Barriers and Facilitators to Using 9-1-1 and Emergency Medical Services in a Limited English Proficiency Chinese Community

Comparison of stroke process measures and clinical outcomes between English and Non-English preferring patients

BACKGROUND

In the United States, limited English proficiency may reduce the quality of care and worsen outcomes after stroke. The aim was to compare stroke process measures and clinical outcomes between English preferring and non-English preferring stroke patients.

METHODS/MATERIALS

This single-center retrospective cohort study evaluated patients from one United States hospital with acute ischemic stroke between July 2013 and June 2022. The primary outcomes were defect-free care, a composite of 7 stroke process measures, and independent ambulation at hospital discharge. Multivariate logistic regression models quantified the association between language preference and outcomes. Secondary outcomes included individual components of defect-free care, discharge modified Rankin scale, and discharge disposition.

RESULTS

There were 4,030 patients with acute ischemic stroke identified, of which 2,965 were matched with language data from the electronic medical record. There were 373 non-English preferring patients, among which 76.9% preferred Spanish and 23.1% were non-English, non-Spanish preferring. In the multivariable model, there was no significant association between non-English preference and defect-free care (OR=0.64, 95% CI=0.26-1.59) or independent ambulation at discharge (OR=0.89, 95% CI=0.67-1.17). When compared to Spanish preferring patients, non-English, non-Spanish preferring patients had more severe strokes (P<0.001) but there was no difference in defect-free care or independent ambulation after adjustment.

CONCLUSION

Our results suggest that process and clinical outcomes are similar regardless of language preference; although, our data are limited by small numbers of non-English, non-Spanish preferring patients. Additional research is needed among this population.

Prevalence of Low-Acuity Pediatric Emergency Medical Services Transports to a Pediatric Emergency Department in an Urban Area

OBJECTIVES

Many patients transported by Emergency Medical Services (EMS) do not have emergent resource needs. Estimates for the proportion of pediatric EMS calls for low-acuity complaints, and thus potential candidates for alternative dispositions, vary widely and are often based on physician judgment. A more accurate reference standard should include patient assessments, interventions, and dispositions. The objective of this study was to describe the prevalence and characteristics of low-acuity pediatric EMS calls in an urban area.

METHODS

This is a prospective observational study of children transported by EMS to a tertiary care pediatric emergency department. Patient acuity was defined using a novel composite measure that included physiologic assessments, resources used, and disposition. Bivariable and multivariable logistic regression were conducted to assess for factors associated with low-acuity status.

RESULTS

A total of 996 patients were enrolled, of whom 32.9% (95% confidence interval, 30.0-36.0) were low acuity. Most of the sample was Black, non-Hispanic with a mean age of 7 years. When compared with adolescents, children younger than 1 year were more likely to be low acuity (adjusted odds ratio, 3.1 [1.9-5.1]). Patients in a motor vehicle crash were also more likely to be low acuity (adjusted odds ratio, 2.4 [1.2-4.6]). All other variables, including race, insurance status, chief complaint, and dispatch time, were not associated with low-acuity status.

CONCLUSIONS

One third of pediatric patients transported to the pediatric emergency department by EMS in this urban area are for low-acuity complaints. Further research is needed to determine low-acuity rates in other jurisdictions and whether EMS providers can accurately identify low-acuity patients to develop alternative EMS disposition programs for children.

Perceptions of Prehospital Care for Patients With Limited English Proficiency Among Emergency Medical Technicians and Paramedics

IMPORTANCE

Patients with limited English proficiency (LEP) experience disparities in prehospital care. On-scene interactions between patients with LEP and emergency medical services (EMS) providers (ie, firefighters/emergency medical technicians [EMTs] and paramedics) are critical to high-quality care and have been minimally explored.

