Use of Interpreter Services in the Emergency Department

Bridging the Language Gap in Healthcare: Implementing a Qualified Medical Interpreter Program for Lesser-Spoken Languages

Linguistic inequity drives systemic disparities in healthcare for non-native English speakers. This study evaluates a project to train and provide qualified medical interpreters (QMI) to assist volunteer and safety-net clinics and community-based organizations in supporting healthcare for immigrants and refugees. We provided scholarships to bilingual community members to take a medical interpreter training course and developed a workforce for those who passed the training course. We focused on lesser-spoken foreign languages such as Arabic, Amharic, Pashto, Dari, and Burmese. Those who passed the course participated in a semi-structured interview to learn about their experiences in the training program, as well as barriers and facilitators to becoming a QMI. To date, 23 people have passed the training and are part of the QMI workforce program that has provided 94 h of interpreter services over four months, serving 66 individual patients. The evaluation showed that community members have interest in becoming QMIs and many have the required language proficiency to enroll and pass training. Finding full-time employment for less spoken languages has proven to be challenging.

The Effect of Language on the Decision to Image in the Evaluation of Atraumatic Headache

BACKGROUND

Patients with limited English proficiency seen in the emergency department (ED) experience lower quality of care and higher diagnostic resource utilization unless they are evaluated in their own language. Despite a low rate of serious pathology identified and the availability of guidelines to direct its use, computed tomography (CT) is commonly used to evaluate atraumatic headache in the ED.

OBJECTIVE

Our aim was to determine whether Spanish-speaking patients with atraumatic headache were more likely than their English-speaking counterparts to undergo head CT, and whether evaluation by a clinician who passed a Spanish proficiency test mitigated this difference.

METHODS

This retrospective observational study used electronic health record data of adult patients presenting with atraumatic headache to a level I trauma center during a 2-year period. Spanish-language testing of clinicians consisted of a brief, unvalidated, in-person, nonmedical verbal test administered by human resources staff.

RESULTS

A total of 3030 patients with atraumatic headache were identified; 1437 were English speaking and 1593 were Spanish speaking. Spanish-speaking patients were older (48.3 vs. 41.9 years), more likely to be women (68.8% vs. 60.5%), and more likely to undergo head CT (31.8% vs. 26.4%). Evaluation by a clinician who passed the Spanish proficiency test had no significant influence on the likelihood of head CT for Spanish-speaking patients after controlling for confounding variables (adjusted odds ratio 0.95; 95% CI 0.75-1.20).

CONCLUSIONS

Spanish-speaking patients are more likely to undergo head CT when evaluated for atraumatic headache than English-speaking patients. Evaluation by a clinician who passed a brief Spanish proficiency test did not mitigate this disparity.

Race and Ethnicity and Primary Language in Emergency Department Triage

Importance

Emergency department (ED) triage substantially affects how long patients wait for care but triage scoring relies on few objective criteria. Prior studies suggest that Black and Hispanic patients receive unequal triage scores, paralleled by disparities in the depth of physician evaluations.

Objectives

To examine whether racial disparities in triage scores and physician evaluations are present across a multicenter network of academic and community hospitals and evaluate whether patients who do not speak English face similar disparities.

Design, Setting, and Participants

This was a cross-sectional, multicenter study examining adults presenting between February 28, 2019, and January 1, 2023, across the Mass General Brigham Integrated Health Care System, encompassing 7 EDs: 2 urban academic hospitals and 5 community hospitals. Analysis included all patients presenting with 1 of 5 common chief symptoms.

Exposures

Emergency department nurse-led triage and physician evaluation.

Main Outcomes and Measures

Average Triage Emergency Severity Index [ESI] score and average visit work relative value units [wRVUs] were compared across symptoms and between individual minority racial and ethnic groups and White patients.

