About voICeThe Department of Intensive Care of the Radboudumc, Nijmegen, the Netherlands, developed a special iPad communication app for awake ICU patients using artificial respiration and for patients with a trachea cannula or an NIV mask. ICU patients are often unable to speak and have to communicate with their neighbors and the professionals by for example lip reading, writing or using a letter board or a keyboard/laptop. Because of several different causes, these methods are not sufficient enough for good communication. Looking at interviews of patients and their neighbors, we can conclude that these methods of communication are seen as very annoying. This causes feelings of despair and frustration for both the patient and the employees.
This communication-app for the iPad developed for ICU patients, named voICe, improves the communication for and with them. Using the app requires only a small amount of muscle power and locomotion, works intuitive and is simple and understandable for everyone. The app “learns” the choices of the patients and adapts itself to these. The communication app also has the possibility to record a video message for patients by a professional or a patient’s neighbor and contains a clearly visible clock and date indication.
The communication-app voICe’s development started in November 2012 and was introduced in the middle of May 2013 to the ICU of the Radboudumc: many other ICU’s in the Netherlands and the Dutch speaking part of Belgium work with voICe now. The English version of the app was released in March 2016
The app voICe is primarily developed for patients at the IC/MC with their communicative limitations. The app can be used as a communication tool as well for others with similar communicative problems during (or partly during) the time sick and the healing process . With that in mind people can help patients after a stroke with a motoric aphasia, patients with a trachea cannula caused by a head/neck problem, patients with a muscle or muscle-nerve illness, patients in geriatrics and many others. A careful estimation, based on the data of the National Intensive Care Evaluation (NICE) 2012, learns us that at the ICU’s in the Netherlands every year at least 12.000 – 15.000 ICU patients during (or partly during) their time sick or their healing process, can use voICe to improve the quality of the communication. No good estimation is possible now about the range for other mentioned groups.
Using voICeThe communication-app voICe has several possibilities/features: The patient (adult or child) can – by touching pictograms (+ text) – indicate if something is needed, if there’s a physical problem or e.g. in the patient’s current mood. The first version contains 46 pictograms, sorted in 6 different themes and based on an inventory of the most common asked questions and shown problems for patients and professionals in the ICU. If the patient touches a pictogram, a voice (man/woman/boy/girl), tells what the patient wants or what is wrong.
The voICe-themes are:
- My feelings
- My body
- My treatment
- My basic words
- My relaxation (2 x; for children a special ‘relaxation’ screen has been developed).
- My caretaking
- The subject ‘pain’ gains extra attention. The patient can indicate through the app where he has pain and through the use of an NRS-score he can indicate the level of pain.
- To expand the possibilities of the communication-app and to make it more complete, the app has a sign- and keyboard. The patient is able to communicate by typing texts or draw/write something. The keyboard is simple, has huge letters and there’s a choice between a QWERTY or a ABC keyboard system.
- The app contains the possibility for the patient’s family/friends to record a personal video message which the patient can play when he has a need for this. One might also consider the possibilities of using the video messages for a day program/schedule or therapy.
- The app contains a clearly visible clock-, day- and date screen which can say the time, day or date when touching the screen. Also, the location can be set and spoken by the app.
- Through the ‘preference screen’ direct contact can be adjusted to the most chosen themes of the patient.
- The app can – for patients with a minimal or no hand locomotion – be used in a ‘yes-no-model’ , where the patient can choose to confirm or to reject pictogram that has been proposed by the patient’s neighbors or a professional. This way of working is comparable with using a keyboard, but it is easier and faster.
- An easy or a basic version with 4 or 6 pictograms (settings).
- The iPad can also install other different (medical) apps. When needed, they can give useful extra information to the patient. If someone chooses to install different apps for the iPad (e.g. about anatomy), communication through voICe can be easy and supportive in explaining/illustrating/locating the disease or discomfort.
Advantages of the voICe app
- Patients get ‘back’ their ‘voice’; they can make clear which problems there are, what they need or what they do not want.
- The patient will become active instead of passive and is able to get back some of the control; he can make choices again.
- Patients, their closest and the workers will be less frustrated by easier communication . People will understand each other faster and better.