OBJECTIVE

To identify EMS-perceived barriers and facilitators to providing high-quality prehospital care for patients with LEP.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, semi-structured focus groups were conducted with firefighters/EMTs and paramedics with all levels of experience from urban areas with a high proportion of residents with LEP from July to September 2018. Data were analyzed from July 2018 to May 2019.

EXPOSURES

Providing prehospital care for patients with LEP.

MAIN OUTCOMES AND MEASURES

The main outcomes were barriers and facilitators to prehospital care for patients with LEP, assessed using thematic analysis. Four domains of interest were examined: (1) overall impressions of interactions with patients with LEP, (2) barriers and facilitators to communication, (3) barriers and facilitators to providing care, and (4) ideas for improving prehospital care for patients with LEP.

RESULTS

Thirty-nine EMS providers participated in 8 focus groups: 26 firefighters/EMTs (66%) and 13 paramedics (33%). The median age of participants was 46 years (range, 23-63 years), and 35 (90%) were male. Participants described barriers to optimal care as ineffective interpretation, cultural differences, high-stress scenarios (eg, violent events), unclear acuity of patient's condition, provider bias, and distrust of EMS. Perceived facilitators to optimal care included using an on-scene interpreter, high-acuity disease, relying on objective clinical findings, building trust and rapport, and conservative decision-making regarding treatment and transport. Providers reported transporting most patients with LEP to hospitals regardless of illness severity due to concern for miscommunication and unrecognized problems. Better speed and technology for interpretation, education for communities and EMS providers, and community-EMS interactions outside emergencies were cited as potential strategies for improvement.

CONCLUSIONS AND RELEVANCE

In this study, EMS providers described many barriers to high-quality care during prehospital emergency response for patients with LEP yet were unaware that these barriers impacted quality of care. Barriers including ineffective interpretation, provider bias, distrust of EMS, and cultural differences may contribute to outcome disparities and overutilization of resources. Future work should focus on the development of targeted interventions to improve modifiable barriers to care, such as improving interpretation and cultural humility and increasing trust.

Breaking through barriers: the need for effective research to promote language-concordant communication as a facilitator of equitable emergency care

Individuals with limited English proficiency (LEP) are at high risk for adverse outcomes in the US health care system. This is particularly true for patients with LEP seeking care in the emergency department (ED). Although professional language interpretation improves the quality of care for these patients, it remains underused. The dynamic, discontinuous nature of an ED visit poses distinct challenges and opportunities for providing equitable, high-quality care for patients with LEP. Evidence-based best practices for identifying patients with LEP and using professional interpretation are well described but inadequately implemented. There are few examples in the literature of rigorous interventions to improve quality of care and outcomes for patients with LEP. There is an urgent need for high-quality research to improve communication with patients with LEP along the continuum of emergency care in order to achieve equity in outcomes.

"I'm sorry, my English not very good": Tracking differences between Language-Barrier and Non-Language-Barrier emergency ambulance calls for Out-of-Hospital Cardiac Arrest

BACKGROUND

One-fifth of Australia's population do not speak English at home. International studies have found emergency calls with language barriers (LB) result in longer delays to out-of-hospital cardiac arrest (OHCA) recognition, and lower rates of bystander cardiopulmonary resuscitation (CPR) and survival. This study compared LB and non-LB OHCA call time intervals in an Australian emergency medical service (EMS).

METHODS

The retrospective cohort study measured time intervals from call commencement for primary outcomes: (1) address acquisition; (2) OHCA recognition; (3) CPR initiation; (4) telecommunicator CPR (t-CPR) compressions, in all identified LB calls and a 2:1 random sample of non-LB EMS calls from January to June 2019. Results for time intervals #1, 2, and 4 were benchmarked against the American Heart Association's (AHA) t-CPR minimal acceptable time standards. Patient survival outcomes were compared.

