Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2019 Mar 6.
Published in final edited form as: Perspect ASHA Spec Interest Groups. 2018 Jan;3(12):99–112. doi: 10.1044/persp3.SIG12.99

The cost of not addressing the communication barriers faced by hospitalized patients

Richard R Hurtig 1, Rebecca M Alper 2, Benjamin Berkowitz 3
PMCID: PMC6402813  NIHMSID: NIHMS975159  PMID: 30854467

Abstract

Preventable adverse events (AEs) lead to poorer patient outcomes, added patient suffering and dissatisfaction, longer hospital stays, and billions in additional annual healthcare spending. Patients facing barriers to communication are three times more likely to experience a preventable adverse event than patients who faced no communication barriers. National data on hospital admissions, incidence and cost of preventable AEs, and the odds ratio regarding the risk of preventable AEs in people facing communication barriers were used to estimate potential benefits of improving patient communication. Reducing communication barriers could lead to an estimated reduction of 671,440 preventable AE cases and a cost savings of $6.8 billion annually. Facilitating patient-provider communication is an ethical and financial imperative. A multi-pronged approach, including increased awareness of and support for speech-language pathology services, is essential to creating a communication-friendly hospital culture, reducing patient suffering, and decreasing the financial cost of preventable AEs. Speech-language pathologists and allied healthcare professionals play a critical role in facilitating patient-provider communication and improving patient outcomes.

Keywords: Augmentative and Alternative Communication, Adverse Medical Events, Patient safety and prevention of medical error, Patient-Provider Communication, Costs of Adverse Events

Introduction

Why is effective patient-provider communication critical in healthcare?

Hospitalized patients face many challenges while healing. Patients are typically hospitalized because they have experienced a significant illness or trauma. Some patients are able to communicate with their caregivers, but many conscious patients face communication barriers. Communication barriers can be the result of physical, cognitive, and/or linguistic differences or limitations. These barriers can impede patient-provider communication, increase the risk of experiencing an adverse event (AE; Bartlett, Blais, Tamblyn, Clermont & MacGibbon, 2008; Cohen, Rivara, Marcuse, McPhillips & Davis, 2005; Joint Commission, 2010), increase patient and provider stress, and decrease patient satisfaction with care (Balandin, Hemsley, Sigafoos & Green, 2007; Hemsley, Balandin & Togher, 2007; Hemsley, Balandin & Worrall, 2011; Hoffman, et al., 2005; Rodriguez, et al., 2016).AEs lead to poorer patient outcomes, unnecessary patient suffering and dissatisfaction, longer hospital stays, and extra healthcare spending each year (Joint Commission, 2011; David, Gunnarsson, Waters, Horblyuk & Kaplan, 2013). Thus, the Joint Commission specifically included meeting patients’ communication needs in its 2012 standards (Blackstone, Garrett & Hasselkus, 2011a; Blackstone, Ruschke, Wilson-Stronks & Lee, 2011b).

The best efforts of nurses to guess what a patient wants can often fall short. Relying on a simple yes/no response and a “twenty questions” approach can be frustrating and often fails. The following case from our work at the University of Iowa Hospitals and Clinics illustrates this:

An elderly woman fell at her home and was emergently admitted to our ICU and was required mechanical ventilation. She was extremely distressed and was desperately trying to communicate with her nurses and her daughter. The endotracheal tube made it impossible for her to speak and the nurses could not make out what she was trying to mouth. She was given a white board and a sharpie and asked to write what she wanted. Because she was supine and had IVs in both arms, her attempts at writing did not produce anything that either the nurses or her daughter could decipher. In an attempt to discover what she was distressed by, she was asked whether she was in pain; she responded “no”. She was asked whether she had questions about her accident; she responded “no”. She was asked whether she was worried about her prognosis; again, she responded “no”. The questioning continued for over twenty minutes. She was getting more distressed as were her nurses and daughter. Finally, she was asked whether what she was worried about was at home; she responded “yes” and after another long round of questions it turned out that what she was worried about was that before she had fallen she had taken some chicken out of the freezer and was worried that it would spoil since it was left on the kitchen counter. The strategy of using yes/no questions to triangulate and determine what the patient wanted had clearly failed leading to increased stress for the patient and the providers.

The magnitude of the problem of adverse medical events

AEs (a.k.a. “medical errors”) are defined as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim” (Kohn, Corrigan, & Donaldson, 2000, p.1). Hospital-initiated changes in provider practices (e.g. handwashing protocols) are critical to helping reduce many preventable AEs. Additional measures to improve patient-provider communication are likely also necessary to prevent AEs, particularly for patients with communication barriers. For instance, a patient with a communication barrier may have a harder time communicating about symptoms of AEs like adverse drug reactions, falls, pressure ulcers, ventilator associated pneumonias, and delirium. If a patient can effectively summon help and communicate about pain or other symptoms, it should be easier for care providers to identify risks and intervene earlier.

