Inpatient Augmentative Communication Program | Preoperative Message Banking

In 1991, one of the nurses from our tracheotomy program came to us and said there are kids who wake up in the ICU after surgery who are absolutely terrified and they can’t communicate. Our Augmentative Communication Program began to meet children at bedside, but immediately recognized that many children had a planned procedure and we could anticipate a nonspeaking condition prior to hospitalization. Boston Children’s Hospital initiated a first-of-its-kind program that supported children to bank messages and then have access to those messages in their own voice using digital technology when they awaken in the ICU. We called this process Message Banking, and we've supporting patients’ ability to bank messages in preoperative clinics and at the beside for more than 25 years.

When possible, a pre-operative consultation is recommended for the speech-language pathologist to work collaboratively with patients, families, and providers in the selection and programming of augmentative communication tools. Patients and families may meet with a speech-language pathologist to identify relevant vocabulary or messages to include in a communication system during a less stressful time. Patients who are able to produce oral speech prior to a planned procedure may also have the opportunity to record messages using their own voice, which can be programmed into recommended communication tools. In some cases, patients who are already inpatient and have highly complex medical needs may not be awake or alert preoperatively, however consultation may still occur with caregivers and providers to identify baseline information and relevant vocabulary or messages.

Why prepare ahead of time?

Research supports the notion that access to AAC enhances patient care and is closely linked to patient satisfaction and safety (Happ, 2004; Patak et al. 2006). Patients admitted to the ICU are already at high risk for communication vulnerabilities based on admitting criteria, and therefore adequate communication with providers and loved ones is key to ensuring patient safety and prevention of adverse events. Pediatric patients may also experience a loss of control, sense of self, and ability to participate in their own care (Garrett et al., 2007), which can in turn result in feelings of insecurity, panic, worry, fear, and anger (Happ et al., 2004) when unable to effectively communicate. The opportunity to reduce communication breakdowns by preparing materials and strategies prior to the onset of a communication vulnerability can potentially prevent these negative factors.

Benefits of early preparation:

• The hospital admission may be stressful to pediatric patients and their families. Establishing communication methods ahead of time may reduce later stress and worry.
• Postoperatively, many patients can experience misunderstanding, confusion, and waxing and waning mental statuses due to effects of medication.
• Early participation in the selection of communication tools and vocabulary can be completed during a less acute and stressful time.
• If able, patients can digitally record their own voice into a communication system using natural inflection, meaning, and intonation.
• Time to familiarize with previously selected communication materials may lead to easier and more functional use.
• Patients often experience a sense of control in their own care and preservation of their personality.

Patients who may benefit from preoperative consultation

A wide variety of patients are seen preoperatively in anticipation of many different medical or surgical procedures and interventions. These patients may include those who have or will be undergoing the following:

• baseline speech, language, and communication deficits
• any form of invasive ventilation
• tracheostomy
• non-invasive ventilation (BiPap, CPap)
• oro-facial surgery
• brain tumor resection or biopsy
• other neuro-surgical procedures
• complex dental procedures
• baseline motor impairment
• anticipated motor impairment
• degenerative neurological or neuromuscular disease
• other

The preoperative consult

At Boston Children’s Hospital, a speech-language pathologist in the Inpatient Augmentative Communication Program is on call weekdays at our main campus location and can be reached to provide face-to-face consultation with patients in the context of their preoperative appointments. If you are unable to meet with an SLP during your visit, phone and email correspondence is recommended to connect prior to your child’s upcoming hospital stay. Have your provider call the inpatient SLP to arrange a preoperative consult.