Overcoming additional barriers in caring for deaf and hard of hearing patients during COVID-19 (2023)

The arrival of the novel coronavirus disease 2019 (COVID-19) in the United States in early 2020 has disrupted traditional clinical care and services. Healthcare facilities have been focusing heavily on managing the surge in COVID-19 patients and minimizing the risk of exposure and spread for those who do not have the virus. To protect doctors and patients, the facilities required personal protective equipment for everyone, introduced visiting restrictions that prevent visitors from helping their loved ones at the medical facility, and eliminated personal medical interpreters. These safety precautions compromise the ability of 17% of all American adults with hearing loss to communicate effectively with their physicians.¹thus affecting the quality of care.

Leading publications highlight significant communication barriers for deaf and hard of hearing (DHH) patients in normal times. This leads to a cascade of negative impacts on health and healthcare: increased readmission rates, increased medical costs, and reduced adherence to therapy.²Age is a strong risk factor for hearing loss and morbidity and mortality from COVID-19. The drastic change in health patterns puts these individuals at a significant disadvantage when it comes to communicating with each other and receiving proper care. Hospitals and designated clinics set up to treat COVID-19 positive patients have restrictions that make it difficult for patients with HDH to communicate (e.g., masks), often with little or no suggested resolution. These safety procedures protect patients and healthcare professionals, but compromise accessible and effective communication for patients with HDH, as required by the Americans with Disabilities Act.³We believe this can be resolved to everyone's satisfaction. Below we list some measures that can be implemented and already implemented to mitigate this new communication barrier between HDH patients and medical staff.

This allows HDH patients or their family members to read the lips of healthcare professionals. These masks are not approved for COVID-19 inpatient services where there is a high possibility of aerosolization. Clear masks not only improve communication, they can alleviate some of the anxiety that the sight of medical staff wearing personal protective equipment can create. Safe'N'Clear is the only version cleared by the FDA for medical use.⁴but others should be on the market soon. Until a clear mask is approved for COVID-19 inpatient services, a powered air-purifying ventilator is an option that would allow patients to see the lips of the person speaking.

Personal sign language interpreters are shifting to remote interpreting roles during the COVID-19 pandemic to save on personal protective equipment and reduce their risk. Remote interpretation can be provided by existing hospital staff interpreters, contracted medical interpreters, or remote video interpretation agencies. Many hospitals have videoconferencing equipment for hearing patients with limited English skills that can be easily adapted for sign language users. In rare cases, interpreters may receive training in personal protective equipment so that they can interpret in person when needed (for example, when a deafblind patient requires tactile signage). When appropriate, remote interpreters can connect virtually via various videoconferencing-based platforms that are HIPAA compliant. They can participate via tablets or laptops secured in mobile units or carts to facilitate communication between DHH patients and physicians. Medical interpreters must be certified and trained in healthcare interpreting.

Smartphones can access various applications for automated subtitling. They provide another personal communication tool and can be used on patients' personal or facility devices. These apps speak slowly and clearly into the device's microphone so that the voice can be transcribed for the listener. Computer-generated speech apps have higher error rates for background noise or accents. Therefore, it is important to speak slowly, clearly and at a comfortable volume to allow for better transcription. There are also live announcers who listen from a distance and record what is being said; these are more accurate but also more expensive. Fortunately, automatic speech recognition (ASR) platforms that incorporate machine learning are rapidly improving and will soon provide a viable alternative for in-person transcription needs.⁵Some existing ASR platforms are Google Live Transcribe, Otter.ai and Interact Streamer.

Virtual preparation is provided through video conferencing based platforms, some of which are not HIPAA compliant. Video conferencing platforms (e.g. Zoom) allow third parties to provide closed captioning; Google Hangout Meet is currently the only known video conferencing platform that provides live captions. HIPAA compliant video visits are often connected to patient portals for easy access to medical record information. Many approved virtual care platforms do not support the three-way video tour, a requirement for a third party (eg, an interpreter) to facilitate communication between a physician and patient. Large companies such as AmWell and Virtual Health support 3-way video tours, allowing the involvement of interpreters (signed or verbal) or real-time remote translation services. If a 3-way video visit cannot be established, clinicians must agree on backup plans to ensure effective communication. This may require the use of BlueJeans or Zoom videoconferencing platforms, or a phone meeting where HDH patients can use one of their favorite telecommunications referral service options.

Telecommunications routing services provide a routing service operator that signs or scripts calls, allowing DHH individuals to communicate with individuals using a standard telephone. An example is a text phone or video relay service, where a relay operator or interpreter relays the typed or signed conversation to a listener and then writes or signs the listener's spoken response back to HRH. Other popular options include closed captioning phone services or the InnoCaption +  app, where an operator transcribes caller responses into text on the phone.

Using posters to inform doctors and staff can be very helpful, especially when the patient is asleep, unresponsive or intubated. These signs can be printed with hearing loss symbols or text and placed in prominent locations in patients' rooms (eg, above the patient's bed or door). They help to reduce the assumptions that the patient will be able to listen and communicate effectively and encourage provision for needed provision.

These communication tools allow for quick communication between doctors and staff when other accommodations cannot be arranged. In addition, these tools can help late-deaf patients who may have difficulty with other forms of adaptation. As many patients with COVID-19 infection use ventilators, these tools can facilitate basic forms of communication when other avenues of communication may be impaired.

Deaf and hard of hearing patients were already struggling to communicate in the pre-COVID-19 world. Now, with the hurdles added, we must not forget the foundation of good care and patient satisfaction: effective doctor-patient communication. Disrupting existing communication paradigms allows us to creatively use face-to-face and remote technology to maximize the accessibility of communication. With the rapid expansion of virtual care, or telemedicine, during this COVID-19 pandemic, we must ensure that patient safety, understanding and access to quality healthcare are maintained for many HDH patients. Finally, we need to ask patients with HDH which communication strategies work best for them. The severity of hearing loss, language and communication preferences, and existing physical, mental, and cognitive limitations can vary. Additional resources, including recommended housing, signage, and resources for hospitals and healthcare professionals, can be found on the National Association of the Deaf's COVID-19 pages.⁶the Association of Physicians with Hearing Loss,⁷and the Hearing Loss Association of America.⁸

Corresponding author:Michael M. McKee, MD, MPH, University of Michigan School of Medicine, Department of Family, 1018 Fuller St, Ann Arbor, MI 48109 (mmmckee@med.umich.edu).

Posted online:July 16, 2020. two:10.1001/jamaoto.2020.1705

Disclosure of Conflicts of Interest:None reported.