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AAC in the ICU: Critical Issues and Preliminary Research

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Title: AAC in the ICU: Critical Issues and Preliminary Research


1
AAC in the ICU Critical Issues and Preliminary
Research
  • Mary Beth Happ, Ph.D., R.N.
  • Kathryn Garrett, Ph.D., CCC-SLP
  • Tricia Roesch, B.S.N., R.N.
  • School of Nursing University of Pittsburgh
  • Duquesne University, Pittsburgh PA

ASHA Convention November 2003 Chicago
2
(No Transcript)
3
Overview
  • Part I Literature Review
  • Part II Feasibility study of electronic
  • VOCAs in the Surgical Otolaryngology Unit
  • and Case Example
  • Part III Feasibility study of electronic
  • VOCAs in the Medical Intensive Care Unit
  • Part IV NIH-funded Intervention Study -- The
    SPEACS Project

4
Note
  • Please refer to the Microsoft Word document by
    the same title for a narrative version of this
    presentation
  • The Word document will also contain the reference
    list.

5
Part I Background
6
Descriptive reports of the mechanical ventilation
experience in the ICU
  • Patients experience
  • FEAR
  • PANIC
  • STRESS
  • As a result of the inability to speak

7
  • Nurse-Patient communication in ICU
  • Brief (lt 5 min), task-oriented, commands
    reassurances during physical care.

8
  • Patients typically communicate with nods,
    gestures, and mouthing words.

9
  • ICU interactions do NOT usually involve
  • communication of the patients ideas,
  • patients initiation of messages or elaboration.

10
  • Communication difficulty with mechanically
    ventilated (MV) patients - related to illness
    severity, anger
  • (Menzel, 1998)
  • Greater difficulty communicating with family than
    with nurses
  • (Menzel, 1998)
  • Under-recognition high levels of pain reported
    in MV patients (SUPPORT studies)
  • RNs/MDs more likely to communicate with patients
    who are more responsive.

11
  • Statement of the Problem
  • Few data-based communication intervention studies
    with acutely/critically ill adults have been
    published
  • (Dowden et al, 1986 Stovsky et al, 1988)
  • Alphabet picture boards preferred by a critical
    care survivors (n5) (Fried-Oken et al, 1991)

12
  • Clinical case reports
  • Introducing AAC preoperatively word banking
    (Costello, 2000)
  • Multidisciplinary post-operative AAC plans for
    head and neck cancer patients (Fox Rau, 2001)
  • Descriptions of AAC use in ICU (Fried-Oken,
    2001)

13
A need exists for
  • Specific data on communication interventions for
    nonspeaking, intensive care unit patients
  • Analysis of high tech versus low tech
    interventions
  • Perceptual, qualitative, and quantitative
    analyses
  • Comparisons between different ICU populations
  • Usage data as well as interactional data

14
General Design of 2 Feasibility Studies
15
Purpose
  • Explore the feasibility of electronic voice
    output communication aids (VOCAs) for use with
    nonvocal patients
  • in a medical ICU and
  • following head-neck cancer surgery.

16
Research Questions
17
What are the
  • Patient characteristics (illness severity,
    neuromotor ability)
  • Usage patterns (message categories, frequency,
    assistance required)
  • Communication quality (ease, satisfaction)
  • Barriers to communication
  • when VOCAs are used by hospitalized adults?

18
Complementary Design
QUAL quan
No hypotheses
Purposive-theoretical sampling
Small samples
Morgan, 1998
19
Settings University of Pittsburgh Medical
Center - Otolaryngology surgical unit - Medical
ICU 20 beds
  • Entry Criteria
  • Respiratory intubation
  • Responsive to verbal stimuli
  • Follows commands consistently
  • Initial Cognitive-Linguistic Screen
  • Dowden, Honsinger Beukelman, 1986

20
Procedures
21
Education Set-Up
  • Nurse Inservice (15 min)
  • Patient Instruction (20 min) reinforcement
  • Message Inventories
  • What does he/she want to say?
  • To whom?
  • How?