To increase compliance with patient care standards, the Centers for Medicare and Medicaid Services (CMS) have stopped reimbursing hospitals for the cost of treating preventable AEs and have implemented a reimbursement model more directly tied to patient outcomes and satisfaction. Preventable AEs or sentinel events pose a significant ethical and financial burden on the United States health care system. The Institute of Medicine report, To Err Is Human: Building a Safer Health System, highlighted the pervasive problem of adverse events (AEs) in health care (Kohn et al., 2000). Preventable AEs in the US may have contributed to somewhere between 44,000 and 98,000 deaths a year. More recent estimates suggest that deaths related to preventable AEs are in excess of 100,000 a year (James, 2013). Adverse drug reactions, ventilator associated pneumonias, pressure ulcers, and patient falls are among the most prevalent preventable AEs. Landrigan, et al. (2010) found that, despite increased hospital awareness of patient safety, the number of patients harmed by medical interventions had remained high (18% of admissions). Furthermore, the report contended that 63% of those injuries were preventable (Landrigan et al., 2010). Health and Human Services (HHS) reported that 13.5% of Medicare beneficiaries had experienced an AE and 1.5% experienced AEs that contributed to their deaths (Levinson, 2010). The number of adverse events annually has been found to be vastly underreported (possibly by a factor of up to 10). Thus, the extra healthcare costs associated with treating the outcomes of adverse events could be in the billions of dollars (Classen, et al., 2011). The prevalence of preventable AEs is seen in other countries as well (Neale, Woloshynowych& Vincent, 2001; David, Gunnarsson, Waters, Horblyuk & Kaplan, 2002; de Vries, Ramrattan, Smorenburg, Gouma & Boermeester, 2008; Wu, Boyle, Wallace & Mazor, 2013). The problem of preventable AEs is particularly relevant to the field of speech-language pathology, because the risk of experiencing an AE is not uniform across all patients (Hemsley et al., 2007; Hemsley et al., 2011; Blackstone, Ruschke, et al., 2011). Patients with impaired communication abilities due to structural, cognitive, linguistic, or a combination of factors are three times more likely to experience a preventable AE than patients with no communication impairments (Bartlett et al., 2008).

Contacting a nurse is the patient’s first and most fundamental means of communication. Many patients are unable to independently call their nurses . Approximately 14% of all conscious hospitalized patients over the age of three are not able to access the nurse call system (Zubow & Hurtig, 2013). Thus addressing patient-provider communication requires ensuring that all patients can access the nurse call system.

The inability to effectively communicate with caregivers during an acute illness makes it difficult for patients to understand their illness, participate in medical decision making, and engage in their treatment. Mechanical ventilation makes it impossible for many patients to speak for an extended period of time (Dasta, McLaughlin, Mody & Piech, 2005; Wunsch, et al., 2010). These “silent patients” cannot express their most basic needs or participate in life-or-death healthcare decisions. Zubow and Hurtig (2013) found that 33% of conscious and ventilated intensive care unit (ICU) patients are unable to communicate with caregivers. More recently Happ, Seaman, Nilsen et al. (2015) reported that 53.9% of their mechanically ventilated ICU patients met their criteria for needing assistance with communication.

These numbers are alarming for both ethical and financial reasons. Specifically, patients have a right to basic communication and healthcare systems have a responsibility to mitigating unnecessary costs. There is an established, positive relationship between patient-provider communication and health outcomes (Balandin, Hemsley, Sigafoos & Green, 2007; Blackstone, Beukelman & Yorkston, 2015; Cohen et al., 2005; Costello, 2000; Divi, Koss, Schmaltz & Loeb, 2007; Dowden, Honsinger & Beukelman, 1986; Downey & Hurtig, 2006; Hemsley et al., 2007; Hemsley et al., 2011; Hurtig & Downey, 2009; Hoffman et al., 2005; Patak, Gawlinski, Fung, Doering & Berg, 2004). These studies identified the ramifications of language-communication barriers in healthcare settings, including: access to healthcare, participation in treatment planning, participation in critical decision-making involving end of life issues, communication with medical providers regarding new or changing symptoms, and the ability to express dissatisfaction with their care.

The role of communication in pain management

Pain has been called the fifth vital sign (Campbell, 1996) and its management is a critical component of patient care. The assessment of pain is more straightforward for patients who can effectively communicate with their caregivers about the locus and magnitude of the pain. Delays in recognizing the pain associated with the tissue break down that can result in a decubitus ulcer, extend a patient’s hospitalization, and result in further medical complications. The following case from Sarah Marshall at the University of Wisconsin University-Madison Communication Aids & Systems Clinic illustrates how critical patient-provider communication about pain can be to positive outcomes:

Working with patients, you see and feel the frustration when they cannot communicate, especially with family. We had a patient who communicated using a speech generating device provided by the hospital. She was able to communicate that she was experiencing stomach pain. When the medical team assessed her abdomen, it was determined that she needed surgery. Without the ability to communicate, this patient, most likely, would have remained in pain for an extended period and would have gone without treatment for an unnecessary amount of time.

The role communication in fall prevention

The Agency of HealthCare Research and Quality developed a toolkit for hospitals to use to prevent falls (AHRQ 2013a) that identifies access to the nurse call system as a critical component to falls prevention. Many patients cannot independently reach for objects at the bedside, get out of bed, and safely ambulate without assistance. Thus, each bed is equipped with a nurse-call pendant so that patients can summon their nurses, if they need: 1) a urinal/bedpan, 2) their phone, 3) to be repositioned, 4) get out of bed. When the patient cannot reach or activate the pendant, the patient has no way to request an item or assistance getting up. This can precipitate a fall if a patients attempts to independently reach for objects or get out of bed. Such falls can result in fractures, head trauma, an increased length of stay, and more patient suffering.

