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Innovation Update

Effective Communication in Emergency Departments

Effective communication is essential to high quality medical care and is particularly difficult in Emergency Departments (ED) due to competing ambient sound. Ambient noise levels are high enough to label the ED as a difficult listening situation – presenting a challenge to communication, even for those with intact peripheral hearing.^1,2 For older patients with hearing loss, the likelihood of poor communication with providers and inadequate preparation for post-discharge care may be quite high. After pilot work, we developed a staged randomized clinical trial to first test efficacy and then, effectiveness of a simple, low cost, point-of-care solution for this problem, the Personal Amplifier (PA). PAs have a microphone attached to an amplifier directing the sound into the wearer’s ears via wired headphones or earbuds.

We conducted a pilot trial to establish feasibility among 133 Veterans who met criteria for hearing loss based on the Hearing Handicapped Inventory-Screen (HHI-S)³ and a single item question. Veterans were randomized to receive amplifiers at the beginning (intervention) or end (control) of their ED visit and were surveyed prior to discharge. We conducted phone calls at five and 35 days to assess ED return visits. Feasibility was quite high with over 65 percent of those who screened positive consenting to participate. Veterans were more likely to be able to listen without effort during their visit if they had a PA compared to those who did not have a PA (76 percent versus 56 percent). More importantly, Veterans with the PAs were much more likely to report that they were told their diagnosis during their visit (75 percent vs. 36 percent). Three percent of intervention Veterans reported an ED revisit within three days compared to 9 percent for control Veterans.⁴

Buoyed by these results, we launched and have nearly completed an efficacy trial of 300 Veterans in two facilities (VA NY Harbor Health System and James J. Peters VA Medical Center) and are now extending this work to an implementation trial that will include VA Syracuse Health Care, VA Eastern Colorado Health Care System, VA North Texas Health Care System, and Durham VA Health Care System facilities. We will use a stepwise increase in ED staff responsibility for implementation from 1) in-ED PA delivery and training Veterans how to use PAs during ED visits to 2) hearing loss screening to determine eligibility for PAs. With anticipated completion by the end of 2025, we aim to develop optimal strategies for screening for hearing loss, PA use, and secure storage and maintenance as guidance for all VA ED facilities across the country in delivering better hearing healthcare for our Veterans.

References

1. Hétu, R. “Mismatches between Auditory Demands and Capacities in the Industrial Work Environment,” Audiology 1994 Jan-Feb;33(1):1-14.
2. Orellana D, Busch-Vishniac IJ, West JE. “Noise in the Adult Emergency Department of Johns Hopkins Hospital,” Journal of the Acoustical Society of America 2007 Apr;121(4):1996-9.
3. Ventry IM, Weinstein “The Hearing Handicap Inventory for the Elderly: a New Tool,” Ear and Hearing 1982 May-June;3(3):128-34.
4. Chodosh J, et al. “The HEAR-VA Pilot Study: Hearing Assistance Provided to Older Adults in the Emergency Department,” Journal of the American Geriatrics Society 2021 Apr;69(4):1071-8.