Costello, 2000
22
Data Collection
  • Enrollment
  • Pre-test Ease of Communication Scale2
  • APACHE, Motor Screen1
  • Daily
  • Observations (20min)
  • Chart Review
  • Extubation
  • Post-test Ease of Communication Scale2
  • Exit Interviews

1. P. Dowden et al. (1986)
2 L.. Menzel (1998).
23
Part II
  • Pilot Research
  • Head and Neck Surgical Unit

24
Funding AACN/ Sigma Theta Tau ONS Foundation/
OrthoBiotech
Mentorship/Consultation Dr. Richard Hurtig,
University of Iowa Stephanie Williams, SLP,
Dynavox Systems, Inc
  • Equipment donations
  • DynaVox Systems, Inc.
  • WordsPlus, Inc.
  • AbleNet

25
TM
DynaMyte
Electronic VOCAs
Message Mate
TM
26
Examples of Patient
Message Screens
DynaMyteTM
27
1
NAUSEA
Say
SICK
Im OK
Pain shot
PAIN
MEDICINE
NOT OK
2
Back Space
HOT
COLD
SAD
HAPPY
ANGRY
AFRAID
HUNGRY
TIRED
3
Clear
MOUTH CARE
TV
BATH
DRINK
BEDPAN
SUCTION
MUSIC
GLASSES
4
I LOVE YOU
Repeat
WHY? WHERE?
NURSE
DOCTOR
FAMILY
HOME
TIME
HEAR
MessageMateTM
MY MOUTH
CAT
DOG
28
Basic Messages
  • Pain
  • Shortness of Breath
  • Suction
  • Help!
  • Hot/Cold
  • Home/Family
  • Anxiety/Worry

29
pole
swivel arm
30
Qualitative Data Analysis
  • Fieldnotes and interviews coded for
  • method
  • content
  • barriers
  • facilitators

31
Quantitative Data Analysis
  • Descriptive statistics (dispersion)
  • Pattern recognition
  • Nonparametric within case comparison (EOC)

32
RESULTS
33
Study 1 Exploring the Feasiblity of VOCAs with
Head and Neck Cancer Patients Following Surgery
MB. Happ1 S. Kagan2 T. Roesch1 E. Holmes1
1 University of Pittsburgh School of Nursing 2
University of Pennsylvania School of Nursing
Funding ONS Foundation/OrthoBiotech
34
Head Neck Sample(n10)
  • 7 men, 3 women
  • all Caucasian
  • 5 MessageMate
  • 5 DynaMyte

35
Observation Interview
  • Observations 66
  • Communication Events 50 (75.8)
  • Formal Interviews 9
  • Patient 8
  • Nurse 1

36
Characteristics (n10)
  • Ages 45-82 yrs (57.112.8)
  • Education 12-20 yrs (13.52.9)
  • Computer Use 7
  • minimal level 3/7

37
  • Procedures
  • Brachytherapy 2
  • Laryngectomy 8

38
Characteristics (cont).
  • Days w/ device 3-24 (9.1 6.2)
  • Post-op days prior
  • to device 1-6 (1.9.1.6)
  • APACHE III 5-53 (27.113.2)

39
Neuromotor Characteristics
  • Motor Screen Tasks 10
  • Write legibly 10
  • Narcotics/sedation 35/50 (70)

40
Usage Patterns
  • VOCAs were used by some of the post surgical
    patients
  • - some required extensive assistance, whereas
    others required limited or no assistance
  • Other modalities were used as well
  • -Writing
  • - Gesture
  • - Mouthing Words
  • - Head Nods

41
Other findings
  • Of the observed communication events in which
    patients utilized the VOCA, patients initiated
    more frequently than a historical
    (no-intervention) group.
  • a slight increase in ease of communication was
    observed in the VOCA group when compared with a
    historical (no-intervention) group.

42
Novel Scenarios in which VOCAS were used
  • Cardiology evaluation
  • Telephone usage

43
What were the barriers to device use?
  • device out-of-reach
  • upper extremity neck wounds
  • blurred vision
  • insufficient staff training in use
  • patient preference for writing or other method

44
Message Content
  • Comfort needs (pain, thirst, suction)
  • Questions about home family
  • I love you ?
  • Questions about tests and condition
  • Phone conversations

45
Characteristics of the head and neck patient
population that may have been associated with
successful AAC device use
  • All were able to write
  • All were liberated from ventilator
  • Voicelessness was expected
  • More independence

46
  • Case Study

47
Tim
  • 46 year old Caucasian male
  • S/P Total laryngectomy tooth extraction
  • No prior history of intubation and mechanical
    ventilation
  • No significant past medical history