The role of communication in preventing pulmonary issues

Caring for mechanically ventilated patients involves frequent oral and tracheal suctioning (Sole, Penoyer, Bennett, Bertrand & Talbert, 2011). These patients, who cannot communicate their suctioning needs effectively, could be at a higher risk for ventilator-associated pneumonia or other complications from a mucous plug. Happ et al. (2015) found that over 50% of their mechanically ventilated patients would have benefited from some form of assistance to communicate with the ICU staff.

The role of communication in detecting adverse drug reactions

When patients are administered a new medication or a blood product an adverse reaction is always possibe. To avoid serious consequences, it is essential that patients can promptly report any reaction to the medication or blood product. Blenkinsopp, Wilkie, Wang, and Routledge, (2007) suggested a role for patient report of adverse drug reactions. Patient care protocols require nurses to monitor patients and solicit any report of adverse reactions, so that they can suspend the delivery of the medication or blood product and provide appropriate treatment (Bielefeldt, 2009). As with pain management, treating patients who experience barriers to communication complicates detecting and mitigating adverse reactions.

The role of communication in preventing delirium and patient stress

Because sedation and reduced mobility are also associated with increased risk delirium (Strøm, Martinussen & Toft, 2010; Davidson, Harvey, Bemis-Dougherty, Smith & Hopkins, 2013; Balas, Vasilevskis, Olsen, et al. 2014) and more recently Post-Traumatic Stress Disorder (Parker, et al., 2015) reducing sedation and early mobilization are becoming more common in ICUs (Hopkins, Choong, Zebuhr & Kudchadkar, 2015). As such one can expect that a greater number of ICU patients will require interventions to address both their AT and AAC needs.

Economic Impact of AEs

Given the changes in CMS reimbursement, hospitals now have added incentives to reduce the incidence of AEs. Medicare has also placed increasing emphasis on patient outcomes and satisfaction, leading hospitals to focus more on patient satisfaction and to examine their care delivery models (e.g., communication-related question on the Hospital Consumer Assessment of Healthcare Providers and Systems Survey: HCAHPS; CMMS, 2017). Rodriguez et al. (2016) reported that providing AAC to adult ICU patients decreased frustration and improved patient satisfaction. While it may not be possible to eliminate all risks associated with inpatient communication impairment, a number of hospitals have implemented a range of technologies to improve patient-provider communication (Blackstone et al. 2015).

The Joint Commission’s hospital accreditation standards (JC, 2010) have established that all patients must have access to their preferred mode of communication and that hospitals must address any communication barriers. Similarly, the National Joint Commission (Brady et al., 2016) has established a “Communication Bill of Rights” for individuals with disabilities. The older 2005 ASHA AAC practice guidelines summarized the importance of communication eloquently “communication is the essence of human life and that all people have the right to communicate to the fullest extent possible. No individuals should be denied this right, irrespective of the type and/or severity of communication, linguistic, social, cognitive, motor, sensory, perceptual, and/or other disability(ies) they may present.”

Of all the health professionals working in hospitals, speech-language pathologists have the training and expertise to help facilitate patient–provider communication for individuals experiencing barriers to communication. Thus, SLPs have a critical role in improving patient outcomes and reducing healthcare costs. The low and high-tech Augmentative and Alternative Communication strategies that have been used with individuals facing chronic communication impairments have also been successfully used with hospitalized patients who may experience barriers to communication on a short-term basis (Blackstone, Beukelman & Yorkston, 2015; Hogan, 2017). It is incumbent on speech-language pathologists working with hospitalized patients, in collaboration with nurses and other allied healthcare professionals, to address the unmet communication needs of all patients who face communication barriers.

To better understand the human and financial cost of communication barriers in hospitals, we present recent, national data about preventable adverse event (AE) rates and the costs of treating the AEs. The selected AEs include “never” events like falls and pressure ulcers (CMS, 2008), as well as ventilator associated pneumonias and adverse drug reaction. These AEs currently have unacceptable frequencies of occurrence and associated treatment costs. Furthermore, for these AEs there is the potential to decrease their occurrence and/or severity by addressing barriers to communication.

The tracking of AEs varies greatly; however, hospitals are required to report the frequency of occurrence for each type of AE to the Joint Commission and regulatory agencies. The most up-to-date reports of the Agency for Hospital Research and Quality (AHRQ), and the American Hospital Association (AHA), provide robust overall estimates for rates of occurrence of the selected AEs (AHRQ, 2013b), ICU and non-ICU population sizes (AHA, 2016), and the costs associated with the treatment of each type of AE (AHRQ, 2013b). Table 1 presents the most recently available data on adverse event rates and the costs associated with treating those adverse events. We used the AHRQ report (2013b) of the rate per 1000 admission for each type of AE as well as average cost of treating each type of AE and the AHA report (2016) on U.S. hospital admissions. This analysis generated an estimate of the total annual costs associated with AEs in excess of $29 billion.

