Vidatalk Communication Application: Usability, Acceptability and Efficacy Study

Ohio State University147 enrolled

Overview

This Phase II Small Business Technology Transfer Research (STTR) will deliver a comprehensive patient communication solution for communication-impaired patients in the intensive care unit that may help decrease days in delirium, decrease anxiety levels, and reduce sedation exposure which are proximal outcomes known to be associated with decreased mechanical ventilation days, shorter lengths of ICU and hospital stay, and lower healthcare cost. The primary goal of this Phase II STTR proposal is to further define user requirements and product specifications and develop a prototype of VidaTalk, a patient-centric, touch pad communication software, to provide mechanically ventilated (MV) patients an evidence-based solution for effectively communicating their needs to care providers and family. A secondary goal is to test the impact of the VidaTalk on clinical outcomes. This study will use mixed methods including observations and interaction with hospitalized patients as they use the VidaTalk tool, surveys and medical record data extraction, product evaluation and brief interview, satisfaction surveys with family members of ICU patients, and focus groups with Registered Nurses. Specific Aim 1. Develop a commercial prototype of VidaTalk that will include multilingual and customizable messages, compatibility with tablet devices, picture symbols, and integration with mobile communication devices. Specific Aim 2. Demonstrate usability with iterative user assessment testing in a clinical setting. Specific Aim 3. Test the clinical efficacy of VidaTalk via android application with MV patients by examining qualitative and quantitative endpoints in a clinical setting. Aim 3 hypothesis: MV patients using VidaTalk will demonstrate significant reductions in patient-reported communication difficulty and frustration, anxiety, sedation exposure, delirium/coma-free days, and improved patient and family satisfaction with ICU care compared to MV patients receiving attention-control (i.e., tablets with health education application). Specific Aim 4. Validation of electronic visual analogue scale, versus current standard paper scale. Specific Aim 5 a, b and c. Test the effect of the communication tablet (VidaTalk) on psychological symptoms in family caregivers.

Treatment-induced communication impairment is one of the most common and distressful symptoms to mechanically ventilated intensive care unit (ICU) patients and is associated with anxiety, panic, anger, frustration, sleeplessness, and distress.This Phase II Small Business Technology Transfer Research (STTR) will deliver a comprehensive solution that may help decrease days in delirium, decrease anxiety levels, and reduce sedation exposure which are proximal outcomes known to be associated with decreased mechanical ventilation days, shorter lengths of ICU and hospital stay, and lower healthcare cost. The primary goal of this Phase II STTR proposal is to further define user requirements and product specifications and develop a prototype of VidaTalk (previously TouchTalk), a patient-centric, touch pad communication software, to provide mechanically ventilated (MV) patients an evidence-based solution for effectively communicating their needs to care providers and family. A secondary goal is to test the impact of the VidaTalk on clinical outcomes (e.g., patient-reported communication difficulty and frustration, anxiety, sedation exposure, delirium/coma-free days, and improved patient and family satisfaction with ICU care). This study will use mixed methods including observations and interaction with hospitalized patients as they use the VidaTalk communication tool, surveys and medical record data extraction, product evaluation and brief interview, satisfaction survey with family members of ICU patients and focus groups with Registered Nurses. Our Phase I STTR successfully delivered a beta prototype that met technical feasibility criteria; however, additional requirements emerged as a common theme from user testing and market analysis. The current study will meet the identified needs for VidaTalk to operate on android devices, be customizable to patients' unique message needs, use pictures symbols for communication, and be able to route patient requests to providers who are not present at the bedside. Specific Aim 1 (Preliminary to Clinical Trial). Develop a commercial prototype of VidaTalk that will include multilingual and customizable messages, compatibility with tablet devices, picture symbols, and integration with mobile communication devices. Specific Aim 2 (Preliminary to Clinical Trial). Demonstrate usability with iterative user assessment testing in a clinical setting. Specific Aim 3. Test the clinical efficacy of VidaTalk via android application with MV patients by examining qualitative and quantitative endpoints in a clinical setting. Aim 3 hypothesis: MV patients using VidaTalk will demonstrate notable reductions in patient-reported frustration and communication difficulty, anxiety, sedation exposure, delirium/coma-free days, and improved patient and family satisfaction with ICU care compared to MV patients receiving attention-control. Specific Aim 4. Validation of electronic visual analogue scale, versus current standard paper scale. Specific Aim 5. Test the effect of the communication tablet (VidaTalk) on psychological symptoms in family caregivers.

