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Wait, That’s Not What He Said? How We Can Better Care For Our Patients With Language Barriers


CASE

History

Chief Complaint from triage (using a telephonic interpreter in Spanish): Abscess


LLE redness with a "Knot" states that he is getting chemotherapy for gallbladder "bursting, burning and redness" denies any bite.

  • 39 yo M with a PMHx of metastatic urothelial carcinoma (dx in 2020, mets to lungs) s/p radical cystoprostatectomy with ileal conduit (2021), and PE presenting with bilateral lower extremity redness and pain below both knees. He is currently being treated with chemotherapy medications pembrolizumab and enfortumab, with his last cycle of enfortumab 5 days prior. He had a visit with his oncologist on the same day, and reported some “redness and burning below the knee” but was still able to ambulate. He had some skin peeling all over his body in the last month, but nothing painful. The pain is a 5/10 in his calves and feet while laying down, but a 10/10 when standing preventing him from walking. The redness has now spread to his upper thighs and arms, and the areas that are red are all “hot”. No animal exposures, no insect bites, no sick contacts. No prior similar experiences, no allergies. He has no bumps in his legs and there has not been any pus that he has seen.

  • Medications: Warfarin 5 mg, Diphenhydramine 25 mg, Hydrocortisone 2.5% topical cream

  • ROS positive for chills, rash and an immunocompromised state

Physical Exam

Vitals: BP 121/71 (BP Location: Right arm, Patient Position: HOB equal/greater than 30 degrees) | Pulse 77 | Temp 37.2 °C (99 °F) (Oral) | Resp 18 | SpO2 99%


Ill-appearing, but non-toxic appearing. Mucous membranes are moist, oropharyngeal cavity was clear of any exudates, blisters or erythema. Normal RRR, normal RR. Tenderness was present to palpation of bilateral calves, but not above the knees.

Confluent erythema present from the ankles to the knees, with a patchy, non-raised erythematous rash present above the knees up to the pelvis. Some patchy erythema on dorsal surface of both forearms. Skin was hot to the touch without purulence. Not diaphoretic.


ED Management

  • Laboratory results: Hb 12.5, WBC 8.20, PMN predominant, Eos % 0.2, AST 50, CRP 2.6, ESR 41, CK 250, Whole Blood Lactate 1.7, INR 1.69, PT 17.[1]

  • Acetaminophen for pain control

  • Vital signs reassessed to ensure there was not an infectious etiology, low threshold to start antibiotics for atypical cellulitis given immunocompromised status

  • Admitted to Solid Tumor Oncology for further evaluation of possible drug reaction

Clinical Question: How can we better care for Spanish-speaking patients with language barriers in the Emergency Department?


SUMMARY OF EVIDENCE

  • There was a clear discrepancy between what this patient’s true chief complaint was as well as his oncologic history, and what was recorded in triage. While a telephonic interpreter was used, the information the patient was trying to convey was not relayed accurately. This leads us to our question—how can we do better to avoid misunderstandings like this in the future?

  • According to the 2019 Census, 41,757,391 people in the United States spoke Spanish at home in addition to or instead of English. Of this population, 39% reported to speak English “less than very well, which is also defined as having limited English proficiency (LEP).[2] Based on this, and depending on the area in which you practice, caring for primarily Spanish speaking patients can be common while working in the ED.

  • Despite federal law requiring the use of a certified medical interpreter for patients with LEP, there are no regulations or monitoring of the quality of the medical history obtained with these services, and no standardized way to enforce if interpreters are actually used.[3,4]

  • There are multiple ways that interpretation services for patients with LEP can be offered in the ED: in person-interpreters, telephone interpreters, trained bilingual staff speakers, and some utilization of online translation services for seemingly “straightforward” cases.[5] In-person interpretation is not always available and is only available for certain languages. Common reasons that telephone interpretation is underutilized is perceived inefficiency, difficulty in clear communication, such as trouble hearing and loss of information due to a lack of visual cues.[6]

