Here are some Case Studies that we wrote up when we were working with the Risk Management folks at our local hospital. These were all "real life" situations and were used to help train staff about working with hard of hearing people, and in many of the changes they have made to their procedures and policies.
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The following situations are a few that were shared with the Hearing Loss Association of Lane County by their members who used a Medical Center’s services during the past year. *Correct names are not used to protect patient confidentiality.

Case One:
Karen, a 58 year-old hard of hearing woman, accompanied her hearing husband to River Bend facility. Her husband Everett, who is hearing, was scheduled for surgery requiring a short stay in the hospital. When Everett was completing the Pre-surgery process, he clearly stated that his wife was very hard of hearing and concerned about how things would go with her communication needs before and after surgery. The staff person did not know about anything that could be done to help with this issue. The morning of his surgery, Karen and her husband checked in at Surgery Waiting. A sign was well-displayed on the counter for people to let staff know of any communication needs.

Karen self-identified immediately, that she is hard of hearing and explained ways the staff could best communicate with her. She articulated that it was critically important to her to talk with the Doctor after Everett’s surgery. She again self-identified her hearing loss and expressed her need for no breakdown in communication. As part of the check-in, Karen was given a form that had blanks to write her name and contact information (home telephone number, cell phone number, etc.). No explanation was given on the form or otherwise as to how or when this information would be used.

The hospital has a vibrating/beeping pager which is handed out if the family member will be outside the waiting area (in the cafeteria or in the lobby, etc). With several hours to wait, Karen and her friend decided to go to the cafeteria. The front desk staff, giving Karen the alerting pager, didn't set this pager to vibrate until she suggested they do so, even though they knew she was hard of hearing. Karen would not be able to hear the pager beeping due to her hearing loss. After returning to the main waiting area, they took back the pager. Karen reminded them of her need to talk with the Doctor and that she would be in the Surgery waiting area for the duration. When the Doctor wanted to talk with Karen after surgery, the front desk staff went around calling her name in the large waiting area. Karen was not able to hear them calling. She later learned the hospital called her at home even as she was in the waiting room. If Karen had known the purpose of the sign-in sheet, she would have given them her cell phone number or her friend’s PDA email address.

After doing everything to self-advocate and express her communication needs, she still missed the opportunity to talk with the Doctor. This made her extremely upset given the care she took to self-identify, explain and to anticipate potential areas where miscommunication could happen. Not having direct information from the Doctor created additional stress for her. The Reception staff quickly apologized and called for the Doctor right away but he had already left the hospital. Arrangements were then made for him to call Karen once Everett was in his room.

Throughout her husband’s hospital stay, nothing much was offered for hearing assistance. Karen continued to self-identify in several situations but did not receive a hospital kit or other things that could have made her experience less stressful.

Points/Questions:
Karen self-identified and strongly advocated her needs. Communication breakdown could have been avoided.
v Policy should be to sign out one of the pagers and set it to vibrate as soon as anyone is identified as hard of hearing. When Karen suggested this to staff after she missed talking to the Doctor, they said they thought this was a good idea. Shifts change frequently or they get busy and forget there is someone needing special assistance.
A note posted behind the desk would serve as a visual reminder that they need to summon/alert the hard of hearing person with the pager, rather than calling out their name.
How is it determined when/how the Hospital kits get distributed?

Case Two:
Bonnie, an 81 year-old woman, began experiencing sudden and sharp pain in her abdomen and difficulty breathing. She made a trip to Emergency at the University hospital on a Tuesday with 6 hours of testing and sent home. She made another emergency trip on Saturday of the same week. (Blood pressure was under 100 during both visits).

During the second visit, she was admitted and diagnosed with a severe Diverticulitis infection. Bonnie stayed in the hospital for four days and received medication around the clock.

Bonnie identified herself in the Emergency Area and again when she was admitted, as being very hard of hearing. She told staff over and over again about the need to wear her cochlear implant processor in order to communicate and that she needed to lip read. Staff was very nice to her and they did put up the sign on her door but they did not use the rest of the Hospital Kit or offer her any Assistive Listening Device. They relied on family members to repeat things or answer for Bonnie.

Staff needs to be trained about the Hospital Kits – what and where they are, and how to use them Patients should not have to expend a lot of energy advocating or educating staff when they are sick and weak. These services should be offered automatically as soon as someone realizes they have a hard of hearing patient or family member involved.
A PockeTalker or Realtime Captioning should have been routinely used with Bonnie.