RESULTS

We identified 50 (14%) LB calls from a cohort of 353 calls. LB calls took longer than non-LB calls (n=100) for: address acquisition (median 29 vs 14 secs, p<0.001), OHCA recognition (103 vs 85 secs, p=0.02), and CPR initiation (206 vs 164 secs, p=0.01), but not for t-CPR compressions (292 vs 248 secs, p=0.12). Rates of OHCA recognition and 30-day-survival did not differ but smaller proportions of LB calls met the AHA standards.

CONCLUSION

Time delays found in LB calls point to phases of the call which need further qualitative investigation to understand how to improve communication. Overall, training call-takers for LB calls may assist caller understanding and cooperation during OHCAs.

Association of Insurance With Use of Emergency Medical Services Among Children

OBJECTIVE

The use of emergency medical services (EMS) can be lifesaving for critically ill children and should be defined by the child's clinical need. Our objective was to determine whether nonclinical demographic factors and insurance status are associated with EMS use among children presenting to the emergency department (ED).

METHODS

In this cross-sectional study using the National Hospital Ambulatory Medical Care Survey, we included children presenting to EDs from 2009 to 2014. We evaluated the association between EMS use and patients' insurance status using multivariable logistic regressions, adjusting for demographic, socioeconomic, and clinical factors such as illness severity as measured by a modified and recalibrated version of the Revised Pediatric Emergency Assessment Tool (mRePEAT) and the presence of comorbidities or chronic conditions. A propensity score analysis was performed to validate our findings.

RESULTS

Of the estimated 191,299,454 children presenting to EDs, 11,178,576 (5.8%) arrived by EMS and 171,145,895 (89.5%) arrived by other means. Children arriving by EMS were more ill [mRePEAT score, 1.13; 95% confidence interval (CI), 1.12-1.14 vs mRePEAT score, 1.01; 95% CI: 1.01-1.02] and more likely to have a comorbidity or chronic condition (OR: 3.17, 95% CI: 2.80-3.59). In the adjusted analyses, the odds of EMS use were higher for uninsured children and lower for children with public insurance compared with children with private insurance [OR (95% CI): uninsured, 1.41 (1.12-1.78); public, 0.77 (0.65-0.90)]. The propensity score analysis showed similar results.

CONCLUSIONS

In contrast to adult patients, children with public insurance are less likely to use EMS than children with private insurance, even after adjustment for illness severity and other confounders.

Medical Characteristics of Foreign Language Patients in Paramedic Care

Background: In this study, medical and socio-demographic characteristics of foreign language patients in prehospital emergency medical care are analyzed and compared with non-foreign language patients. Methods: We performed retrospective chart review of rescue operations in four emergency medical service stations in Northern Germany over seven months as part of the DICTUM Rescue study (DRKS00016719). We performed descriptive analyses including test statistics and used partial correlation to adjust for patients’ sex and age. Results: Patients with limited German proficiency were served in 2.2% of all 7494 covered rescue operations. On average, these patients were two decades younger than their German speaking counterparts. There were significantly more patients with limited German proficiency with gynecological and obstetric problems, especially births, as well as psychiatric disorders, especially suicide attempts. Conclusions: Our findings suggest that the existing preventive programs for pregnant women and people at risk of suicide do not sufficiently reach patients with limited German proficiency. Additionally, giving birth and psychiatric breakdowns are exceptional and sensitive situations, both for patients and the paramedic staff, where the ability to communicate safely appears to be of enormous importance to enable safe treatment.

Working toward Equity in Emergencies (WE) through Stop the Bleed: A pilot collaborative health program with the Somali community in Seattle

BACKGROUND

We developed a culturally-adapted program (WE Stop the Bleed) to increase bleeding control knowledge and self-efficacy among Somali individuals, and to build trust between Somali individuals and first responders.

METHODS

WE Stop the Bleed was piloted in the Seattle Somali community with first responders as skills coaches. The program included: 1) adapted ACS Stop the Bleed program; 2) cultural exchange. We evaluated knowledge, self-efficacy, and trust between Somali participants and first responders using a pre/post survey.