Results

There were 249 829 visits (149 861 female [60%], American Indian or Alaska Native 0.2%, Asian 3.3%, Black 11.8%, Hispanic 18.8%, Native Hawaiian or Other Pacific Islander <0.1%, White 60.8%, and patients identifying as Other race or ethnicity 5.1%). Median age was 48 (IQR, 29-66) years. White patients had more acute ESI scores than Hispanic or Other patients across all symptoms (eg, chest pain: Hispanic, 2.68 [95% CI, 2.67-2.69]; White, 2.55 [95% CI, 2.55-2.56]; Other, 2.66 [95% CI, 2.64-2.68]; P < .001) and Black patients across most symptoms (nausea/vomiting: Black, 2.97 [95% CI, 2.96-2.99]; White: 2.90 [95% CI, 2.89-2.91]; P < .001). These differences were reversed for wRVUs (chest pain: Black, 4.32 [95% CI, 4.25-4.39]; Hispanic, 4.13 [95% CI, 4.08-4.18]; White 3.55 [95% CI, 3.52-3.58]; Other 3.96 [95% CI, 3.84-4.08]; P < .001). Similar patterns were seen for patients whose primary language was not English.

Conclusions and Relevance

In this cross-sectional study, patients who identified as Black, Hispanic, and Other race and ethnicity were assigned less acute ESI scores than their White peers despite having received more involved physician workups, suggesting some degree of mistriage. Clinical decision support systems might reduce these disparities but would require careful calibration to avoid replicating bias.

Impact of Native Language, English Proficiency, and Language Concordance on Interpersonal Care During Evaluation of Acute Coronary Syndrome

BACKGROUND

High-quality interpersonal interactions between clinicians and patients can improve communication and reduce health disparities among patients with novice English proficiency (NEP). Yet, little is known about the impact of native language, NEP, and native language concordance on patient on perceptions of interpersonal care in the emergency department (ED).

OBJECTIVE

To determine the associations of native language, NEP, and native language concordance with patient perceptions of interpersonal care among patients undergoing evaluation for suspected acute coronary syndrome (ACS) in the ED.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included 1000 patients undergoing evaluation for suspected ACS at an urban ED from 2013 to 2016.

MAIN MEASURES

English- and Spanish-speaking patients were surveyed to identify native language, English proficiency (classified as advanced, intermediate, or novice), and perceived language of the treating ED clinician. Patient perceptions of interpersonal care were assessed using the Interpersonal Processes of Care (IPC) survey, a validated 18-item tool for assessing social-psychological domains of patient-clinician interactions. IPC scores ≤ 4 were categorized as sub-optimal (range, 1-5). The associations between native language, English proficiency, and native language concordance with sub-optimal communication were assessed using hierarchical logistic regression adjusted for all three language variables, sociodemographic characteristics, and depression.

KEY RESULTS

Nine hundred thirty-three patients (48.0% native non-English-speaking, 55.7% Hispanic) completed the IPC; 522 (57.4%) perceived native language concordance. In unadjusted analyses, non-English native language (OR 1.38, 95% CI 1.04-1.82) and NEP (OR 1.45, 95% CI 1.06-1.98) were associated with sub-optimal communication, whereas language concordance was protective (OR 0.61, 95% CI 0.46-0.81). In fully adjusted analyses, only language concordance remained significantly associated with sub-optimal communication (AOR 0.62, 95% CI 0.42-0.93).

CONCLUSIONS

This study suggests that perceived native language concordance acts as a protective factor for patient-clinician interpersonal care in the acute setting, regardless of native language or English proficiency.