Table 1.

Rates of Adverse Events and Associated Costs

Adverse Event Number Average Cost Total Cost
Adverse Drug Reaction 1,427,266 $5,000 $7,136,328,030
Falls 254,995 $7,234 $1,844,636,318
Pressure Ulcer 1,151,021 $17,000 $19,567,351,050
Ventilator Associated Pneumonia 38,958 $21,000 $818,110,062
Open in a new tab

Calculation of Adverse Event Risk Reduction and Cost Savings

Using these national data, it is possible to estimate the reduction in the number of these AEs and the associated costs of treating the AEs.

ReductioninAE=(((TotalPatients)∗(PercentageofAlertPatients))∗(PercentofpatientsfacingcommunicationBarrier)))∗(AE-Rateadjustedforincreasedrisk)ReductioninAEcosts=(ReductioninAE)∗(AverageAEtreatmentcost)

A key component of these calculations is the increased risk associated with barriers to communication. Bartlett et al. (2008) examined the risk factors associated with preventable AEs and found that the odds of experiencing a preventable AE were 3x higher in patients with barriers to communication (i.e., language differences and/or communication impairment) as compared to patients with no communication impairment (Mean 3; 95% CI 1.43–6.27). The adjusted odds ratios were based on analyses that controlled for potential confounders like hospital, admission date, age, sex, admission profile, and comorbidities (Bartlett, 2008). We used the mean odds ratio and boundaries of the confidence interval to calculate potential risk-reduction and cost-savings values for each of the four targeted AEs. A low estimate of risk and cost reduction for each AE reflects the amount that would be saved if the odds of an individual with impaired communication experiencing an AE were the same as those of an individual with no communication impairment (i.e. reduction from 1.43 to 1 odds ratio). The middle estimate reflects the reduction from an odds ratio of 3 to 1 and the high estimate reflects the reduction in the odds ratio of 6.27 to 1.

While Bartlett et al. (2008) have not broken down their increased risk assessment by type of hospital unit, there are many more patients facing barriers to communication in an ICU than a non-ICU environment. ICU patients often have more critical health concerns—frequently accompanied more often by communication difficulties—than non-ICU patients. These difficulties can result from both the inability to independently access the nurse call (Assistive Technology “AT” need) and to use normal modes of oral and/or written communication (Alternative and Augmentative Communication “AAC” need). Therefore, the rates of anticipated AE risk and cost reduction resulting from improving communication need to be calculated separately for ICU and non-ICU patients. Zubow and Hurtig (2013) found that 19% of ICU patients had both an AT and an AAC need; whereas only 1% of non-ICU patients had an AT and an AAC need at any given time. These domain-specific (i.e., ICU vs. non-ICU) rates of impaired communication were used in our calculations to ensure the most robust, conservative risk and cost reduction estimates. Adjusting for an estimated 50% ICU patient sedation rate is also critical to generating accurate estimates. The sedation rate estimate is consistent with data about the communication readiness (53.9%) of mechanically ventilated ICU patients (Happ et al., 2015).

Figure 1 provides an overview of the steps we used to calculate risk and cost reduction.

Figure 1.

Figure 1

Open in a new tab

Overview of steps used to calculate risk and cost reduction for selected AEs.

Results

Patients with an AT or AAC Need

Our estimates for the reduction in number of AEs and corresponding cost reduction values are presented in Table 2. Combining the estimates of each of the AEs yields an annual reduction in AEs of 139,170 cases for ICU patients and 408,736 cases for non-ICU patients, totaling to 547,906 fewer annual AE cases estimated across all patients. This corresponds to a potential annual cost reduction of $1.4 billion for ICU patients and $4.1 billion for non-ICU patients, with an overall potential cost reduction of $5.5 billion dollars across all patients.

Table 2.

Middle estimate of AE and related cost reduction for ICU and non-ICU patients who need AT or AAC.

Adverse Event Estimated Annual Reduction in Number of Cases Estimated Annual Cost Reduction (Millions of Dollars)
Pressure Ulcers ICU 55,771 948
Non-ICU 166,049 2,823
Total 221,820 3,771
Ventilator Associated Pneumonias ICU 1,888 40
Non-ICU N/A N/A
Total 1,888 40
Falls ICU 12,355 89
Non-ICU 36,786 266
Total 49,141 355
Adverse Drug Reactions ICU 69,156 346
Non-ICU 205,901 1,000
Total 275,057 1,346
Open in a new tab

Patients with an AT and AAC Need

Our estimates for the reduction in number of AEs and corresponding cost reduction values are presented in Table 3. Combining the estimates of each of the AEs yields an annual reduction in AEs of 79,091 cases for ICU patients and 44,444 cases for non-ICU patients, totaling to 123,535 fewer annual AE cases estimated across both settings. This corresponded to a potential annual cost reduction of $809 million for ICU patients and $448 million for non-ICU patients, with an overall potential cost reduction of $1.257 billion dollars across all patients.

Table 3.

Middle estimate of AE and related cost reduction for ICU and non-ICU patients who need AT and AAC.