48
Tim
  • High school graduate
  • Previous personal computer use
  • Vision corrected with eyeglasses
  • Right hand dominance

49
Tim
  • Motor screening tasks
  • APACHE score 29
  • Glasgow Coma Scale (GCS) 15

50
Enrollment
  • Immediate post operative phase
  • Transferred from Medical Intensive Care Unit
    (MICU) to Head and Neck ICU
  • Patient appeared withdrawn
  • Deferred until third post operative day
  • just dont feel like it
  • No device training prior to study enrollment

51
Device Set Up
  • Device options
  • Message Mate- simple, smaller message capacity
  • DynaMyte- larger capacity, multi-level message
    display
  • At bedside
  • Duration 1.5 hours
  • Initial method of communication
  • Writing/Gestures

52
Tims Requests
  • Voice selection
  • Message deletions
  • Yes/No
  • What time is it?
  • Message Additions
  • Hello Good-bye

53
Tims Requests
  • Icon/Message change
  • Performed at bedside
  • Requested by patient and/or family
  • During entire enrollment period
  • Affect change

54
Observation of Communication Events (OCEs)
  • 7 OCEs from 5 study days
  • Narcotic analgesia
  • 5/7 OCEs
  • Additional non-AAC methods
  • Head Nods
  • Hand Gestures

55
Tims AAC Use
  • Most utilized mode
  • Keyboard feature
  • Utilized bilateral hands predominantly index
    fingers and thumb
  • 6 available pop-up icons with additional
    methods
  • Effective navigation

56
General Interactions with AAC Use
  • Convey feelings to nurse
  • Pain
  • Anxiety
  • Establishing need for suctioning
  • Requesting assistance in bathing
  • Communication with RNs, MDs, family

57
Aspects of AAC Use
58
Feedback
  • Tim
  • I can say everything I want to say right now
    through typing VOCA and writing.
  • I am satisfied with the way I communicate in the
    hospital.
  • Tims Sister
  • Patients need this device until prosthesis is in
    place. It is a great help.

59
Practical Challenges
  • Patient lost access to the device when he
    transferred off of the Head and Neck Unit (to
    Cardiology)
  • Expensive
  • Nursing, Physician, Clinician unfamiliarity
  • Battery back up
  • Infection control issue -- how to keep the device
    sterile
  • Discharge to home without device?

60
Tim Taught Us
  • Communication method needs to be customized for
    each patient
  • Options for changes/deletions of various messages
    at all times
  • Once a method is established, it is difficult to
    change or add another method

61
Results of this exploratory study will be
submitted for publication.
  • Stay tunedyou will be able to access more
    specific data after the manuscript has been
    accepted to a peer-reviewed journal.

62
Part III
  • Pilot Study 2 -- Medical Intensive Care Unit
    (MICU)

63
Exploring the Feasiblity of VOCAs with
Nonspeaking ICU Patients
M.B. Happ, PhD T. K. Roesch, BSN
64
MICU Sample(n11)
  • 15 patients identified
  • 11 participated (73)
  • 7 men, 4 women
  • 10 Caucasian

65
Observation Interview
  • Observations 49
  • Communication Events 41 (83.7)
  • Formal Interviews 14
  • Patient 8
  • Family 3
  • Clinician 3

66
Characteristics (n11)
  • Ages 20-72 yrs (45.516)
  • Education 0-16 yrs (131.9)
  • Computer Use 6

MR patient excluded from mean
67
Characteristics
  • Intubation
  • Tracheostomy 4
  • Oral ET tube 7
  • Primary Medical Dx
  • Pneumonia/ARDS/Sepsis 7
  • Lung CA 1
  • COPD 1
  • Subglottic Stenosis 1
  • SCI 1

68
Characteristics (cont).
  • Days w/ device 1-14 (5.7 4.6)
  • Ventilator Days 1-44 (15.512.2)
  • APACHE III 10-54 (27.516.1)

69
Neuromotor Characteristics (n11 Study
Patients)
  • Motor Screen Tasks 8
  • - Blind, quadriplegia
  • - Quadriplegia
  • Morbid Obesity
  • Write legibly 3

