ICU Delirium Prevention for Patients Who Speak a Language Other Than English

Abstract

Background: Delirium acquired in the intensive care unit, ICU delirium, is a common neurologic sequela of critical illness, affecting up to 70% of patients. The incidence and duration of ICU delirium is associated with increased mortality, increased hospital length of stay, and increased healthcare costs. After hospital discharge, having experienced ICU delirium is independently associated with long-term cognitive impairment and post-traumatic stress disorder. ICU delirium prevention depends on effective communication to complete complex interventions. Due to a language barrier adding to communication challenges, critically ill patients who speak a language other than English (LOE) may be at higher risk for ICU delirium. Gaps in our knowledge perpetuate inequitable access to evidence-based interventions and disparities in outcomes for LOE patients. Purpose: This dissertation aims to examine how language barriers experienced by LOE critically ill patients influence adherence to ICU delirium prevention interventions. Methods: The first study (Chapter 2) describes and compares ABCDEF bundle fidelity for critically ill LOE patients to English-speaking patients by performing secondary data analysis of the Society of Critical Care Medicine (SCCM) ICU Liberation Dataset of ABCDEF bundle completion. The second study (Chapter 3) describes facilitators and barriers to implementing delirium interventions among critically ill LOE patients using qualitative thematic analysis. The third study (Chapter 4) assesses the acceptability, feasibility, and appropriateness of the VidaTalk™ application as an implementation strategy to increase the reach of the ABCDEF bundle to LOE ICU patients using convergent a mixed-methods study design. Results: In Chapter 2, We found that the odds of adherence to the A, E, and F elements were statistically significantly higher for LOE patients compared to English speaking patients, while the odds of adherence to the C and D elements were significantly lower for LOE patients compared to English-speaking patients. Additionally, LOE patients had a longer length of stay, longer length of mechanical ventilation, and higher odds of mortality compared to English-speaking patients. These findings indicate a disparity in the ABCDEF bundle those results in worse healthcare outcomes for LOE patients. In Chapter 3, The analysis revealed barriers on the institutional, unit, and individual levels. The institutional level barriers included limited access to interpreter devices, technological issues with the interpreter devices, and communication lags during interpretation. Unit level barriers included time constraints due to staffing and unit culture. Individual barriers included biases reducing use of interpreters and taking shortcuts, healthcare worker inexperience, lack of knowledge regarding the ABCDEF bundle and cultural humility. The facilitators on the institutional level included the resources and training provided to improve cultural humility and interpretation. The unit level facilitators include adequate staffing, easy access to interpreters, and high expectations of adherence to ABCDEF bundle elements. Individual facilitators were experienced health care workers (HCWs) who had knowledge of the benefits of the ABCDEF bundle elements and therefore prioritized them for patients regardless of language. In this chapter, we highlight major challenges to communication with LOE patients experience by HCWs and LOE ICU survivors alike. These challenges contribute to reduce quality and adherence to the ABCDEF bundle for LOE patients. In Chapter 4, the VidaTalkTM device was found to be acceptable, feasible, and appropriate for use with critically ill LOE patients. Healthcare workers liked the device because it was easy to use, enabled fast basic communication, empowered patients to express their needs, and had many preset phrases that were targeted toward the ABCDEF bundle elements. However, HCWs were concerned that patients who were already delirious would not be able to use the device. They also wanted more pre-set caregiver responses, categorized by bundle element, that would enable them to easily speak back to the patient. Conclusion: LOE patients experience health disparities in care and outcomes in the intensive care unit. The barriers prevent HCWs from being able to implement ABCDEF bundle measures with fidelity. The facilitators address the barriers, but do not overcome them entirely. Future research on generating interventions to enhance effective communication at the beside between LOE patients and English-speaking HCWs is necessary.