Interventions

Aim 1 - VidaTalk - post-extubationOTHER

Observation of task completion will be made while patients complete a series of messages using the VidaTalk app: * Tell me you are tired * Tell me you are having pain * Rate this pain * Tell me there is pain in your back * Tell me your pain is sharp * Ask to see the doctor * Write your favorite color by drawing with your finger * Type "How are you?" Patients will also complete a 1-item difficulty rating and a 3-item After-Scenario Questionnaire (ASQ) after each task. Patients will also be asked to (a) comment on the customization of the app and make suggestions; (b) rate the extent to which they would use the device if they were an ICU patient and unable to speak. Group 1 only: Patients will be asked about their preferences for customizing the VidaTalk app.

Aim 2 - VidaTalk - intubatedOTHER

Usability testing prior to clinical trial. The company will have performed further iterative design assessments and engineered a Vidatalk tablet application prototype for a field-test for functionality (human-device interaction factors, feasibility, and usability) and acceptability. Data will be collected by a trained data collector as in Aim 1 with the addition of Ease of Communication and Frustration ratings before and after the testing sequence. To reduce burden, patients in this group will complete the 3-item ASQ one time after all tasks are completed. They will also complete a 13-item System Usability Scale (SUS).

Aim 3 - VidaTalk tablet appDEVICE

Patients in the intervention group will receive a protocolized instruction in the use of the VidaTalk application and mounting of the device including patient return demonstration of key features, and review/ testing to competence conducted by a trained interventionist. When available, a family member may be included in surveys about the patients hospital stay, if patient agrees. The interventionist will visit patients briefly (5-10 minutes) each day to check user needs and concerns and will review or retrain on message options if needed.

Aim 3 - attention-control with non-VidaTalk tabletOTHER

Patents randomized to the control group will receive a protocolized introduction to the bedside Android device without the VidaTalk app, focusing instead on a common tablet application. Daily visits will be conducted with control group patients to query on use of the attention-control tablet.

Eligibility

Sex: ALLMin age: 18 YearsMax age: 99 Years

Medical Language ↔ Plain English

Aim 1: Inclusion Criteria: 1. ≥18 years old 2. Able to communicate in English 3. Awake alert, responding appropriately to commands. 4. Normal (aided or unaided) hearing and vision 5. Able to control head, arm and hand movements 6. Physiologically stable and in no acute distress (per nurse report) Exclusion Criteria: 1. Pre-existing communication impairments 2. Diagnosis of severe dementia or brain injury 3. CAM-ICU positive for delirium 4. unresponsiveness or inattention Aim 2: Inclusion Criteria: 1. ≥18 years old 2. Able to communicate in English 3. Awake alert, responding appropriately to commands. 4. Normal (aided or unaided) hearing and vision 5. Able to control head, arm and hand movements 6. Physiologically stable and in no acute distress (per nurse report) 7. Intubated via oral endotracheal or tracheal tube without speaking valve, receiving mechanical ventilation Exclusion Criteria: 1. Pre-existing communication impairments 2. Diagnosis of severe dementia or brain injury 3. CAM-ICU positive for delirium 4. unresponsiveness or inattention Aim 3: Inclusion Criteria: 1. ≥18 years old 2. Able to communicate in English 3. Awake alert, responding appropriately to commands. 4. Normal (aided or unaided) hearing and vision 5. Able to control head, arm and hand movements 6. Physiologically stable and in no acute distress (per nurse report) 7. Intubated via oral endotracheal or tracheal tube without speaking valve, received mechanical ventilation during past 48 hours Exclusion Criteria: 1. Pre-existing communication impairments 2. Diagnosis of severe dementia or brain injury 3. CAM-ICU positive for delirium 4. unresponsiveness or inattention Aim 5 Inclusion Criteria: 1. Family caregivers of patient participants enrolled in Aim 3 as identified by the patient or self 2. \>/=18 years old 3. Able to read and speak English 4. Non-professional, unpaid caregiver 5. Plans to visit at least 3 days/ week during ICU stay 6. Reliable telephone access (for follow-up assessment) Exclusion Criteria: 1. Age under 18 years 2. Unable to read and speak English 3. Severe uncorrected hearing loss 4. Self-reported diagnosis of dementia or Alzheimer's 5. Self-reported psychiatric disorder (bipolar disorder, schizophrenia) or substance abuse requiring inpatient treatment within the last 12 months 6. Unreliable telephone access

