in preventable adverse events.7
Few options exist to facilitate communication for continuously mechanically ventilated patients. Often, communication is limited to mouthing words, hand gesturing, and head nodding, which can be time-consuming and ineffective.8–10 Also, patient communication is typically limited to answering specific questions posed to them.
Current primary methods for assistive communication include communication boards (CB) and speech-generating touch screen devices; yet many patients lack the fine motor control necessary to navigate these devices independently.11 Further, a previous investigation found that only 27% of alert and oriented mechanically ventilated intensive care unit (ICU) patients could write legibly.12 The electrolarynx has recently been employed in case studies and series with some success, but its utility remains unclear.13 14 Speaking tracheostomy tubes and one-way speaking valves have also been employed for patients with tracheostomies, but typically require ventilator breaks for cuff deflation, and thus cannot be routinely employed.15
It has been postulated that an assistive technological aid such as an eye-tracking device (ETD) may be able to address this unmet need in mechanically ventilated patients without oral motor or fine motor abilities.11 ETDs detect eye movement and position, and then integrate data to create a gaze point for selection on a screen; this selection is then verbalized to the patient and caregiver by the ETD computer.16 ETDs have tremendous potential (customizable pages, writing by gaze detection, and surfing the world wide web by gaze detection alone) to facilitate freedom of communication beyond our pre-selected pages. ETDs are well established as a beneficial communication method for patients with neuromuscular disorders, in particular Amyotrophic Lateral Sclerosis (ALS).17 18 However, the use of ETDs as communication devices in the ICU has not been extensively examined. In this pilot study, we investigated the use of assistive communication devices by mechanically ventilated patients in a surgical ICU. We evaluated basic needs that would commonly be addressed in routine ICU care and alsosought to determine if there were any other issues or concerns that patients needed to relay to health care providers.
Setting and patients
This pilot prospective study was conducted in the 14-bed trauma/surgical ICU of an academic tertiary care medical center. The medical center is also an American College of Surgeons-verified level I trauma center. We evaluated admitted trauma/surgical ICU patients for enrollment during a consecutive 30-week period (July 2016–February 2017), from Monday through Friday. We evaluated the communication needs and abilities of a highly select patient population: patients receiving continuous mechanical ventilation via an endotracheal tube or tracheostomy at the time of screening, English-speaking, without cognitive impairment, and without traumatic brain injury that resulted in impaired motor or eye scores on the Glasgow Coma Scale. To ensure the absence of cognitive impairment, patients were assessed for their ability to follow commands by looking in three directions and responding yes or no to their correct name and an incorrect name. Patients had to be alert and calm (ie, Richmond Agitation-Sedation Scale score −1, 0, or +1). To avoid any interference in patient care, sedation, if any, could not be turned off for the study. The study was originally designed to be conducted on two consecutive days, with either the communication board (CB) or ETD used initially on the first day and the other device used first on the second day. However, given difficulty in recruiting patients to participate on two consecutive days, a modification was made whereby patients were evaluated on a single day. At the end of the continuous enrollment period, additional patients were recruited from a convenience sample during a non-continuous 3-month period, ending in January 2018.
Materials
The Tobii Dynavox I-15 eye tracking device (Tobii Dynavox, Danderyd, Sweden; figure 1) and Vidatak EZ communication board (Acuity Medical, Annapolis, MD; figure 2) were employed for this study. The ETD is composed of a camera, a projector, and a preprogrammed algorithm, all of which are integrated into a free-standing monitor.16 The device was calibrated with each patient at each new usage session. Calibration was achieved by having the patient follow a cursor with their eyes to five points on the screen. Several page-sets available from the manufacturer were adapted by the study team to reflect the picture-word sets on the CB. Four main pages were created. The patient could select any item on the screen by maintaining their gaze on the selection for 400 milliseconds. Selections made by gazing were then verbalized by the ETD computer. Although the ETD we used also has a touch screen; this feature was not used during the study. Meanwhile, Vidatak EZ communication boards are composed of dual-sided laminated cardboard and feature pictures, words, and letters.
Tobii Dynavox I-15 eye tracking device.
Vidatak EZ picture board.
Design
Once consented for the study, patients were introduced to the CB and ETD with a brief 1-minute introduction detailing how to access the ETD screens and the items on the CB. Orientation duration was brief by design to create a comparable user experience between the CB and ETD; the CB required minimal orientation due to its design, and thus orientation to the ETD was also kept brief.
Patients were verbally asked four basic needs yes-or-no questions: (1) ‘Are you in pain?’ (2) ‘Is your position comfortable?’ (3) ‘Do you feel that the room temperature is okay?’ and (4) ‘Do you need suctioning?’ Accuracy of the response was confirmed by the examiner repeating the patient’s response and asking ‘is this correct?’ The patient would then nod their head in response. For example, if a patient pointed to ‘yes’ on the CB when asked if they were in pain, the staff would state, ‘You indicated that you are in pain, is this correct?’ The patient would nod their head yes or no and the accuracy of their response was recorded. The patients were then asked if they had anything else that they would like to communicate and were given the opportunity to respond. Patients that were in odd-numbered rooms were evaluated with the ETD first, followed by the CB, whereas patients in even-numbered rooms were assessed with the CB followed by the ETD.
Study procedures were completed by first-year and second-year medical students. An occupational therapist or nurse was needed to observe each patient encounter as a requirement for enrollment during the 30-week period of continuous recruitment. Patients with limited ability to point to objects on the CB were assisted by staff pointing. Patient and observer preference between assistive (CB and ETD) and baseline forms of communication (head nodding or writing) was assessed. The patient’s/observer’s limited exposure and familiarity with the ETD precluded a meaningful assessment of patient and provider preference between the CB and ETD.
Data analysis
Basic descriptive (median, IQR) and inferential (Wilcoxon rank-sum) statistics were performed using SPSS V.23.0 to compare device accuracy. Because of the small sample size, further statistics were not performed.