70
Neuromotor Characteristics(n49 observations)
  • Narcotic analgesia 13 (26.5)
  • Anxiolytics/sedation 22 (44.9)

71
Usage Patterns
  • Ventilated patients in the MICU used VOCA systems
    in over 1/4 of the observed communication events
  • However, usage patterns ranged from limited to
    required cues to use.
  • Most of the patients used more than one
    communication method
  • Increased patient initiations were associated
    with availability of the VOCA

72
Observed VOCA Messages
  • I love you ? 9
  • FAQs (go home, restraints, breathing
    tube) 4
  • Anxiety/worry/ fear 4
  • Pain 3
  • Comfort (thirst, position, cold) 3
  • Family 1

73
Novel Scenarios in which MICU patients used VOCAs
to communicate
  • Informed consent to participate in research
    diagnostic testing
  • Semantically complex message building
  • Patient initiated messages
  • What is your religion?
  • Is the house clean?
  • I want my sister!

74
Quality
  • Patient ratings of Ease of Communication
    increased significantly in the VOCA versus no
    VOCA (pretreatment) condition.

75
Anecdotal Reports of Satisfaction
  • That VOCA was a good thing there, it really
    helped me. (patient)
  • It was easier to understand what she wanted. I
    cant read sign languageIm not a good guesser.
    (husband)
  • I think its more complete and decisive. (RN)

76
Satisfaction
  • Whenthey patients got the hang of this, they
    used it almost as a sole means of communication.
    They like this and they like the fact that people
    tend to respond to voice. And this was their
    voice. - RN
  • People dont communicate with people who dont
    communicate back. - RN

77
Satisfaction
  • Suggested Design Improvements
  • Larger screens
  • Greater touch sensitivity
  • Easier keyboard access (DynaMyte)
  • Simplier less expandable (DynaMyte)
  • Realtime Tracking/Storage of Messages
  • Backlighting (MessageMate)

78
Barriers
  • poor positioning/out-of-reach
  • UE weakness
  • blurred vision
  • fluctuating cognition/attention
  • deterioration in condition

79
Barriers
  • Staff time constraints
  • Lack of knowledge about device
  • Device complexity

80
Barriers
  • It was easier for me to talk with him, and not
    have to pull out the device, because time is
    precious around here Where he could get his
    point across to me with lip talking, it seemed to
    lessen the time - RN

81
Partner Behaviors that Facilitated VOCA use
  • Cueing patients in selection of messages
  • Repositioning patient or device
  • Aids glasses, hearing, access tools
  • Patience with slow message generation
  • Improved condition and UE strength

82
What we learned about AAC
  • Start simple
  • Basic instruction card
  • SLP support
  • Tech support
  • Partner training

83
What we learned about AAC
  • Use progressive, expandable techniques
  • Capitalize on combined methods
  • Cueing
  • Consistency
  • Repeat instructions

84
For further information and specific data from
Study 2
  • Keep an eye out for the following article
  • Happ, M.B., Roesch, T.K., Garrett, K.L. (in
    press --expected 2004). Exploring the use of
    electronic VOCAs in the medical intensive care
    unit. Heart Lung, 33, issue 2 or 3.

85
Part IVIntroduction to theSPEACS Project
86
Time for a large-scale study
  • A large n study across multiple ICU units
  • Planned prospective design with 3 patient/nurse
    cohorts
  • Treatment A systematically designed AAC and
    basic communication intervention package
    implemented by nurses and an SLP
  • Quantitative analysis of the INTERACTIONS between
    the nonspeaking patient AND the primary nurse
    caregiver

87
SPEACS
  • Study of Patient-Nurse Effectiveness with
    Assisted Communication Strategies

88
Multidisciplinary Research Team
  • Mary Beth Happ, Ph.D., R.N.
  • Kathryn Garrett, Ph.D., CCC-SLP
  • Susan Sereika, Ph.D.
  • Elisabeth George, Ph.D., R.N.
  • Michael Donahoe, M.D.
  • Judith Tate, M.S., R.N.
  • School of Nursing University of Pittsburgh
  • Duquesne University
  • University of Pittsburgh Medical Center

Expert consultants Maria Connolly, B.S.,R.N. --
Loyola University Melanie Fried-Oken, Ph.D.,
CCC-SLP -- OHSU Neville Strumpf, Ph.D., R.N. --
U. of Penn
89
5-Year Funding (2003 -- 2008) National
Institute of Child Health and Human Development
(NICHHD) Improving
Communication with Nonspeaking Patients in the
ICU (R01-HD043988-01)
90
Overview
  • Background and Rationale
  • Research Questions Study Aims
  • Research Design Model
  • Independent Variables Description of 2-Phase
    Intervention Packages
  • Procedures
  • Dependent Variables/Data Collection
  • Data Analysis
  • Potential Challenges
  • Invitation to Comment