Adverse Event Estimated Annual Reduction in Number of Cases Estimated Annual Cost Reduction(Millions of Dollars)
Pressure Ulcers ICU 31,695 539
Non-ICU 18,055 307
Total 49,750 846
Ventilator Associated Pneumonias ICU 1,073 23
Non-ICU N/A N/A
Total 1,073 23
Falls ICU 7,022 51
Non-ICU 4,000 29
Total 11,022 80
Adverse Drug Reactions ICU 39,302 197
Non-ICU 22,388 112
Total 61,690 309
Open in a new tab

Overall Reduction in AEs for Patients Facing any Barrier to Communication

Combining the estimates for the two communication barrier groups (i.e., AT or AAC and AT and AAC) yields an estimated 671,440 fewer case of our AEs annually as a result of facilitating communication. This corresponds to an estimated $6.8 billion cost reduction annually for the four preventable AEs included in these analyses.

Additional Costs Associated with Adverse Events

Our estimates were based on aggregated national data and must therefore be applied with caution to estimate the potential savings for individual hospitals. The CRICO Strategies (2016) identified both provider-provider and patient-provider communication breakdowns as factors contributing to added malpractice risks. The cost of malpractice claims associated with AEs is not trivial and mitigating strategies include involving patients and family members (Bennett et al, 2000). The calculations of costs we have presented here did not include malpractice awards that also contribute to the total social costs associated with AEs (Goodman et al., 2011).

Discussion

Communication and Adverse Event Reduction

Good patient–provider communication is an ethical imperative and critical to patient well-being. It also has the potential of providing significant healthcare savings by decreasing the risk of preventable AEs. The results of our calculations demonstrate the potential return-on-investment for facilitating communication and reducing the frequency of preventable pressure ulcers, ventilator-associated pneumonias, falls, and adverse drug events. Specifically, the data suggest a potential cost reduction of $6.8 billion annually. Communication interventions might not bring the risk of these AEs down to that of individuals who do not experience any barriers to patient-provider communication. However, even the most conservative estimates (i.e., cutting the added risk in half) suggest that patient suffering could be reduced and AE-associated costs could be decreased by an estimated $3.4 billion annually. This potential improvement of patient outcomes and reduction of health care costs underpins the argument for the importance of speech-language pathology services focused on supporting patient–provider communication in hospitalized patients.

Clinical Implications

The health care community has begun to recognize the importance of better patient–provider communication. The Joint Commission’s standards on patient communication (JC, 2010) mandate that hospitals must find ways to enable their patients to summon a nurse or another care provider and to effectively communicate with the provider they summoned. Unfortunately, many hospitalized patients continue to face barriers to communicating with their care providers. The barriers to communication are not limited to those based on physical limitations, which preclude using speech and/or access to the standard nurse call. Language differences can also inhibit communication and must be considered when addressing communication needs (Cohen et al., 2005; Bartlett et al., 2008). As reducing sedation and early mobilization are becoming more common in ICUs (Hopkins et al., 2015), one can expect that a greater number of ICU patients will be conscious and require interventions to address both their AT and AAC needs. Speech-language pathologists are best positioned to advocate for all hospitalized patients with complex communication needs. While a large portion of the caseload of hospital-based SLPs has focused on the assessment of swallowing, addressing the broad communication needs of hospitalized patients is within the scope of practice (ASHA, 2016). The range of strategies and tools that are part of best practices in AAC are the very ones that can be used to address patients’ complex communication needs ranging from access to the nurse call system to being able to effectively communicate with their healthcare providers and family (ASHA, n.d.). Examples of implementing AAC strategies with adult and pediatric patients in acute care settings can be found in Hurtig, Nilsen, Happ and Blackstone (2015) and Costello, Santiago and Blackstone (2015). SLPs are primed to take a leadership role and work with hospital administrators to foster a culture of communication embraced by all hospital employees and advocate for resources to support patient-provider communication for all. Effective AAC interventions require more than just making technology available. SLPs must assess the communication barriers faced by patients and provide a range of tools that can be implemented quickly at the bedside. The SLPs will also need to provide both the patients and all their communication partners with training to ensure that the AAC strategies are implemented with fidelity. School-based SLP works with teachers and family members to ensure an effective implementation of a child’s AAC strategies in the classroom and at home; hospital-based SLPs must work with the entire healthcare team treating the hospitalized patients to eliminate the communication barriers that can contribute to adverse outcomes, lower patient satisfaction, and increased staff stress. There is no single tool or strategy that can address the needs of all patients. SLPs and allied healthcare professionals (e.g. occupational therapists and physical therapists) must work together to tailor solutions that meet the needs of each individual patient and to adapt those solutions as the patient’s condition changes. While some SLPs may not consider meeting the needs of patients with limited English proficiency as part of their scope of practice, the use of AAC tools, like bilingual communication boards and SGDs, can provide a critical tool to address the communication barriers faced by patients who have limited English proficiency (Hurtig, Czerniejewski, Bohnenkamp, & Na, 2013).