Conceptual Model of Emergency Department Utilization among Deaf and Hard-of-Hearing Patients: A Critical Review

Deaf and hard-of-hearing (DHH) populations are understudied in health services research and underserved in healthcare systems. Existing data indicate that adult DHH patients are more likely to use the emergency department (ED) for less emergent conditions than non-DHH patients. However, the lack of research focused on this population’s ED utilization impedes the development of health promotion and quality improvement interventions to improve patient health and quality outcomes. The purpose of this study was to develop a conceptual model describing patient and non-patient (e.g., community, health system, provider) factors influencing ED utilization and ED care processes among DHH people. We conducted a critical review and used Andersen’s Behavioral Model of Health Services Use and the PRECEDE-PROCEED Model to classify factors based on their theoretical and/or empirically described role. The resulting Conceptual Model of Emergency Department Utilization Among Deaf and Hard-of-Hearing Patients provides predisposing, enabling, and reinforcing factors influencing DHH patient ED care seeking and ED care processes. The model highlights the abundance of DHH patient and non-DHH patient enabling factors. This model may be used in quality improvement interventions, health services research, or in organizational planning and policymaking to improve health outcomes for DHH patients.

The influence of culture on care receivers' satisfaction and aggressive tendencies in the emergency department

Introduction

Reducing aggressive tendencies among care receivers in the emergency department has great economic and psychological benefits for care receivers, staff, and health care organizations. In a study conducted in a large multicultural hospital emergency department, we examined how cultural factors relating to ethnicity interact to enhance care receivers’ satisfaction and reduce their aggressive tendencies. Specifically, we explored how care receivers’ cultural affiliation, individual cultural characteristics, and the cultural situational setting interact to increase care receivers’ satisfaction and reduce their aggressive tendencies.

Method

Data were collected using survey responses from 214 care receivers. We use structural equation models and the bootstrap method to analyze the data.

Results

Care receivers’ openness to diversity (an individual cultural characteristic) was positively related to their satisfaction that was associated with lower aggressive tendencies, only when they were affiliated with a cultural minority group and when the cultural situational setting included language accessibility.

Conclusion

Our results demonstrate that cultural affiliation, individual cultural characteristics, and cultural situational setting can affect care receivers’ satisfaction and aggressive tendencies in a multicultural emergency department context. In particular, high cultural openness of care receivers, and making information accessible in their native language, increased satisfaction and reduced aggressive tendencies among cultural minority care receivers in our study.

Association of Primary Language and Hospitalization for Ambulatory Care Sensitive Conditions

BACKGROUND

Limited English proficiency is associated with decreased access to ambulatory care, however, it is unclear if this disparity leads to increased use of emergency departments (EDs) for low severity ambulatory care sensitive conditions (ACSCs).

OBJECTIVE

We sought to determine the association between the patient's preferred language and hospital utilization for ACSCs.

RESEARCH DESIGN

We conducted a retrospective cohort study of all ED visits in New Jersey in 2013 and 2014. The primary outcome was hospital admission for acute ACSCs, chronic ACSCs, and fractures (a nonambulatory care sensitive control condition). Secondary outcomes included intensive care unit (ICU) utilization and length of stay. Mixed-effect regression models estimated the association between preferred language (English vs. non-English) and study outcomes, controlling for demographics, comorbidities, and hospital characteristics.

RESULTS

We examined 201,351 ED visits for acute ACSCs, 251,193 visits for chronic ACSCs, and 148,428 visits for fractures, of which 13.5%, 11.1%, and 9.9%, respectively, were by non-English speakers. In adjusted analyses, non-English speakers were less likely to be admitted for acute ACSCs [-3.1%; 95% confidence interval (CI), -3.6% to -2.5%] and chronic ACSCs (-2.3%; 95% CI, -2.8% to -1.7%) but not fractures (0.4%; 95% CI, -0.2% to 1.0%). Among hospitalized patients, non-English speakers were less likely to receive ICU services but had no difference in length of stay.

CONCLUSIONS

These findings suggest non-English-speaking patients may seek ED care for lower acuity ACSCs than English-speaking patients. Efforts to decrease preventable ED and increase access to ambulatory care use should consider the needs of non-English-speaking patients.