91
Definition of Augmentative Alternative
Communication (AAC)
  • All communication methods that supplement
    natural speech including unaided (signing,
    vocalizations) or aided (writing, typing,
    electronic device) techniques
  • - from Beukelman Mirenda, 1998

92
Natural Approaches
  • Mouthing words
  • Writing
  • Gesture

93
(No Transcript)
94
  • Natural, minimally aided communication strategies
    are the most frequently used by nonspeaking
    patients in the ICU.
  • Typically, AAC devices are not available.
  • Problems with relying on natural communication
    alone can include
  • Mouthing Patients often cannot clearly mouth
    words around the endotracheal tube
  • Writing Paper/pen is not made available, the
    patient is illiterate, or upper extremity
    function is inadequate
  • Gestures Patients/nurses have no consistently
    shared gestural lexicon (Connolly, 1992)
  • Opportunities Patients do not receive adequate
    opportunities to initiate their own topics and
    messages (e.g., Please find my reading glasses)
  • Rate Message co-construction can be a slow
    process

95
Prosthetic Oral Approaches
  • Electrolarynx
  • Tracheostomy one-way speaking valve

96
Aided StrategiesLow tech symbol boards/direct
selection
97
TM
Electronic VOCAs synthesized or digitized
voice output symbolized messages multiple
level option scanning option
DynaMyte
Message Mate
TM
98
(No Transcript)
99
Challenges
  • AAC is not considered customary care
  • Nurses do not have easy access to AAC
    technologies
  • Nurses do not receive training in their use
  • Natural communication strategies and/or AAC
    technologies are not applied systematically to
    all conscious ICU patients
  • Communication strategies are not individualized
    for specific patients
  • Ongoing consultation about communication
    strategies typically is not available for nurses
    in the ICU

100
SPEACS
  • Study of Patient-Nurse Effectiveness with
    Assisted Communication Strategies

101
RQ/Specific Aim 1
  • What is the impact of two experimental
    interventions
  • Basic Communication Skills Training (BCST) for
    nurses
  • AAC techniques and education individualized SLP
    consultation
  • (AAC-SLP)
  • on ease, quality, frequency and success of
    nurse-patient communication?

102
RQ/Specific Aim 2
  • How do interactions in the two communication
    intervention conditions (BCST and AAC-SLP)
    compare with those in a control (usual care)
    cohort?

103
Research Model
104
Happ, M.B. Garrett, K.L. (2003)
105
Our HYPOTHESIS
  • AAC-SLP gt BCST gt Control on
  • ease
  • quality
  • frequency
  • successfulness
  • of nurse-patient communication interactions.

106
Research Design
107
Nonconcurrent Cohort Designwith Repeated Measures
Year 2 BCST X1T1 T2 T3 T4
Year 3 AAC-SLP X2T1 T2 T3 T4
Year 1 Control T1 T2 T3 T4
108
2 Settings
  • Medical ICU
  • Cardiothoracic ICU

109
Independent Variables
110
Condition 1 - Usual Treatment
  • No specific communication training for nurses
  • Communication interaction and intervention at the
    discretion of the patient or untrained nurses

111
Condition 2 -- BCST
  • Training for nurses in basic communication skills
    prior to data collection
  • Delivery
  • 2 hour inservice (instruction roleplay) with
    SLP lt2 months prior to data collection
  • Website consistently available

112
Sample Basic Communication Skills
  • Approach patient
  • Alert patient (George)
  • Tag yes/no questions (Yesor No?)
  • Provide auditory or written choices
  • Ask open-ended questions when appropriate (Tell
    me whats on your mind.)
  • Instruct patients to use specific natural
    modalities if they do not initiate
  • Show me one of the gestures we talked about.
  • Write it for me.
  • Can you mouth the words more clearly?
  • Interpret utterances/mirror gestures

113
Condition 3 -- AAC SLP
  • Incorporates basic communication skills training
  • SLP also works with nurse to develop
    individualized communication intervention plan
    for each patient.
  • SLP also sets up AAC technologies, conducts
    message inventory, teaches patient, and trains
    nurse as appropriate
  • SLP is available on an ongoing basis to consult
    with nurse about communication