Institutional commitment is imperative when establishing a ‘culture of communication’ and optimizing patient-provider communication for all patients. The SLP plays a critical role both in terms of advocating for patients’ communication rights and in providing professional services to address the patients’ complex communication needs. The success achieved by the SLPs in providing patients with the means to summon help and to communicate with their caregivers, will bring the entire healthcare team to appreciate the value of patient-provider communication. The ability to express one’s wants and needs, to engage with friends, family, and caregivers, and to participate in decision-making processes is a basic human right that is most important during times of a medical crisis. The data demonstrate the potential human, ethical, and financial benefits of meeting every patient’s communication needs. While there are costs associated with meeting the AT and AAC needs of patients, the estimates of AE reductions and cost savings demonstrate a large potential return on investment. The cost of reusable communication boards and assistive devices would be considerably lower than the costs associated with preventable AEs. This fact should make it easier for SLPs to make the case to hospital administrators to provide the necessary support in terms of staff, equipment, and materials. Building a culture of communication can help mitigate the adverse effects resulting from communication barriers.

Acknowledgments

We would like to acknowledge the support of the University of Iowa Hospitals and Clinics nursing staff with particular thanks to Michele Wagner and Karen Stenger. We also thank Sarah Blackstone for advice on the preparation of this manuscript and Sarah Marshall at the University of Wisconsin-Madison for discussion of clinical cases. Additionally, Research reported in this paper was supported in part by the National Institute of Nursing Research of the National Institutes of Health under Award Number R43NR016406 & R44NR016406. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Disclosures

This research was supported in part by NIH/NINR SBIR grants (R43NR016406 & R44NR016406) to Iowa Adaptive Technologies, Inc. (dba Voxello®). Dr. Hurtig is the Vice-President and Chief Scientific Officer of Voxello®. Dr. Berkowitz served as the Director of Product Development at Voxello®. Dr. Alper is a paid consultant of Voxello®. The publication of study results is not contingent upon the sponsor’s review or censorship of the manuscript.

Contributor Information

Richard R. Hurtig, University of Iowa

Rebecca M. Alper, Temple University.