Outcomes

Primary Outcomes

Mean Daily Patient-reported Communication Difficulty Rating Using Single Item 0-4 Rating Scale

Aim 3 - Mean item score of daily by patient self report using a single item Likert-type scale from the Ease of Communication Scale (ECS) where scores range from 0 "not hard at all" to 4 "extremely hard"

Time frame: Daily post-randomization until extubation or ICU discharge up to maximum of 28 days in the ICU

Secondary Outcomes

Mean Patient Reported Anxiety Score Using Visual Analogue Scale

Aim 3 - Calculated mean of daily measure by patient mark (x) or point on the Visual Analogue Scale for anxiety, a 100 mm vertical line ranging from 0 ("not anxious at all") to 10 ("most anxious I've ever been").

Time frame: Daily post-randomization until extubation or ICU discharge up to maximum of 28 days in the ICU

Mean Patient Frustration With Communication

Aim 3 - This will be the calculated mean of the daily Communication Frustration scale - a single item scale reported by the patient, ranging from 0 "not frustrating" to 4 "extremely frustrating"

Time frame: Daily post-randomization until extubation or ICU discharge up to maximum of 28 days in the ICU

Mean Daily Sedation Exposure

Used in Aim 3 only. Calculation of benzodiazepine and morphine equivalents (for opiates) using hospital conversion charts (pharmacy conversion chart). All benzo IV doses were converted to Lorazepam IV doses. All opioid IV doses were converted to morphine IV doses. All benzo oral doses were converted to Lorazepam oral doses. All opioid oral doses were converted to morphine oral doses. Oral doses were converted to IV equivalents. Summed doses of Lorazepam IV and morphine IV were calculated for each study day for each patient. Doses were converted to milligrams per kilogram based on the patient's body weight. Higher numbers indicate greater sedation and/or opiate exposure.

Time frame: Daily post-randomization until extubation or ICU discharge up to maximum of 28 days in the ICU daily in ICU

Ease of Communication at Extubation /ICU Discharge

Ease of Communication Scale -10-item likert scale total score ranging from 0-40. Each item is 0-4 likert scale, total score is sum of all items with higher scores indicating greater communication difficulty.

Time frame: measured at Extubation /ICU Discharge

Percentage of Patients Scoring in the "Calm" Range During Study Days on Richmond Agitation Sedation Score

The Richmond Agitation Sedation Scale, a 10-level observational rating of agitation-sedation motor activity ranging from +4 'combative' to -5 unresponsive, with 0 as calm. Since this is a categorical measure, we compared proportion of patients with RASS in -1 to +1 (calm) range during study days.

Time frame: Daily post-randomization until extubation or ICU discharge up to maximum of 28 days in the ICU

Delirium/Coma -Free Days

Aim 3 -Delirium/coma-free days is defined as the number of days alive and free of delirium and coma during the 28-day study period. Delirium will be coded as present when a patient displays both features 1 and 2, and either 3 or 4 of the CAM-ICU (Confusion Assessment Method). Coma is defined as a RASS (Richmond Agitation-Sedation Scale ) assessment score of -4 or -5.