- Through constant reminders for date, time and place, the patient can improve his orientation.
- Hearing and seeing a (video) message of one of the closest of the patient can be a support; we can also imagine a message about the daily program for the patient.
- Depending on the patient, caregivers can adjust the care in a better way. The app makes it possible for them to communicate easier and more focused with the patient. In this way they’re able to gain specific information about the patient in a short and systematic way and they can directly ask the patient for feedback about the healthcare provision and other interventions.
Frequently Asked Questions FAQ
The app is downloadable in the Apple store of iTunes. Search at ‘voice intensive care’, ‘voice’ or ‘intensive care’. link to iTunes There’s a free trial with basic words and a paid, complete version. This costs €79,99. If you need a large number of voICe apps, you can purchase the app at the VPP program of Apple. https://volume.itunes.apple.com/nl/store.
Try to use the app with a stylus. There are several styli available; thick, with good rubber grip. This way unintentional moves with the wrist/hand can be ignored. Make sure that catheters /lines are bandaged and can’t hang loose. Use a supporting pillow where the iPad can stand in sloping straight.
Go to ‘settings’. Below the current location you can, by using the button -modify-, you can enter your new location. To change the explicit message, touch the button ‘record’ and speak the desirable message. Through play you can control if this has been recorded well. With the button -reset- you go back to the normal settings.
Approximately 5 minutes.
For protection of the iPad and out of hygiene protection we have, in the Radboudumc, chosen to place an Apple Smart Case (material polyurethane) around the iPad, in combination with a matte screen protector. This way the iPad is protected in a fair way against bumps and can still be cleaned with an alcohol cloth. In reality this works out excellent. An advantage of the matte screen protector is that this minimizes the reflection when someone is looking at your screen sideways, what occurs frequently in reality when 2 people are busy with voICe. A good alternative for the Apple Smart Case is the Griffin Airstrap Med iPad case, which has been developed in collaboration between doctors and nurses in the USA for the use in hospitals for example. Standard cleaning consists of – if visible contaminated- cleaning with a cleaning cloth and – always – disinfection with an alcohol cloth, comparable with the hand hygiene agreements.
With isolation prescriptions the iPad has to be handled conform these prescriptions when taking it into and taking it away from the room. If the patient at that room can communicate excellent with the app and wants to, it can be considered to assign the iPad to this patient and so minimalize the traffic of the iPad from and to the corridor.
Try the free version of voICe first and look if this succeeds. After this, look if the swipe move can be made in a logical order. For example, by numbering ABC on a notebook. If that works out, you can learn to work with voICe. You can always contact us.
No, for now voICe functions on the iPad (iOS).
The app was first published in the Dutch language. The English language has been available since June 2016 . Other languages aren’t in production yet.
The app requires iOS 6.1 or newer. The app isn’t about iPad 1! We advise hospitals to consider what they’re going to do with their iPad and choose the iPad with the right amount of memory.
An user can log in and use the pictograms ‘preferences’ and ‘messages’. An administrator can manage the app: users can be seen, watch their preferences and erase them.
- Store the iPad at an easily accessible but theft-proof location. Let nurses also be able to use it at the night shifts in order to get used to it. Download useful apps. (e.g. a pharmatherapeutic compass or anatomical apps)
- Implementation requires first of all awareness of the fact that the population of patients at the ICU changes, that patients wake up and need communication. Nurses and other care-professionals need to play an active role in this. Educate every caretaker who surrounds the bed, including paramedics. And educate nurses more often, because they’re frequently the communication initiators. Also invite speech therapists, if it’s allowed, to introduce the app to the patient.
- Try also working ‘the other way aroud’ and show the patient the pictograms in the app, ask if the showm pictogram is an issue for the patient; this way, all the information about a patient’s needs can be discovered in 5 minutes without having to cope with motoric or concentration problems !
- The app isn’t difficult. Touching the pictograms usually speaks for itself. When creating a code to log in, video and preferences pictograms, often explanation is needed.
- Specify first the correct patient category and then move on. (for example cannula-patients who have normal wrist/hand functions and are not sedated.
- Invite the patient’s family to introduce and use the app to the patient. First start by the 4 and then the 6 pictograms-screen, just to try if this works out.