RESULTS

Attendance exceeded a priori goals (27 community participants, 13 first responders). 96% of participants would recommend the training. Knowledge and self-efficacy improved pre/post (62%-72%, 65%-93% respectively). First responders indicated increased comfort with Somali individuals, and participants reported positive changes in perceptions of first responders.

CONCLUSIONS

WE Stop the Bleed is a feasible and acceptable program to increase bleeding control knowledge and self-efficacy among participants and build trust between participants and first responders.

Emergency Medical Services Utilization by Children

OBJECTIVE

The aim of this study was to compare demographic and clinical features of children (0-14 years old) who arrived at general emergency departments (EDs) by emergency medical services (EMS) to those who arrived by private vehicles and other means in a rural, 3-county region of northern California.

METHODS

We reviewed 507 ED records of children who arrived at EDs by EMS and those who arrived by other means in 2013. We also analyzed prehospital procedures performed on all children transported to an area hospital by EMS.

RESULTS

Children arriving by EMS were older (9.0 vs 6.0 years; P < 0.001), more ill (mean Severity Classification Score, 2.9 vs 2.4; P < 0.001), and had longer lengths of stay (3.6 vs 2.1 hours; P < 0.001) compared with children who were transported to the EDs by other means. Children transported by EMS received more subspecialty consultations (18.7% vs 6.9%; P < 0.05) and had more diagnostic testing, including laboratory testing (22.9% vs 10.6%; P < 0.001), radiography (39.7% vs 20.8%; P < 0.001), and computed tomography scans (16.8% vs 2.9%; P < 0.001). Children arriving by EMS were transferred more frequently (8.8% vs 1.6%; P < 0.001) and had higher mean Severity Classification Scores compared with children arriving by other transportation even after adjusting for age and sex (β = 0.48; 95% confidence interval, 0.35-0.61; P < 0.001). Older children received more prehospital procedures compared with younger children, and these were of greater complexity and a wider spectrum.

CONCLUSIONS

Children transported to rural EDs via EMS are more ill and use more medical resources compared with those who arrive to the ED by other means of transportation.

Ethnicity and pre-hospital care for people with suspected cardiac pain: cross-sectional study

OBJECTIVES

Few studies have investigated the quality of pre-hospital care by ethnicity. We aimed to investigate ethnic differences in pre-hospital ambulance care of patients with suspected cardiac pain.

METHODS

We conducted a cross-sectional analysis of retrospective electronic clinical data for patients with suspected cardiac pain over one year (August 2011 to July 2012) extracted from a single regional ambulance service. This included patient demographic data, clinical measurements, drugs administered and outcomes, such as transportation to hospital or referral to primary care. We used multivariate regression to investigate differences in care by ethnicity comparing non-White with White patients.

RESULTS

There were 7046 patients with suspected cardiac pain, with 4825 who had ethnicity recorded including 4661 (96.6%) White and 164 (3.4%) non-White. After correcting for age, sex, socio-economic status and whether transported to hospital, non-White patients were significantly more likely to have temperature [odds ratio (OR) 2.96, P = 0.007], blood glucose (OR 3.95, P = 0.003), respiratory rate (OR 4.94, P = 0.03) and oxygen saturation (OR 2.43, P = 0.006) recorded. Non-White patients were significantly less likely to be transported to hospital (OR 0.43, P = 0.03).

CONCLUSION

There were significant differences in pre-hospital ambulance care for non-White compared with White patients with suspected cardiac pain. These differences could be due to differences in clinical condition or case-mix, language and cultural barriers, limited understanding of appropriate use of health care services, recording bias or true differences in provider management. Further analysis should involve larger and more complete data sets to explore ethnic differences in greater detail.

(Non-)utilization of pre-hospital emergency care by migrants and non-migrants in Germany

OBJECTIVES

This study was designed to explore the utilization and non-utilization of pre-hospital emergency care by migrants and non-migrants, and the factors that influence this behaviour.