Benjamin Berkowitz, Stanford University

References

  1. Agency for Healthcare Research and Quality (AHRQ) Preventing Falls in Hospitals A Toolkit for Improving Quality of Care. Rockville, MD: 2013a. Retrieved from: https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/index.html. [Google Scholar]
  2. Agency for Healthcare Research and Quality (AHRQ) Annual hospital-acquired condition rate and estimates of cost savings and deaths verted from 2010 to 2013. Rockville, MD: 2013b. Retrieved from: https://www.ahrq.gov/professionals/quality-patient-safety/pfp/index.html. [Google Scholar]
  3. American Hospital Association (AHA) Fast facts on US hospitals. Chicago, IL: 2016. Retrieved from: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. [Google Scholar]
  4. American Speech-Language-Hearing Association. Augmentative and Alternative Communication (Practice Portal) n.d Retrieved March, 21, 2018, from www.asha.org/Practice-Portal/Professional-Issues/Augmentative-and-Alternative-Communication/
  5. American Speech-Language-Hearing Association. Scope of practice in speech-language pathology [Scope of Practice] 2016 Available from www.asha.org/policy/
  6. Balandin S, Hemsley B, Sigafoos J, Green V. Communicating with nurses: The Experiences of 10 adults with cerebral palsy and complex communication needs. Applied Nursing Research. 2007;20(2):56–62. doi: 10.1016/j.apnr.2006.03.001. [DOI] [PubMed] [Google Scholar]
  7. Balas MC, Vasilevskis EE, Olsen KM, et al. Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Critical Care Medicine. 2014;42(5):1024–1036. doi: 10.1097/CCM.0000000000000129. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Bartlett G, Blais R, Tamblyn R, Clermont RJ, MacGibbon B. Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Canadian Medical Association Journal. 2008;178(2):1555–1562. doi: 10.1503/cmaj.070690. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Bielefeldt S. The rules of transfusion: best practices for blood product administration. American Nurse Today. 2009;4(2):27–30. [Google Scholar]
  10. Bennett RG, O'Sullivan J, DeVito EM, Remsburg R. The increasing medical malpractice risk related to pressure ulcers in the United States. Journal of the American Geriatrics Society. 2000;48(1):73–81. doi: 10.1111/j.1532-5415.2000.tb03033.x. [DOI] [PubMed] [Google Scholar]
  11. Blackstone S, Beukelman D, Yorkston K. Patient provider communication in healthcare settings: Roles for speech-language pathologists and other professionals. San Diego, California: Plural Publishing, Inc; 2015. [Google Scholar]
  12. Blackstone S, Garrett K, Hasselkus A. New hospital standards will improve communication: Accreditation guidelines address language, culture, vulnerability, and health literacy. The ASHA Leader. 2011;16(1):24–25. doi: 10.1044/leader.OTP.16012011.24. [DOI] [Google Scholar]
  13. Blackstone S, Pressman H. Patient communication in health care settings: new opportunities for augmentative and alternative communication. Augmentative and Alternative Communication. 2016;32(1):69–79. doi: 10.3109/07434618.2015.1125947. [DOI] [PubMed] [Google Scholar]
  14. Blackstone SW, Ruschke K, Wilson-Stronks A, Lee C. Converging communication vulnerabilities in health care: An emerging role for speech-language pathologists and audiologists. Perspectives on Culturally and Linguistically Diverse Populations. 2011;18(1):3–11. [Google Scholar]
  15. Blenkinsopp A, Wilkie P, Wang M, Routledge PA. Patient reporting of suspected adverse drug reactions: a review of published literature and international experience. Br J Clin Pharmacol. 2007;63(2):148–156. doi: 10.1111/j.1365-2125.2006.02746.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Brady NC, Bruce S, Goldman A, Erickson K, Mineo B, Ogletree BT, Paul D, Romski M, Sevcik R, Siegel E, Schoonover J, Snell M, Sylvester L, Wilkinson K. Communication services and supports for individuals with severe disabilities: Guidance for assessment and intervention. American Journal on Intellectual and Developmental Disabilities. 2016;121(2):121–138. doi: 10.1352/1944-7558-121.2.121. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Campbell JN American Pain Society. Presidential address (1996) Pain Forum. 1995;5:85–88. doi: 10.1016/S1082-3174(96)80076-6. [DOI] [Google Scholar]
  18. Centers for Medicare and Medicaid Services. Hospital-acquired conditions. Baltimore, MD: 2008. Retrieved from: http://www.cms.hhs.gov/HospitalAcqCond/06_HospitalAcquired_Conditions.asp#TopOfPage. [Google Scholar]
  19. Centers for Medicare and Medicaid Services. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Baltimore, MD: 2017. Retrieved from: http://www.hcahpsonline.org. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, et al. “Global Trigger Tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs. 2001;30(4):581–589. doi: 10.1377/hlthaff.2011.0190. [DOI] [PubMed] [Google Scholar]
  21. Cohen AL, Rivara F, Marcuse EK, McPhillips H, Davis R. Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics. 2005;116(3):575–579. doi: 10.1542/peds.2005-0521. [DOI] [PubMed] [Google Scholar]
  22. Costello JM. AAC intervention in the intensive care unit: The Children’s Hospital Boston Model. Augmentative and Alternative Communication. 2000;16:137–153. [Google Scholar]
  23. Costello JM, Santiago RM, Blackstone SW. Pediatric Acute and Intensive Care in Hospitals. In: Blackstone S, Beukelman D, Yorkston K, editors. Patient Provider Communication in Healthcare Settings: Roles for Speech-Language Pathologists and Other Professionals. San Diego, California: Plural Publishing Inc; 2015. [Google Scholar]
  24. CRICO Strategies. Malpractice Risks in Communication Failures: 2015 Annual Benchmarking Report. Cambridge, MA: 2016. Retrieved from: https://www.rmf.harvard.edu/cbsreport. [Google Scholar]
  25. Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: The contribution of mechanical ventilation. Critical Care Medicine. 2005;33(6):1266–1271. doi: 10.1097/01.ccm.0000164543.14619.00. [DOI] [PubMed] [Google Scholar]
  26. David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS. Economic measurement of medical errors using a hospital claims database. Value in Health. 2013;16:305–310. doi: 10.1016/j.jval.2012.11.010. [DOI] [PubMed] [Google Scholar]
  27. Davidson JE, Harvey MA, Bemis-Dougherty A, Smith JM, Hopkins RO. Implementation of the pain, agitation, and delirium clinical practice guidelines and promoting patient mobility to prevent post-intensive care syndrome. Critical Care Medicine. 2013;41:S136–S145. doi: 10.1097/CCM.0b013e3182a24105. [DOI] [PubMed] [Google Scholar]
