In May, the Department of Health and Human Services’ (HHS) Office of Civil Rights issued a final rule that bans hospitals that receive federal funds from discriminating against transgender people, the disabled, and people with limited English proficiency (LEP). (More information about this rule is available at: http://bit.ly/1YCYEbl.) In issuing the rule, HHS Secretary Sylvia Burwell noted that it was a key step toward realizing equity within the healthcare system.
Among other things, the rule clarifies what accommodations hospitals must make to meet the needs of LEP patients, specifying, for example, what makes an interpreter qualified. In fact, meeting the needs of LEP patients has long been an issue of concern for The Joint Commission (TJC). In May 2015, TJC issued a report noting that 20% of the U.S. population speaks a language other than English at home, and that approximately 25 million people, or 8.6% of the population, can be defined as LEP. Further, the report noted that by 2021, roughly half of all newly insured people in the United States will be minorities who are less likely to speak English. (More information is available at: http://bit.ly/2aMdfjF.)
What makes these data points noteworthy is the reality that LEP patients are at higher risk for adverse events than patients who are fluent in English. There is evidence that a growing number of hospitals are beginning to realize that the kind of investments needed to accommodate LEP patients may pale in comparison to the tab for maintaining the status quo.
Experts agree that there is plenty of room for improvement in the way hospitals endeavor to meet the needs of LEP patients. Joseph Betancourt, MD, MPH, director of the Disparities Solutions Center at Massachusetts General Hospital in Boston, explains that one of the biggest challenges is that many hospitals across the country don’t have even a basic foundation in place for communicating with LEP patients.
“There still are many hospitals that don’t have a dedicated interpreter service or, quite frankly, a real plan to effectively manage language barriers in healthcare delivery,” he observes.
These hospitals still rely on family members of patients to act as interpreters or hospital workers who may have some knowledge of the patient’s native tongue, but no proper training in medical interpreting, Betancourt notes.
“If we go to the next level, we do have some hospitals that have invested in dedicated interpreter services and who do have telephonic vendors in place, but their ability to use them effectively is hampered by the fact that they really haven’t built the systems, nor have they trained their caregivers on how to use these services efficiently,” he says.
For example, Betancourt notes that a provider may be well aware that the hospital has a dedicated interpreter service, but pressed for time, he or she wil nix the idea of waiting for an interpreter to come down, and just press forward. In fact, this is a particularly common scenario in the fast-paced emergency setting.
“The ED is a real cauldron for difficulties in these areas. There is no doubt that individuals in the ED are working in a high-stress, high-risk environment,” Betancourt explains. “These individuals need to move fast and need to get people triaged, so if the [interpreting] system isn’t built to support the emergency service in a timely fashion, it just won’t be used.”
Consider Potential for Errors
However, providers should understand that shortcuts of this nature can produce severe consequences. Glenn Flores, MD, the distinguished chair of health policy research at the Medica Research Institute in Minnetonka, MN, describes the case of a 6-month-old infant who presented to the ED with vomiting and diarrhea.
“The triage history given by the mother was interpreted by the boy’s 12-year-old sister, and no medical interpreter was requested. The sister stated that the patient had four dirty diapers and three episodes of vomiting that day,” Flores explains.1
The boy was triaged to a non-urgent level of care where the documentation stated that he had vomited seven times that day with no diarrhea.
“The boy was discharged shortly thereafter with a diagnosis of vomiting and with instructions only in English for rehydration solution by mouth,” Flores notes. “Three days later, the boy returned to the ED in severe distress with new onset of bloody stools. He was admitted to the hospital and died six hours later from septic shock.”
In another case, a 12-year-old paraplegic female presented to a children’s hospital ED with shortness of breath, fever, a urinary tract infection, and tachycardia. She spoke minimal English, and her mother only spoke Spanish, Flores explains.
“An interpreter was not available until three hours after [the patient’s] initial presentation. Neither telephone nor video interpretation was considered by staff,” he says.2
Flores explains that it took 90 minutes for the medical staff to figure out that the patient recently had traveled to Mexico where she had been diagnosed with a renal abscess. He notes that 30 minutes after the interpreter’s arrival, the patient went into cardiac arrest. She died 23 minutes later.
“The autopsy revealed bilateral septic pulmonary emboli, a left leg thrombosis and sepsis as causes of death,” Flores says.
These are just two cases, but Flores contends that they are emblematic of what can happen when effective interpretation services are not available or leveraged when LEP patients present for care.
“Substantial scientific evidence documents that optimal communication, patient satisfaction, outcomes, resource utilization, clinical research quality, and patient safety occur when LEP patients have access to adequate language services,” he says.
Flores stresses that using ad hoc interpreters — whether they are family members, people in the waiting room, untrained ED staff, or even a primary caregiver who has limited English proficiency — is no substitute for using a trained medical interpreter. Further, he warns about the overconfidence that some healthcare providers have regarding their own fluency in the patient’s primary language.
One other shortcut providers must avoid: using Google Translate for medical interpretation.
“Google translate can be grossly inaccurate in medical encounters, placing patients at significant risk for harm,” Flores warns. “Google Translate specifically states that it should not be used in safety-critical circumstances. It should never be used to replace a trained, professional medical interpreter.”