Confidentiality and Capacity

This article focuses on confidentiality and capacity issues affecting patients receiving care in the emergency department. The patient-physician relationship begins with presumed confidentiality. The article also clarifies instances where a physician may be required to break confidentiality for the safety of patients or others. This article then discusses risk management issues relevant to determining a patient's capacity to accept or decline medical care in the emergency department setting. Situations pertaining to refusal of care and discharges against medical advice are examined in detail, and best practices for mitigating risk in informed consent and barriers to consent are reviewed.

Healthcare Access for the Deaf in Singapore: Overcoming Communication Barriers

Good communication between healthcare providers and patients is vital to effective healthcare. In order to understand patients' complaints, make accurate diagnoses, obtain informed consent and explain treatment regimens, clinicians must communicate well with their patients. This can be challenging when treating patients from unfamiliar cultural backgrounds, such as the Deaf. Not only are they a linguistic and cultural minority, they are also members of the world's largest and oft-forgotten minority group: the disability community. Under Article 25 of the United Nations Convention on the Rights of Persons with Disabilities ("CRPD"), persons with disabilities have rights to the same range, quality and standard of free or affordable healthcare and programmes as provided to other people. Yet communication barriers and healthcare providers' lack of familiarity with Deaf culture can impair the quality and accessibility of healthcare for the Deaf. This essay analyses the scope of this issue in Singapore: a state party to the CRPD which has a vibrant Deaf community, and yet no legislative or constitutional guarantees of the rights of persons with disabilities. In addition to exploring the communication barriers faced by Deaf patients in Singapore, this essay highlights ways in which healthcare providers and the state can support community-based initiatives to overcome these barriers.

Using patient companions as interpreters in the Emergency Department: An interdisciplinary quantitative and qualitative assessment

OBJECTIVES

To explore the perceived and actual quality of communication and the conversational mechanisms through which misunderstandings arise in linguistically diverse Emergency Department consultations.

METHODS

A mixed method approach was used, based on audio-records of consultations which rely on patient companions for linguistic support, and ethnographic contextual data. Interpreting errors and their potential impact on the clinical reasoning process and doctor-patient relationships were quantitatively assessed. Complementary qualitative ethnographic research provided a richer understanding of the context. The study involved interdisciplinary collaboration with specialists in applied linguistics, medicine, and psychology.

RESULTS

Accurate interpretation occurred in as few as 19% of interpreter speech turns. Answering for the patient and omitting information were the most frequent errors. The nature and severity of the impact of the errors varied. Answering for the patient had the greatest clinical impact. The omission of messages from the doctor to the patient negatively affected doctor-patient relationships.

CONCLUSION

Gaps were observed between the perceived and the actual quality of communication, although patient companions often provided useful information.

PRACTICE IMPLICATIONS

In addition to raising awareness among doctors on the potential risks of using AHIs, EDs should adjust their management to increase the utilization of onsite and remote PIs.

A Reversed Trend: Care for Limited English Proficiency Patients in the Pediatric Emergency Department

Objectives

Previous studies in pediatric emergency departments (EDs) showed patients with limited English proficiency (LEP) had gaps in care compared with English-speaking patients. In 2010, the Joint Commission released patient-centered communication standards addressing these gaps. We evaluate the current care of LEP patients in the Children's Healthcare of Atlanta (CHOA) EDs.

Methods

This was a retrospective cohort study of patients <18 years that presented to our EDs in 2016. Length of stay (LOS), change in triage status, return-visit rates, and hospital disposition were compared between patients who requested an interpreter and those who did not.

Results

The population included 152,945 patients from 232,787 ED encounters in 2016. Interpreters were requested for 12.1% of encounters. For ED LOS, a model-adjusted difference of 0.77% was found between interpreter groups. For change in triage status, adjusted odds were 7% higher in the interpreter requested cohort. For ED readmission within 7 days, adjusted odds were 3% higher in the interpreter requested cohort. These effect sizes are small (ES < 0.2).

Conclusions

Our study showed low ES of the differences in ED metrics between LEP and English-speaking patients, suggesting little clinical difference between the two groups. The impact of this improvement should be further studied.