Case Three:
Donna, a 58-year old woman, with no history of heart problems, began experiencing chest pains and shortness of breath while at home. Alone and scared, she drove herself to Emergency. Having “deaf speech” often times makes it easy for others to recognize Donna has a significant hearing loss. Although she’s not usually shy about self-identifying about her hearing loss (she’s been hard of hearing since a child), she did not self-identify during this stressful situation. Donna, being in pain and stressed, did not ask for accommodations (Hospital kit, signage, PockeTalker), nor was she offered anything.

After preliminary testing, she was admitted to the Cardiology Unit for more testing. At that time she did not have an advocate with her. In the Unit, there was no signage and no offer of amplification. Before one of the procedures, she was asked to watch an educational video which was not captioned. She was asked to sign an Informed Consent/Release form. Donna told the nurse that she was unable to understand the video without captions. At this time, the nurse asked a family member (not involved in Donna’s care) if she had watched the video. When the family member said she had, the nurse told Donna she could go ahead and sign the Informed Consent/Release, even though Donna was not able to understand the medical process she was signing for.

Still alone, scared and stressed, approximately 36 hours took place without any accommodations with communication access from the hospital Staff. She had to ask many times for repeats and said she could not understand what she was being told. Once her friends learned about her emergency, she received their help with advocating for her communication needs.

Points/Questions:
Donna was alone and frightened. She didn’t self-identify but could be identified as hard of hearing because of her speech and many requests for repeats.

Case Four:
Allan, a 55-year old male, was scheduled for knee replacement surgery. As part of the process for people receiving this type of surgery, he attended an orientation meeting. A presentation was given and an educational video was shown to give patients an idea of what to expect. Ann Browning, a Patient Care Coordinator, was very good about facing people and speaking clearly. The video shown was not captioned which made it nearly impossible for Allan to understand.

At the Pre-Registration process, the first part was given via a phone interview with Allan’s sister, who is involved with his care. During this interview, she informed the Registration person that Allan is hard of hearing, so it could be noted on his chart.

When they went to the hospital to meet with the Anesthesiologist, they met with a nurse who went over the list of prescriptions that Allan would be taking. No accommodations were in place during this meeting. With each person they saw, they asked them to face them and speak at a reasonable pace.

Day of Surgery, the staff was really good with making sure Allan could hear. In the Surgery Waiting area, the phones (available for family to talk with the Surgeon) were not Hearing Aid compatible nor were they amplified.

Allan was admitted to the hospital for several days. During the initial time, there was no Hospital Kit or signage used. When his sister brought him her own personal Kit for him to use, it was then that staff posted a “LAMP” sign (Look At Me Please). Despite the presence of the LAMP sign, his sister had to remind people to face him when they were trying to talk with him.

Allan especially had difficulty with understanding the doctor; whose poor communication skills made it a challenge for both Allan and his sister with following what he was saying. Nothing else was offered in terms of accommodations.

Points/or Questions:
Allan didn’t self-identify but had an advocate who spoke up several times.
Doctors are an important part of the HCAC project process – how can we educate them about interacting with hard of hearing patients/family?
If the educational videos are deemed important, why are they being shown without captions?

Case Five:
Bonne, is a 48-year old hard of hearing of a hearing patient having day surgery. Being responsible for her husband’s care, she was given an educational video at a Pre-surgical appointment, to watch which was not captioned. The voice was also dubbed by a different person, which made it impossible to lip-read the narrator.

In the Surgery Waiting Area, a call came for Bonne from the surgeon, reporting about her husband. The phones in the private room made available for family to take these calls were not hearing-aid compatible nor amplified. Unable to hear what the doctor was saying, she quickly asked the receptionist if she would take the call for her. In an open and full room of people, the receptionist reported (in a loud voice) what the surgeon was saying and the type of surgery that was performed.

The inability to take the call in the private manner as allowed to those without a hearing loss, led to feelings of embarrassment and violation of patient confidentiality.

Points/or Questions:
Bonne experienced unequal access to services as allotted to the hearing population
Experienced lack of privacy, embarrassment, and dependency on receptionist to take calls.

Case Six:
Susan, a 57-year old hard of hearing woman was having surgery (Short Stay). At the Pre-Registration process, she was identified as a hard of hearing person. The Registration person asked if she would like to use a PockeTalker/ FM system during the Patient interview process. Susan accepted her offer and with the use of this device, was able to communicate well and easily answer the questions. She also noticed a sign on the wall to let the staff know if using a Cochlear Implant (no MRI).