Time frame: Daily, from enrollment to 28 days post-enrollment

Family Satisfaction With Care in the Intensive Care Unit FS-ICU

(Aim3 )The Family Satisfaction with ICU Care (FS-ICU 24R) questionnaire overall satisfaction score is derived from questions 1 through 24 (26 items) and combines two subscale summary scores. The satisfaction with care summary score is derived from the questions numbered 1 through 14 (which consists of 16 questions because question 2 has parts a, b and c). The satisfaction with decision making summary score is derived from questions 15 through 24 (10 questions). All questions are coded as integers from 1 (worst) to 5 (best). Rescale the summary scores from 1 through 5 to 0 through 100 by subtracting 1 from the scores (so they can range from 0 to 4) and then multiplying each score by 25.

Time frame: One 10 minute survey will be given at patient's ICU discharge or extubation

Electronic Visual Analogue Scale-validation Measure

(Aim4) visual analogue touch screen scale via android tablet with REDCap link. Not able to calculate because the touch screen scale was unreliable. Patients often needed assistance with the touch screen cursor for this experimental measure. We determined that pencil and paper analogue scale was superior for this patient population.

Time frame: Only measured at baseline, order of administration randomized before or after paper version

Patient Satisfaction With Care

A 24-item survey with lower scores indicating greater satisfaction with care.

Time frame: Measured at extubation or discharge from ICU which ever comes first

Family Member Anxiety

(Aim 5) Hospital Anxiety and Depression Scale (HADS) Anxiety sub scale including 7 items each scored from 0-3 with total scores ranging from 0 - 21 with higher scores indicating higher levels of anxiety.

Time frame: Baseline, patient extubation or discharge from ICU, 1-month, 3-month, 6-month post-discharge

Family Member Depression

(Aim 5). Hospital Anxiety and Depression Scale (HADS-D)- Depression Subscale including 7 items each scored from 0-3 with total scores ranging from 0 - 21 with higher scores indicating higher levels of depression symptoms.

Time frame: Baseline, patient extubation or discharge from ICU, 1-month, 3-month, 6-month post-discharge

Post-traumatic Stress Symptoms: Impact of Events Scale-revised (IES-R)

(Aim 5) Impact of Events Scale-revised. The IES-R is a 22-item self-report instrument with three subscales including intrusion (8 items), avoidance (8 items), and hyperarousal (6 items). The respondent is asked to report the degree of distress experienced for each item in the past 7 days. Each item is scored on a five-point Likert scale (0, not at all; 1, rarely; 2, occasionally; 3, fairly often; and 4, often) and total scores range from 0 to 88. Higher scores are representative of greater distress.

Time frame: 1-month, 3-month, 6-month post-discharge

Family Communication Difficulty

Family Communication Survey administered to participant families. Sum of 9-items with each item rating 0 (not at all) to 4 (extremely difficult), resulting in a total summed score from 0 - 36. Higher scores indicate greater difficulty.

Time frame: baseline and extubation or discharge from the ICU

Communication Task Error Rate

Aims 1 \& 2 - count of the number of errors recorded by video screen capture for each of 8 communication tasks. Individual patients ranged from 0 to 9 errors, however this measure contains no upper range per task as it is a count of actual observed errors committed by patients.

Time frame: Measured during 30-60 minute usability testing visit which occurs at study completion. This outcome applies only to Aim 1 & 2 arms.

Total Error Rate

Aims 1 \& 2 - calculated mean of the total number of errors recorded by video screen capture divided by the number of communication tasks completed (8 maximum) Aim 1 extubated patients. Using group 1 and group 2 summary data, 11 patients completed 82 tasks (6 were abandoned, 5 of these by one patient). Removing abandonments, total number of errors = 25/ 82 tasks = 0.30 error rate. Aim 2 intubated patients. 11 patients completed 69 tasks (18 were abandoned; 1 task was refused). Removing abandonments, total number of errors = 60/ 69 tasks = 0.87error rate.