METHODS

A cross-sectional representative German survey was conducted in a sample of 2.175 people, 295 of whom had a migration background. An additional sample of 50 people with Turkish migration background was conducted, partially in the Turkish language. Apart from socio-demographics, the utilization of emergency services and the reasons for non-utilization were assessed.

RESULTS

Migrants had a higher utilization rate of pre-hospital emergency care (RR = 1.492) than non-migrants. Furthermore, migrants who were not born in Germany had a lower utilization rate (RR = 0.793) than migrants who were born in Germany. Regarding non-utilization, the most frequently stated reasons belonged to the categories initial misjudgment of the emergency situation and acting on one's own behalf, with the latter stated more frequently by migrants than by non-migrants.

CONCLUSIONS

To prevent over-, under-, and lack of supply, it is necessary to transfer knowledge about the functioning of the medical emergency services, including first aid knowledge.

Emergency communications within the limited English proficient Chinese community

Limited English speaking communities face communication challenges during emergencies. Our objective was to investigate Chinese limited English proficiency individuals' perceptions of and inclination to interact with emergency communication systems. A telephone survey was conducted in Mandarin or Cantonese with 250 ethnic Chinese individuals who spoke little or no English. Respondents who spoke no English were less likely to name 9-1-1 as their first source of help for a medical emergency than those who spoke some English (p < 0.01). Those reporting higher levels of confidence in handling the situation were more likely to name 9-1-1 as their first source of help, as were those who listed 9-1-1 as their most trusted source of help (p < 0.01). For this group, the results indicate that calling 9-1-1 may require a sense of self-efficacy. Not calling 9-1-1 in a medical emergency can have serious health consequences, thus interventions are needed to increase confidence in accessing 9-1-1.

Strategies Used by Prehospital Providers to Overcome Language Barriers

OBJECTIVE

Language barriers are commonly encountered in the prehospital setting but there is a paucity of research on how prehospital providers address language discordance. We sought to identify the communication strategies, and the limitations of those strategies, used by emergency medical services (EMS) providers when confronted with language barriers in a variety of linguistic and cultural contexts.

METHODS

EMS providers were queried regarding communication strategies to overcome language barriers as part of an international, multi-site, sequential explanatory, qualitative-predominant, mixed methods study of prehospital language barriers. A survey of EMS telecommunicators was administered at dispatch centers in New Mexico (United States) and Western Cape (South Africa). Semi-structured qualitative interviews of EMS field providers were conducted at agencies who respond to calls from participating dispatch centers. Survey data included quantitative data on demographics and communication strategies used to overcome language barriers as well as qualitative free-text responses on the limitations of strategies. Interviews elicited narratives of encounters with language-discordant patients and the strategies used to communicate. Data from the surveys and interviews were integrated at the point of analysis.

RESULTS

125 telecommunicators (overall response rate of 84.5%) and a purposive sample of 27 field providers participated in the study. The characteristics of participants varied between countries and between agencies, consistent with variations in participating agencies' hiring and training practices. Telecommunicators identified 3rd-party telephonic interpreter services as the single most effective strategy when available, but also described time delays and frustration with interpreter communications that leads them to preferentially try other strategies. In the field, all providers reported using similar strategies, relying heavily on bystanders, multilingual coworkers, and non-verbal communication. Prehospital providers described significant limitations to these strategies, including time delays, breaches of patient confidentiality, and inaccurate interpretation. Participants suggested various resources to improve communication with language-discordant patients.

CONCLUSIONS

Prehospital providers rely upon similar, informal strategies for overcoming language barriers across a variety of locations, provider types, and linguistic and cultural contexts.

The Need for More Prehospital Research on Language Barriers: A Narrative Review

INTRODUCTION

Despite evidence from other healthcare settings that language barriers negatively impact patient outcomes, the literature on language barriers in emergency medical services (EMS) has not been previously summarized. The objective of this study is to systematically review existing studies of the impact of language barriers on prehospital emergency care and identify opportunities for future research.