Susan met with the nurse regarding a list of medicines that would be taken. Although her chart was flagged with special communication needs, the nurse was not good with facing her. Susan was unable to lip-read and use visual cues that would have helped her with better understanding the nurse.

The Day of Surgery, no accommodations (Hospital Kit/Signage/ FM) were present neither in Short Stay nor in the Recovery Area. During the time in Recovery, Susan experienced a bad reaction to her medicine and became extremely stressed and afraid. Staff tried to help her but being stressed and in pain, her ability to communicate was greatly compromised.

Points/or Questions:
How realistic is it for the “alternative” format for one-on-one education work? Captioning was necessary
How realistic is it for busy staff and/or Doctors to write down on paper what’s being said? Captioning was needed.

Case Seven:
Leona, an 85-year old late-deafened female, experienced chest pains. She was admitted to Cardio Unit after complaining of chest pains (point of entry most likely Emergency) and was held for observation and testing. During this time, her niece visited her and noticed that signs from the Hospital Kit were posted in Leona’s room. However, her communication needs became “invisible” due to lack of signage on her person or on her IV pole whenever she left her room for testing.

Leona, given an educational video to watch about one of the procedures, was unable to understand it as the video did not have captions.

When the doctor came to see her after the testing, he did a good job with communicating by standing near her and speaking slower and clearly. Extremely deafened, she asked after the doctor finished speaking, “…so Doctor, what is your diagnosis?” He had just gone over the test results and stated his diagnosis. She had smiled and nodded – but had not understood him at all. This incident underscores that for some people, even in the best of circumstances (good lighting, quiet room, careful communication) ; their hearing loss is so severe that one-on-one communication is not successful. Realtime Captioning or Pocketalker was needed in this situation. As is the case with many hard of hearing and late deafened people, she did not use sign language.
Points/or Questions:
How is it decided on what part of the hospital kit gets used (which included signage for when the patient is mobile)? Signage needs to be mobile.
Realtime Captioning was the only realistic method of communication for this very deafened patient.

Case Eight:
Jean is an 81-year old late-deafened spouse and care-giver of a hearing patient. Jean and her 82-year old husband Fred, visitors from WashingtonState, were in town visiting friends. The day after they arrived, he suddenly disappeared and after a search by police and friends, was found driving dazed and confused the next morning in a town 45 miles away. Fred was initially taken to Urgent Care (Willamette St) by friends. He then transferred to Sacret Heart Emergency on recommendation by the clinic and was admitted as a patient.

With combined factors of stress over the whereabouts of her missing husband, fatigue, and needing to focus on getting her husband the health care he needed, Jean’s ability to advocate for her hearing needs was greatly reduced. She may not have self-identified at the beginning but it is readily apparent that she has a significant hearing loss, even with hearing aid amplification.

Jean, aware of the Hospital Communication access program, later asked her friend to request a Hospital Kit/FM for her. The nurse called Javier’s office and was initially told only he could provide this kit but he couldn’t be located. She was asked to keep trying as kits are intended to be available 24/7. The nurse discovered that kits were in Admitting and said one would be shortly retrieved. After waiting several hours and periodic checks, no hospital kit or FM was brought up.

In the meantime, the Neurologist came to talk with Jean and Fred with some of the initial test results. Jean struggled without the use of a PockeTalker or FM to understand his fast speaking pace. She did her best to keep up by using good communication strategies - self-identifying, positioning for better light on the Doctor’s face and asking for repeats. As Jean left for the night, the nurse apologized for not having a hospital kit/FM for her to use that evening and promised to have one waiting for her in the morning.

When Jean returned the next day, a different nurse informed her, “You won’t be getting one of those. They don’t work and no one likes them anyway.” At this point, friends brought their personal PockeTalker and kit for her to use and contacted Javier (who promptly brought her a hospital kit and FM*). When the Neurologist came to speak with her again, Jean now using the PockeTalker was able to understand him very well. She experienced less fatigue and stress and used the device for the duration of her husband’s hospital stay (3 days).

*Note: It was hard to hear using the hospital FM system. Upon a research call to General Technologies (where they were purchased), it was discovered that the system that was being used has inadequate amplification and they are being replaced with a stronger system.

Points/or Questions:
Jean – Issue of perceived importance of need (Deaf needsv understood more readily than hard of hearing/LD needs) Challenge – wide range of hearing loss – hard to identify sometimes.
Updated: Javier is exchanging the current Array FM systems for the Williams Sound Systems which produce a better quality sound.