AAC Implementation in Acute Care

When we discuss AAC, we often talk about young, emerging communicators. AAC is often used to support language development in children with developmental disabilities. Another exciting area of AAC is supporting communication in those with acquired conditions.

Currently, I am a speech language pathologist working with adults in the acute care setting. The term “acute care” refers to short-term treatment for an urgent medical condition or severe illness. For example, a person who has been in a car accident may be treated at a hospital for life-threatening injuries. The services they receive in the hospital are considered acute care. Once medically stable, the patient may go to a rehabilitation facility. Depending on their needs, some patients may also return home. At home they will follow up with medical providers by appointment. These follow-up services would no longer be considered acute care. For this discussion, the “acute care setting” refers to medical care provided in a hospital.

As an SLP working in acute care, I see a lot of patients who can benefit from some form of AAC. For example, a patient with a stroke may have difficulty expressing their needs or speaking clearly. A patient who needs a ventilator may not be able to speak and thus needs alternative forms of communication during acute illness. A patient with a traumatic brain injury may experience changes in their cognition that affect how they engage with others.

In the acute setting, high-tech devices often aren’t available for everyone. Patients are only seen for a brief period of time in this setting. Furthermore, many patients have rapidly evolving conditions. This makes AAC assessment for long-term needs a moving target. As a result, AAC interventions often rely on no-tech or light-tech interventions. They focus on meeting short-term communication needs. There are some exceptions. For example, a patient’s smartphone or tablet may be used to support communication in some cases.

Each patient has unique needs and strengths. AAC resources can be limited. So, some creativity may be necessary to develop individualized communication supports. Considerations when selecting appropriate AAC interventions may include:

• Access: Consider vision, hearing, sensorimotor deficits, and cognition
• Vocabulary: Setting-specific vocabulary is crucial so a patient can engage in their medical care
• Feasibility: It may not be realistic to put AAC in place that is too complex
• Training and education: Implementing AAC requires training the patient, family members, and staff

A few examples of AAC I’ve utilized in my practice include:

• Communication boards – With setting-specific vocabulary and individualized when possible
• Writing implements – Paper/pen, whiteboard/markers, etc.
• Yes/no cards and picture cards – To provide choices for light-tech eye gaze access. May also be used to provide larger symbols for those with vision or motor deficits.
• Switches – Either for partner-assisted scanning or with a single recorded message. Recorded phrases such as “I need help” or “Please get my communication board’ may be useful.
• Capitalizing on non-verbal communication – Gestures, head nods, facial expressions
• Text-to-speech software on a patient’s personal device

As a case example, I was once working with a patient who had dementia and a history of stroke. She had now experienced another stroke. This patient was not speaking and now had weakness in both arms that affected her ability to access many forms of AAC. I tried using a communication board but was having trouble establishing a reliable access method. I tried asking simple yes/no questions, but the patient’s nonverbal responses (such as head nods) were inconsistent. So, I decided to turn to low-tech yes/no cards. She quickly took to using the yes / no cards by directing her eye gaze at her response. She was soon communicating with eye gaze from a choice of two – whether that was with yes/no cards or tangible objects.

In another case, I worked with a patient with a degenerative neurologic condition called progressive supranuclear palsy. His speech was very quiet and difficult to understand. He was also predominantly Spanish-speaking. This created several communication barriers even with a Spanish-English interpreter present. We were able to implement a switch with the phrase “I need help” so he could get the attention of staff when needed. We also placed signs in his room stating that he needed his communication board. We utilized a communication board with picture symbols. The patient could choose icons by pointing with his right hand. This allowed him to communicate his needs, when he was in pain, and more. He could use his verbal speech as much as possible with strategies to improve vocal loudness. But we also had AAC in place that he and staff could use to repair communication breakdowns.

I’ve had the privilege of witnessing great successes with AAC for many patients in the acute care setting. However, there are several barriers to implementation and carryover to keep in mind. These may include:

• Rapid day-to-day changes in patients’ medical and cognitive status. A patient’s needs may change from one day to the next.
• Inability to offer thorough AAC training to family / caregivers and medical staff
• Time constraints impacting the ability to create individualized AAC supports
• Ensuring consistent access to supports that are available

While there may be barriers, implementing AAC in acute care is possible. It is also necessary to ensure that patients can make choices in their medical care. It may take some extra work on our part as speech-language pathologists, and it won’t always be easy. But with the right tools, we can ensure that all individuals can communicate, even in difficult situations.