METHODS

A systematic review with narrative synthesis of publications with populations specific to the prehospital setting and outcome measures specific to language barriers was conducted. A four-prong search strategy of academic databases (PubMed, Academic Search Complete, and Clinical Key) through March 2015, web-based search for gray literature, search of citation lists, and review of key conference proceedings using pre-defined eligibility criteria was used. Language-related outcomes were categorized and reported as community-specific outcomes, EMS provider-specific outcomes, patient-specific outcomes, or health system-specific outcomes.

RESULTS

Twenty-two studies met eligibility criteria for review. Ten publications (45%) focused on community-specific outcomes. Language barriers are perceived as a barrier by minority language speaking communities to activating EMS. Eleven publications (50%) reported outcomes specific to EMS providers, with six of these studies focused on EMS dispatch. EMS dispatchers describe less accurate and delayed dispatch of resources when confronted with language discordant callers, as well as limitations in the ability to provide medical direction to callers. There is a paucity of research on EMS treatment and transport decisions, and no studies provided patient-specific or health system-specific outcomes. Key research gaps include identifying the mechanisms by which language barriers impact care, the effect of language barriers on EMS utilization and clinically significant outcomes, and the cost implications of addressing language barriers.

CONCLUSION

The existing research on prehospital language barriers is largely exploratory, and substantial gaps in understanding the interaction between language barriers and prehospital care have yet to be addressed. Future research should be focused on clarifying the clinical and cost implications of prehospital language barriers.

A Mixed Methods Study of Health Care Experience Among Asian Indians in the Southeastern United States

PURPOSE

The study explored health care experiences among Asian Indian immigrants living in the Southeastern United States.

DESIGN AND METHOD

A concurrent triangulation mixed methods design was used with a purposive sample of 125 Asian Indian immigrants aged between 40 and 64 years in the survey and 10 participants in the focus group.

RESULTS

The majority of the participants had health insurance and higher socioeconomic status. They had a moderate level of knowledge on the U.S. health care system and health insurance while presenting moderate satisfaction with the system. Barriers to health care services and needs in the health care system were identified from both quantitative and qualitative data. Some of the barriers were high costs, dissatisfaction with services, and inconvenience in accessing services. Participants called for self-management and community-based health programs as well as culturally tailored health care services.

DISCUSSION AND CONCLUSION

Findings congruent with prior studies further support the importance of comprehending Asian Indians' unique cultural background and experiences in the health care system. This study can be the foundation for culturally competent care to advance the body of transcultural nursing knowledge.

IMPLICATIONS FOR PRACTICE

Culturally congruent community-based health care programs are needed to provide better care for the ethnic minority to maintain and promote their health status.

Preparedness for cardiac emergencies among Cambodians with limited English proficiency

In the United Sates, populations with limited English proficiency (LEP) report barriers to seeking emergency care and experience significant health disparities, including being less likely to survive cardiac arrest than whites. Rapid utilization of 9-1-1 to access emergency services and early bystander cardiopulmonary resuscitation (CPR) is crucial for successful resuscitation of out-of-hospital cardiac arrest patients. Little is understood about Asian LEP communities' preparedness for emergencies. In this exploratory survey, we sought to assess intentions to call 9-1-1 in an emergency and knowledge of CPR in the Cambodian LEP community. We conducted an in-person interview with 667 Cambodian adults to assess their intentions to call 9-1-1 and their awareness of and training in bystander CPR. While the majority of participants stated that they would call 9-1-1 in an emergency, almost one-third of the sample would call a friend or family member. Awareness of CPR was very high but training in CPR was lower, especially for women. A higher level of English proficiency and greater proportion of time in the US was a strong predictor of CPR training and intention to call 9-1-1 in an emergency. This suggests that greater efforts need to be made to reach the most linguistically-isolated communities (those with little or no English) with emergency information in Khmer.