Restoration of Voice for Tracheostomy Patients in the Intensive Care Unit
10 June 2016 Last updated:
27 June 2016
Restoration of voice for tracheostomy patients in the intensive care unit
Royal Prince Alfred (RPA) Hospital implemented the first randomised controlled trial in the world that demonstrated the benefits of using an in-line speaking valve in an Intensive Care Unit (ICU) environment, to restore the voice of mechanically-ventilated tracheostomy patients.
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To improve the care and quality of life of ICU patients, by restoring their voice at the earliest opportunity.
- Improves patient communication, leading to more timely and effective care.
- Engages patients in the assessment process, so they can express their wishes and provide information that supports clinical care.
- Increases staff productivity, as less time is required to communicate with patients verbally compared with non-verbal methods of communication.
- Enhances collaboration between different disciplines in ICU, to deliver quality care and achieve patient goals.
- Provides a foundation for translational research and partnering with patients.
The loss of voice is highly stressful and traumatic for patients who are acutely unwell. It reduces their ability to be heard and prevents them from discussing their admission and effectively communicating with staff about their care needs. This can lead to less effective patient care, as well as patient and staff dissatisfaction.
One of the most common causes of prolonged voicelessness is cuffed tracheostomy tubes used in the ICU. Although it facilitates prolonged medical ventilation, it can be one of the most negative experiences of hospitalisation. It was determined that restoring the patient’s voice at the earliest opportunity following this procedure would improve patient participation and care in the ICU.
- A randomised trial of early speech intervention (ESI) versus standard management for tracheostomy patients was conducted in the ICU at RPA Hospital.
- 30 patients were selected to participate in the trial.
- ESIs included cuff deflation and use of the Passy Muir ventilation and speaking valve during mechanical ventilation.
- ESIs were implemented by speech pathologists and supported by other ICU staff.
- Guidelines were developed by speech pathology and ICU teams, with a collaborative approach to implementing staff education.
- Sustained - the initiative has been implemented and is sustained in standard business.
- June 2010 – March 2015
- Intensive Care Unit, Royal Prince Alfred Hospital
- Sydney Local Health District
- University of Sydney
- The primary outcome measure was time from tracheostomy insertion to phonation. ESI significantly hastened return to voice (median difference = 11 days, hazard ratio = 3.66, 95% CI = 1.54 to 8.68) and had no detrimental impact to the duration of tracheostomy cannulation days, mechanical ventilation in days, length of stay in ICU or length of stay in hospital.
- The early intervention group was admitted on average 14 days less than standard intervention. Although this did not translate to a statistically significant difference, it did translate to a difference in healthcare cost.
- The average cost difference in the provision of speech pathology interventions were two additional occasions of service. There was no extra cost in staffing other disciplines or any difference in ICU bed days for the early intervention.
- There were no significant adverse events from the early intervention and reported clinical events were equal between the groups.
- Quality of life was significantly improved as a result of the project, measured by the ability to be understood by others and cheerfulness. General health status improved by 16 points on a 100-point scale with voice. Patients reported a sense of happiness and relief when their voice was restored. At a six-month follow up interview, patients reported how stressful their voicelessness was and how it restricted their care requests, participation in their care and ability to interact with staff.
- Patients reported that restoration of their voice improved relationships with their family and staff. Patients stated:“I could actually be understood and didn’t have to think to explain.”
“It was pleasing to be able to speak again. Mainly you felt although you were getting better, recovering from the worst of your illness”.
- Staff in ICU reported an improved ability to care for patients when effective communication was restored and were keen to establish this as standard practice. Improved patient communication crossed all professional, social and cultural boundaries.
- The return of the patient’s voice was seen as a step in recovery and led to patients becoming more engaged in healthcare decisions. It was also important for patients that didn’t survive their ICU admission, as they got the opportunity to speak to the medical team and their loved ones about end of life care plans. In some cases, it provided patients with an opportunity to say their last words to their family before passing away.
This project was a finalist in the 2015 NSW Health Awards, Translational Research category.
The team learned the importance of patient communication and staff collaboration as a result of this project. Further trials examining specific outcomes, such as safety, need to be conducted to increase translation of results.
- Carroll SM. Silent, slow lifeworld: The communication experience of nonvocal ventilated patients. Qualitative Health Research 2007; 17(9): 1165-1177.
- Dikeman KJ, Kazandjian MS. Communication and swallowing management of tracheostomized and ventilator-dependent adults. Clifton Park, New York: Thomson Learning, Inc. Delmar Learning; 2003.
- Elpern EH, Borkgren Okonek M, Bacon M et al. Effect of the Passy-Muir tracheostomy speaking valve on pulmonary aspiration in adults. Heart & Lung 2000; 29(4): 287-293.
- Freeman-Sanderson A, Togher L, Phipps P et al. A clinical audit of the management of patients with a tracheostomy in an Australian tertiary hospital intensive care unit: Focus on speech-language pathology. International Journal of Speech-Language Pathology 2011; 13(6): 518-525.
- Freeman-Sanderson A, Togher L, Elkins M et al. Return of voice for ventilated tracheostomy patients in ICU: A randomized controlled trial of early-targeted intervention. Critical Care Medicine; 44(6): 1075-81.
- Freeman-Sanderson A, Togher L, Elkins M et al. Quality of life improves with return of voice in tracheostomy patients in intensive care: An observational study. Journal of Critical Care 2016; 33: 186-191.
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- Happ MB, Tuite P, Dobbin K et al. Communication ability, method, and content among nonspeaking nonsurviving patients treated with mechanical ventilation in the intensive care unit. American Journal of Critical Care 2004; 13(3): 210-218.
- Leder SB. Importance of verbal communication for the ventilator-dependent patient. Chest 1990; 98(4): 792-793.
- Magnus VS, Turkington L. Communication interaction in ICU: Patient and staff experiences and perceptions. Intensive and Critical Care Nursing 2006; 22(3): 167-180.
- Royal College of Speech and Language Therapists (RCSLT). Position Paper: Speech and Language Therapy in Adult Critical Care. England: RCSLT; 2006.
- Speech Pathology Australia. Position Paper: Tracheostomy Management. The Speech Pathology Association of Australia Limited; 2005.
- Sutt AL, Cornwell P, Mullany D et al. The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients. Journal of Critical Care 2015, 30(3): 491-494.
Dr Amy Freeman-Sanderson
A/Head of Department Speech Pathology
Royal Prince Alfred Hospital
Sydney Local Health District
Phone: 02 9515 9845
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