Enhancing Communication in Critical Care: The Virtual Way

A Critical Need for Communication

In the urgency of a critical care setting, communication is a key—but often overlooked—factor in both the patient experience and the effectiveness of care. In this setting, virtual care solutions can make a tremendous positive difference. 

Critical care refers to the treatment patients receive in intensive care units (ICUs). All large hospitals have ICUs that house patients whose condition is life-threatening or unstable. Critical care is synonymous with intensive care, where patients receive comprehensive round-the-clock care to stabilize and manage perilous conditions.

Admission to the ICU for critical care is reserved for patients who have one or more impaired organs, or who require respiratory support. Directors of critical care and ICU directors in health systems are responsible for managing the patient experience in such settings.

When done right, communication in a critical care setting improves patient outcomes, boosts psychological recovery, and increases the satisfaction of both the family and the patient. These benefits have been clear in connecting ICU patients to their families during the COVID lockdown.

Communication Challenges in the ICU

Communication in critical care settings poses a range of challenges, including language comprehension, cultural differences, and dealing with the stress of the situation.

Indeed, half of all family members of ICU patients report communication with physicians to be inadequate. Almost three-quarters report confusion over what is communicated to them.

One of the unique challenges of communication in a critical care setting is that the patients themselves are often unable to communicate because they are sedated or intubated. Nearly 95% cannot give consent to invasive therapies, such as being put on life support or having an operation performed. Thus, it is up to the healthcare team to communicate among themselves, and with the relatives of patients.

Critical Care Setting
Critical Care is one of the most challenging healthcare settings. Communication is crucial.

Where to Start?

If you’re interested in putting together a communication strategy for your ICU, it’s easy to get lost in the weeds. There is a lot of medical advice out there about talking to ventilated patients. We won’t get into that, but here’s a great algorithm for what to do in such a situation.

Rather, we’ll focus on the other two communication scenarios that are more frequent in such a setting. These are communication among healthcare professionals and with the caregivers and families of patients.

A successful communications model for critical care includes policies to improve communication on both these fronts. And in both cases, virtual care can facilitate stronger communication, whether through sharing notes, scheduling appointments, or providing greater accessibility.

Adaptive Communication

Adaptive communication means shifting “modes” to communicate effectively with different people in different situations.

As the objective is to get the patient out of the ICU as soon as possible, it is easy to rush communications. But clear and effective communication is in fact key to reducing the length of an ICU stay, while promoting the best outcomes.

During a patient’s stay in the ICU, team leaders need to apply a number of different communication modes. They must:

  • Direct during a crisis
  • Listen to arguments and handle disagreements during inter-professional discussions
  • Exercise patience when talking to an intubated patient
  • Convey information clearly when discussing with the family
  • Be realistic when explaining the prognosis
  • Be honest when providing updates
  • Be compassionate if negotiating the withdrawal of treatment plans

That’s a lot of different communication skills, all for the same case!

Thus, an adaptive mindset is crucial. Leaders can best act according to the situation if they have built the temperament for it through training. But as a starter, they can simply recognize that they may have to adapt their tone and behavior throughout the care process.

Adaptive Communication

Inter-professional Communication

In ICUs, 37% of errors are due to poor communication between physicians and nurses.

Interventions available to reduce such errors include the daily goal sheet and bedside dashboards. The daily goal sheet includes tasks to be completed, the care plan, and the communication agenda for the day. Bedside dashboards include progress notes and document the status of daily goals. Door communication cards, posted on the door of the patient’s room, are used for the same purpose but are not as effective as the other two measures.

If you’re designing a communication strategy, make sure you include at least one of these measures—and the more, the better. Many templates are available to document communication and close the communication loop between physicians and nurses. If you have a virtual care platform in place, you can create such protocols and include it as a part of your intensive care pathway.

In addition to following strong documentation practices, all staff must be trained at a group level if the organization is serious about improving the quality of interactions and aligning goals between physicians and nurses. Team training is better than individual training, as it better replicates real-world scenarios, where healthcare professionals have to interact with each other.

Multidisciplinary team training increases trust and respect of each other’s role in healthcare. Multidisciplinary shift evaluations—where at the end of the shift, all staff gather to discuss what they did right and what needed to improve—increase team accountability. It is possible to conduct such meetings virtually, using a virtual care platform that allows members of the care team to collaborate on a patient’s case.

Family & Caregiver Communication

During the distressing time of a family member’s illness, family meetings are an essential aspect of healthcare professionals’ responsibilities. Many experts think that conducting family meetings should be treated as a procedure, with some even saying that it requires no less skill than an operation.

While other medical aspects in critical care are proceduralized, such as sedating a patient or inserting catheters, the same level of training is not provided for communicating with the family. Learning about communications both via formal training and also by observing others leading the family meetings can improve the quality of family communication. To proceduralize the family visit, it can be included as an event in a patient’s intensive care pathway.

Non-verbal communication is very important in critical care. Nurses must not hesitate to provide physical comfort, such as consoling the caregivers and families when a prognosis is not looking good. They can also find themselves on the receiving end of backlash caused by the fear and anxiety of the patient’s family or caregivers. Through training and direct experience, staff is expected to find a balance between maintaining boundaries and recognizing the family’s needs.

Finally, proper scheduling is important. Enough time must be allowed for each family meeting that the process is not rushed. With digital scheduling, visits can more easily be planned and spaced out in advance.

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COPD Education – Onboarding

Objective

To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Actors
Patient, Educator (Nurse, RT, the Physician could also be the educator)

Timelines
One 60-90 min session with the Educator

Description
  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
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COPD Education – Continuous Maintenance

Objective 

To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

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  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
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COPD Respiratory Status Follow-up

Objective

Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

Description
  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
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  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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