  28. Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand public hospitals I: occurrence and impact. New Zealand Medical Journal. 2002;115(1167):1–9. [PubMed] [Google Scholar]
  29. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Quality & Safety in Health Care. 2008;17:216–223. doi: 10.1136/qshc.2007.023622. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: A pilot study. International Journal for Quality in Health Care Advance Access. 2007:1–8. doi: 10.1093/intqhc/mzl069. [DOI] [PubMed] [Google Scholar]
  31. Dowden P, Honsinger M, Beukelman D. Serving non-speaking patients in acute care settings: An intervention approach. Augmentative and Alternative Communication. 1986;2:25–32. doi: 10.1080/07434618612331273840. [DOI] [Google Scholar]
  32. Downey D, Hurtig R. Rethinking the use of AAC in acute care settings. Perspectives on AAC. 2006;15(4):3–8. [Google Scholar]
  33. Goodman JC, Villareal P, Jones B. The social cost of adverse medical events, and what we can do about it. Health Affairs. 2011;30(4):590–595. doi: 10.1377/hlthaff.2010.1256. [DOI] [PubMed] [Google Scholar]
  34. Happ MB, Seaman JB, Nilsen ML, et al. The number of mechanically ventilated ICU patients meeting communication criteria. Heart & Lung. 2015;44:45–49. doi: 10.1016/j.hrtlng.2014.08.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Hemsley B, Balandin S, Togher L. Narrative analysis of the hospital experience for older parents of people who cannot speak. Journal of Aging Studies. 2007;21:239–254. doi: 10.1177/1049732311415289. [DOI] [Google Scholar]
  36. Hemsley B, Balandin S, Worrall L. The 'Big 5' and beyond: nurses, paid carers, and adults with developmental disability discuss communication needs in hospital. Applied Nursing Research. 2011;24(1):e51–e58. doi: 10.1016/j.apnr.2010.09.001. [DOI] [PubMed] [Google Scholar]
  37. Hoffman JM, Yorkston KM, Shumway-Cook A, Ciol MA, Dudgeon BJ, Chan L. Effect of communication disability on satisfaction with health care: A survey of Medicare beneficiaries. American Journal of Speech-Language Pathology. 2005;14(3):221–228. doi: 10.1044/1058-0360(2005/022). [DOI] [PubMed] [Google Scholar]
  38. Holden K. No longer voiceless in the ICU. The ASHA Leader. 2017;22:40–41. doi: 10.1044/leader.OTP.22122017.40. [DOI] [Google Scholar]
  39. Hopkins RO, Choong K, Zebuhr CA, Kudchadkar SR. Transforming PICU culture to facilitate early rehabilitation. Journal of pediatric intensive care. 2015;4(04):204–211. doi: 10.1055/s-0035-1563547. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Hurtig R, Czerniejewski E, Bohnenkamp L, Na J. Meeting the Needs of Limited English Proficiency Patients. Perspectives on Augmentative and Alternative Communication. 2013;22(2):91–101. [Google Scholar]
  41. Hurtig RR, Downey DA. Augmentative and alternative communication in acute and critical care settings. San Diego, California: Plural Publishing. Inc; 2009. [Google Scholar]
  42. Hurtig R, Nilsen M, Happ EB, Blackstone S. Acute Care/Hospital/ICU-Adults. In: Blackstone S, Beukelman D, Yorkston K, editors. Patient Provider Communication in Healthcare Settings: Roles for Speech-Language Pathologists and Other Professionals. San Diego, California: Plural Publishing Inc; 2015. [Google Scholar]
  43. James JT. A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety. 2013;9:122–128. doi: 10.1097/PTS.0b013e3182948a69. [DOI] [PubMed] [Google Scholar]
  44. Kohn LT, Corrigan JM, Donaldson MS. To err is human: Building a safer health system, A report of the Committee on Quality of Health Care in America. Washington, D.C: National Academic Press; 2000. [PubMed] [Google Scholar]
  45. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine. 2010;363:2124–2134. doi: 10.1056/NEJMsa1004404. [DOI] [PubMed] [Google Scholar]
  46. Levinson DR. Report No. OEI-06-09-00090. Department of Health and Human Services Office of Inspector General; 2010. Adverse events in hospitals: National incidence among Medicare beneficiaries. [Google Scholar]
  47. Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. Journal of the Royal Society of Medicine. 2001;94:322–330. doi: 10.1177/014107680109400702. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Parker AM, Sricharoenchai T, Raparla S, Schneck KW, Bienvenu OJ, Needham DM. Posttraumatic stress disorder in critical illness survivors: a meta-analysis. Critical care medicine. 2015;43(5):1121–1129. doi: 10.1097/CCM.0000000000000882. [DOI] [PubMed] [Google Scholar]
  49. Patak L, Gawlinski A, Fung NI, Doering L, Berg J. Patients’ report of health care practitioner interventions that are related to communication during mechanical ventilation. Heart & Lung. 2004;33(5):308–320. doi: 10.1016/j.hrtlng.2004.02.002. [DOI] [PubMed] [Google Scholar]
  50. Rodriguez CS, Rowe M, Thomas L, Shuster J, Koeppel B, Cairns P. Enhancing the communication of suddenly speechless critical care patients. Am J Crit Care. 2016;25(3):e40–e46. doi: 10.4037/ajcc2016217. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Sole ML, Penoyer DA, Bennett M, Bertrand J, Talbert S. Oropharyngeal secretion volume in intubated patients: the importance of oral suctioning. Am J Crit Care. 2011;20(6):e141–e145. doi: 10.4037/ajcc2011178. [DOI] [PubMed] [Google Scholar]
  52. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: A randomised trial. Lancet. 2010;375:475–480. doi: 10.1016/S0140-6736(09)62072-9. [DOI] [PubMed] [Google Scholar]
  53. The Joint Commission. Advancing effective communication, cultural competence, and patient-and family-centered care: A roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission; 2010. [Google Scholar]
  54. The Joint Commission. Summary data of sentinel events reviewed by The Joint Commission. Oakbrook Terrace, IL: The Joint Commission; 2011. [Google Scholar]
  55. Wu AW, Boyle DJ, Wallace G, Mazor KM. Disclosure of adverse events in the United States and Canada: an update, and a proposed framework for improvement. Journal of Public Health Research. 2013;2(32):186–193. doi: 10.4081/jphr.2013.e32. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Wunsch H, Linde-Zwirble WT, Angus DC, Hartman ME, Milbrandt EB, Kahn JM. The epidemiology of mechanical ventilation use in the United States. Critical Care Medicine. 2010;38(10):1947–1953. doi: 10.1097/CCM.0b013e3181ef4460. [DOI] [PubMed] [Google Scholar]
  57. Zubow L, Hurtig R. A demographic study of AAC/AT needs in hospitalized patients. Perspectives on Augmentative and Alternative Communication. 2013;22(2):79–90. doi: 10.1044/aac22.2.79. [DOI] [Google Scholar]

RESOURCES