  • The reason that the ED is a particularly high risk area for communication errors for LEP patients is due to visits being unplanned, so interpreter services cannot be arranged in advance like they could in other healthcare settings, there are multiple instances of discrete communication between patients and various clinicians, and visits occur in a setting in which there is crowding, high acuity and large patient volume, which can affect equitable care provision and accurate communication of medical information.[7]

  • As a telephonic interpreter was used in triage for this patient, the accuracy of this form of interpretation is called into question. There are many studies that focus on clinical outcomes based on use of an interpreter vs not using an interpreter, but not many that examine differences in accuracy based on method of interpretation. However, there have been studies that demonstrate parents of patients in a pediatric ED were more likely to be able to accurately report their child’s diagnosis after use of a video-based interpreter than a telephonic interpreter.[8] In other studies, it has been reliably demonstrated that both patients and providers prefer in-person interpreters to remote interpretation, and between methods of remote interpretation, video conferencing was preferred.[9,10] However, there is an increased cost associated with interpretation done via video-conferencing, which may influence its frequency of use in EDs.[8]

  • This does affect health outcomes for LEP patients:

    • LEP patients are less likely to use primary care services, and therefore are more likely to utilize the ED for primary care compared to English-speaking patients.[5]

    • LEP patients who are not provided adequate interpretation have been shown to have longer lengths of stay, increased rates of ED revisits and increased error in home medication administration following ED visits.[4]

    • LEP patients were less satisfied with courtesy, respectfulness, and quality of discharge instructions, as well as being less likely to receive follow-up appointments. It has also been demonstrated that Hispanic patients have a higher chance of being intubated, as well as receiving inadequate analgesics.[11]

    • There has been evidence to indicate that bias influences triage of LEP patients, as it has been shown that minority patients receive lower acuity triage scores than non-Hispanic white patients despite having similar symptoms. As a consequence patients with LEP are more likely to have an unanticipated escalation of care to the ICU within 24 hours of admission, indicating the severity of their illness was missed.[7]

  • In the literature, there have been a variety of solutions proposed to improve the care of LEP in the ED:

    • Increased qualitative and quantitative research on the care of LEP patients in the Emergency Department, as there are still gaps in the description and characterization of the breadth of health disparities and inequity faced by these patients.[7]

    • Increased education on the importance of adequate interpretation for LEP patients, the adverse effects of underutilizing these services, and explanation of what resources are available and how to use them. This education can occur during Grand Rounds, on shift with case based training, during Nursing Huddle, and during orientation of first-year residents.[4]

    • Environmental restructuring in the ED, such as screen savers with remote interpreter phone numbers, phones with speaker capability added to each ED room, in person interpreter request buttons added to the ED track board.[4]

    • The creation of new tools/acronyms to help identify clinical symptoms in LEP patients. For example, the AHORA tool is a Spanish-language tool to help Spanish speaking patients identify stroke symptoms in the prehospital setting[12], which the majority of patients who have utilized it have thought it was very useful and easy to learn and understand.[13] These should be created in a variety of languages and awareness about them and how to use them should be increased among ED clinicians.

  • Note: It has been demonstrated that the term “limited English proficiency” is falling out of favor due to being deficit focused and increasing the stigma these patients face.[14] This term is used in this blog post because that is what was used in the majority of reference papers, but the points made about changing our terminology to more patient-centered language are very important. In addition, though we focus on Spanish speaking patients in this post, we see patients that speak a variety of languages, and they all deserve the same standard of care outlined here.

RECOMMENDATIONS

  1. Educate ED staff, including medical students, about how to identify patients with LEP, the adverse outcomes they often face due to having a language barrier and inadequate interpretation.