114
Nurse Sample (quasi-random selection)
  • 5 RNs/unit 10 RNs x 3 phases
  • 30 RNs
  • RN Entry Criteria
  • 1-year critical care experience
  • Full-time staff, not permanent night
  • Selected from pool of volunteers

115
Patient Sample
  • 3 pts/RN 30 pts x 3 phases
  • 90 patients
  • Patient Entry Criteria
  • Respiratory intubation
  • Likely to remain intubated for a min of 48 hrs
  • Understand English
  • Glasgow Coma Scale gt 13
  • Exclusion
  • Premorbid inability to communicate verbally or
    nonverbally (a score of lt3 on the NOMS
    cognition, expressive, and receptive language
    subscales
  • Delirium or limited movement OK

116
Dependent Variables
117
Data Sources
  • Transcriptions of videorecorded nurse-patient
    interactions
  • 3 minute segments -- 2x/day for 2 days for each
    nurse/patient dyad
  • Observer ratings
  • Field Notes
  • Clinical record/chart

118
  • Videotapes of the 2-minute nurse/patient
    interactions will be transcribed and coded for
    the following variables
  • How frequently did the patient initiate
    communication?
  • With which modality?
  • How many of the nurse-patient communication
    exchanges resulted in successful message
    communication?
  • How many breakdowns occurred? How many were
    successfully repaired?
  • How often did the nurse demonstrate behaviors
    that facilitated communication?
  • What was the function of the message?

119
Observer Ratings of Ease of Communication
120
  • Field Notes will also be compiled for qualitative
    analysis of
  • Setting variables
  • Topics
  • Affect
  • Unusual circumstances
  • Presence of restraints
  • Patients cognitive status
  • Etc.

121
Data Sample
  • 4 observations/pt x 30 pts/phase
  • 120 observations/phase
  • x 3 phases
  • 360 observations

122
Covariates
  • Will specific patient or nurse variables
    explain/predict patterns in the data?

123
  • Patient Co-variates
  • Gender
  • Type of ICU
  • Premorbid communication ability
  • Measured by subscales of the NOMS
  • Severity of Illness (APACHE)
  • Length of Intubation prior to study enrollment
  • Degree of Agitation (CAM-ICU)
  • Degree of Sedation (RASS)
  • Motor Ability (Lowenstein)

124
  • Nurse Co-variates
  • Total nurse contact time with patient
  • Time elapsed since training
  • Critical care experience

125
Interventions
AAC/SLP
BCST
Voiceless Patient
Communication Process
Nurse
Level of Consciousness Illness Severity Communicat
ion Fx Motor Fx
Nurse Contact Time Time Elapsed Since Training
Outcomes
Quality
Success
Ease
Frequency
126
Data Analysis (S.S.)
  • Exploratory data analysis
  • Hierarchical generalized linear modeling (HGLM)
  • Linear contrasts based on hypotheses
  • Model assessment (i.e., residual analysis and
    evaluation of outlier/ influential observations)

127
Potential Problems Solutions
  • Brief ICU stays/2 day data collection period
  • Variable nurse scheduling/ day nurses only,
    request same patient
  • Fluctuation in patient condition/ track delirium
    and severity of illness as a covariate
  • Diffusion of the intervention/ assess in 2 ICUs,
    use 3 separate cohorts
  • Measurement intrusiveness and complexity/ extra
    effort
  • Is 2 days enough time to develop an effective
    communication intervention?/ oh well -- it
    represents the real life challenge!

128
Our timeline
  • January 2004 Final Instrument Development
    Pilot Testing of Procedures
  • March 2004 Nurse/Patient enrollment for
    Usual Care Condition
  • March 2005 Begin BCST Condition
  • January 2006 Begin AAC-SLP Condition
  • January 2007 Data Analysis
  • July 2008 Complete Data Summarization

129
Questions and Comments from the Audience
130
Handouts
  • Please cite information from this presentation as
    follows
  • Correspondence
  • Mary Beth Happ, Ph.D., R.N.
  • University of Pittsburgh
  • mhapp_at_pitt.edu
  • Kathryn Garrett, Ph.D., CCC-SLP
  • Duquesne University
  • garrettk_at_duq.edu
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