Address Post-discharge Care
Communicating effectively with LEP patients extends beyond interactions that take place while such patients are in the hospital. They also need to understand written instructions, an area ripe for improvement, according to Betancourt.
“It is a particularly huge issue because on top of the fact that there are probably not the best systems in place to support LEP patients, we have a real dearth of patient materials in different languages,” he says. “So these individuals are getting some level of instruction with the help of an interpreter [while they are in the ED], but then if they have any questions, they are really in a tough spot. They have no one to call. They don’t really have a good navigator in place.”
In fact, Betancourt and colleagues highlighted this issue in a report they completed for the Agency for Healthcare Research and Quality, in which they identified several high-risk scenarios in which language barriers posed a significant risk of a medical error. (The entire report is available at: http://bit.ly/OcrakX.)
“ED care was one of those high-risk scenarios because people are leaving with instructions that they often don’t understand ... and that can lead to a whole series of errors,” Betancourt observes.
Some hospital systems are creating multilingual call lines or other innovative solutions so that LEP patients can access the help they need in a language they understand when they have questions about their care post-discharge, but the need for such solutions is only growing with the increasing diversity of the U.S. population.
Betancourt notes that an increasing number of hospitals are getting the message.
“There is greater attention on issues related to patient safety, and the research clearly tells us that minorities and patients with LEP suffer more medical errors with greater clinical consequences than their white counterparts,” Betancourt explains. “So if you are a hospital and you care about patient safety, you need to turn your attention to those issues.”
Weigh Costs/Benefits
Another force pushing hospitals to improve in this area is the move toward value-based purchasing, which places a premium on caring for patients who frequently utilize the system or are high-cost, Betancourt observes.
“What we understand about these patients is that they are quite vulnerable, and language barriers can play a very significant role,” he explains. “If you are getting paid on a value-based contract whereby you are compensated on your care of a group of patients with heart failure or a group of patients with diabetes ... then it really behooves you to make investments to address language barriers to avoid absorbing costs that come from patients misunderstanding.”
Letting this issue slide has other financial ramifications as well, Betancourt warns.
For example, he describes the case of an LEP patient who presents to the ED with head pain, and there is no interpreter on site who can translate the patient’s story.
“The provider will just send the patient to get a CT scan because he or she needs information,” Betancourt explains. “Think about the cost to the healthcare system for that unnecessary CT scan when, in fact, an interpreter, for a fraction of the cost, could have allowed that ED physician to do his or her job, get a really good history, and figure out that the issue was sinusitis and not a subarachnoid hemorrhage.”
Flores suggests ED administrators and providers push for all states to provide third-party reimbursements for interpreter services for LEP patients.
“Currently, only 12 states and Washington, DC, do so, but it is relatively simple to achieve,” he explains. “The state legislature just has to approve interpreter services being a covered service under Medicaid. By not doing so, states are missing out on millions of dollars of federal Medicaid/CHIP [Children’s Health Insurance Program] matching funds that could be flowing to them.”
Implement Best Practices
To find out whether your own ED is communicating effectively with LEP patients, Flores directs ED managers to complete a two-step process. Managers should consistently collect and record in the electronic medical record (EMR) whether patients speak a language other than English at home. If yes, then record what that language is and how well the person speaks English: very well, well, not well, or not at all.
“Any response other than ‘very well’ classifies this person as LEP,” Flores notes, explaining that these questions come straight from the U.S. Census Bureau. “Monitor relevant outcomes for LEP patients, including wait time in the ED, time spent in the ED, hospital admission rates, medical errors, patient safety events, and mortality rates.”
How might ED clinicians take steps to improve LEP communications in their own work settings? It’s a challenge without supportive healthcare systems, Betancourt acknowledges.
“I would say the best thing ED physicians can do is advocate in their own systems to support interpreter services and ways to manage language barriers,” he says.
Emergency leaders also should consider implementing a host of best practices that can ensure that communications with LEP patients are optimal, Flores explains. He suggests the following steps:
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Collect English proficiency data on all patients, using the simple questions from the U.S. Census Bureau described above.
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Record LEP data as a permanent and prominent part of the EMR.
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Provide trained, professional medical interpreters or bilingual providers to all LEP patients and families.
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Post multilingual signage throughout the ED, imaging, and lab departments and other areas frequented by emergency patients.
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Provide professionally translated prescriptions, discharge instructions, and any other handouts in a patient’s primary language, and review these materials with the patient with the assistance of a medical interpreter.
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Identify ED clinicians and staff who speak languages other than English, test their proficiency in these languages, and provide additional training to those who are not fluent.
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Create a database of all bilingual providers and staff to be used as a resource for LEP patients and families.
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Refer LEP patients and families to resources that can help them learn English.
REFERENCES
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Flores G. Families facing language barriers in healthcare: When will policy catch up with the demographics and evidence? J Pediatr 2014;164;1261-1264.
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Mosquera R, Samuels C, Flores G. Family language barriers and special-needs children. Pediatrics 2016; in press.
SOURCES
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Joseph Betancourt, MD, MPH, Director, Disparities Solutions Center, Massachusetts General Hospital, Boston. Email: [email protected].
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Glenn Flores, MD, Distinguished Chair of Health Policy Research, Medica Research Institute, Minnetonka, MN. Email: [email protected].