  2. Enhance ED staff knowledge of the different types of interpretation services available and how to access them. In addition, increasing the ease of access for these services by having increased accessibility to phones, adding interpreter requests to ED track boards, and increasing environmental cues.[4]

  3. Providing in person interpreters whenever possible due to increased satisfaction of both providers and patients as well as improved accuracy[9,10], and if remote options must be used, it is worthwhile to assess the cost of utilizing video conferencing instead of telephonic interpretation to improve patient comprehension and decrease the rate of errors.[8]

  4. Increasing both qualitative and quantitative research better characterizing the experience of patients with language barriers in the ER, the quality of care they receive, clinical outcomes compared to primarily English-speaking counterparts, and on the effectiveness of potential interventions to improve these domains.[7]

  5. Creating and utilizing clinical tools in different languages, such as the AHORA tool to identify stroke symptoms.[12]

REFERENCES

1. Wetzel R. 10 REASONS RESEARCH SUPPORTS USING PHONE INTERPRETATION: PART 1. Cyracom Language Services Blog. Published August 18, 2014. Accessed March 23, 2023. https://blog.cyracom.com/10-reasons-why-you-should-be-using-opi-at-your-facility-according-to-research-part-1

2. Dietrich S, Hernandez E. What Languages Do We Speak in the United States? United States Census Bureau: Stories. Published December 6, 2022. https://www.census.gov/library/stories/2022/12/languages-we-speak-in-united-states.html

3. Litzau M, Turner J, Pettit K, Morgan Z, Cooper D. Obtaining History with a Language Barrier in the Emergency Department: Perhaps not a Barrier After All. West J Emerg Med. 2018;19(6):934-937. doi:10.5811/westjem.2018.8.39146

4. Taira BR, Onofre L, Yaggi C, Orue A, Thyne S, Kim H. An Implementation Science Approach Improves Language Access in the Emergency Department. J Immigr Minor Health. 2021;23(6):1214-1222. doi:10.1007/s10903-020-01127-x

5. Chan YF, Alagappan K, Rella J, Bentley S, Soto-Greene M, Martin M. Interpreter Services in Emergency Medicine. J Emerg Med. 2010;38(2):133-139. doi:10.1016/j.jemermed.2007.09.045

6. Benda NC, Bisantz AM, Butler RL, Fairbanks RJ, Higginbotham J. The active role of interpreters in medical discourse – An observational study in emergency medicine. Patient Educ Couns. 2022;105(1):62-73. doi:10.1016/j.pec.2021.05.029

7. Gutman CK, Lion KC, Fisher CL, Aronson PL, Patterson M, Fernandez R. Breaking through barriers: the need for effective research to promote language‐concordant communication as a facilitator of equitable emergency care. J Am Coll Emerg Physicians Open. 2022;3(1). doi:10.1002/emp2.12639

8. Lion KC, Brown JC, Ebel BE, et al. Effect of Telephone vs Video Interpretation on Parent Comprehension, Communication, and Utilization in the Pediatric Emergency Department: A Randomized Clinical Trial. JAMA Pediatr. 2015;169(12):1117. doi:10.1001/jamapediatrics.2015.2630

9. Heath M, Hvass AMF, Wejse CM. Interpreter services and effect on healthcare - a systematic review of the impact of different types of interpreters on patient outcome. J Migr Health. 2023;7:100162. doi:10.1016/j.jmh.2023.100162

10. Locatis C, Williamson D, Gould-Kabler C, et al. Comparing In-Person, Video, and Telephonic Medical Interpretation. J Gen Intern Med. 2010;25(4):345-350. doi:10.1007/s11606-009-1236-x

11. Dorian Ramirez, Kirsten G. Engel, Tricia S. Tang. Language Interpreter Utilization in the Emergency Department Setting: A Clinical Review. J Health Care Poor Underserved. 2008;19(2):352-362. doi:10.1353/hpu.0.0019

12. Banerjee P, Koumans H, Weech MD, Wilson M, Rivera-Morales M, Ganti L. AHORA: a Spanish language tool to identify acute stroke symptoms. Stroke Vasc Neurol. 2022;7(2):176-178. doi:10.1136/svn-2021-001280

13. Stead T, Ganti L, McCauley E, et al. What Do Spanish Speakers Think of the Andar, Hablar, Ojos, Rostro, Ambos Brazos o Piernas (AHORA) Stroke Tool? Cureus. Published online December 26, 2021. doi:10.7759/cureus.20720

14. Ortega P, Shin TM, Martínez GA. Rethinking the Term “Limited English Proficiency” to Improve Language-Appropriate Healthcare for All. J Immigr Minor Health. 2022;24(3):799-805. doi:10.1007/s10903-021-01257-w


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