Lost in interpretation: 16 minutes could save you a lifetime.

Your patient is a 44 year-old Hispanic man presenting to the emergency department because of anal pain. He reports that he has had anal pain for over one week and was seen in an emergency department several days ago where he was given some medication to help decrease the pain, but the meds have not seemed to help. On physical examination he has one large nonthrombosed external hemorrhoid. On further questioning you find that he has been taking his steroid suppositories... but orally.

Approximately 66% of medical error sentinel events have been attributed to communication--we spend a lot of time dissecting how tribalism, cultural difference, and the rapid growth of technology contribute to this problem, but what about when your patient speaks a different language?

Patients who have limited English proficiency are a particularly dangerous population because it's tempting (both for the patient and the provider, neither of whom want to be in the patient room longer than they have to) to "get by" with shared colanguage skills instead of waiting for a formal interpreter. On average, visits utilizing a formal interpreter take about 16 minutes longer than visits without. In the emergency department, 16 minutes can seem like a lifetime. But... it's not a lifetime. A lifetime is what you could save by providing patients with appropriate interpretation services and not allowing their 8-year old sister, the medical assistant, or the patient down the hall serve as an ad-hoc interpreter.

Ad-hoc interpretation for patients with limited english proficiency is associated with the following horrifying statistics:

* 20% more labs

* 10% more abdominal CTs for the chief complaint of abdominal pain

* 1 day longer admission durations

* 66% less analgesia

* 50% less patient satisfaction

* 50% less understanding of discharge diagnosis AND treatment and plan.

Even something as concrete as CT-PE yield decreases when attempting ad-hoc interpretation for patients with limited English proficiency. The CT-PE yield for English speaking patients is 10%. For patients with limited English proficiency, that number goes down to 1%.

So what to do?

1. Get more interpreters or convince your administration to get more interpreters. Use the statistics above to convince them. A recent study in internal medicine found that the addition of interpretation headsets to the head of every bed decreased readmission rates for patients with limited English proficiency by 5% at a time when readmission rates for all other patient populations were increasing. Over 8 months this intervention resulted in a savings of 160K even after including the cost of interpreter services and equipment upkeep.

2. Use technology wisely. Don't use Google Translate, which has been demonstrated to woefully misinterpret 50% of discharge instructions. For example, "Your son had a seizure" in Swahili, becomes "Your son is dead." In Polish, "Your husband has the opportunity to donate his organs" becomes, "Your husband can give away his tools." Do try an application designed specifically for medical translation, like canopyspeak or medibabble. These apps have commonly used medical phrases formally translated into various languages which are then available in a dropdown. Some of the languages even have audiofiles attached to use for vision-impaired patients, or patients who can't read. These apps are a bit clunky for the history and physical or ultimate discharge discussion, nor will they help YOU understand your patient, but they are helpful for those in-between-moments, when you just need to update them, or ask one dangling-bit of a question.

3. Use a formal interpreter. Recognize that your patient in front of you is scared, unwell, and would appreciate being spoken to in their own language. Recognize the long-term benefits of using an interpreter and do so, even though it stings while you're listening to hold music. Use that time to do your physical exam, bring a computer into the room to chart while the interpreter and the patient are talking. Use your time effectively but don't do so at the cost of your patients with limited English proficiency.

Your next patient, who may speak "a little English," says Thank you.

Or "Gracias," or "Arigatô," or "спасибо," or "Eşekkür ederim," or... you get the drift.

References:

Wilson CC. Patient safety and healthcare quality: the case for language access. International Journal of Health Policy and Management 2013; 1:251-253.

Waxman MA, Levitt MA. Are Diagnostic Testing and Admission Rates Higher in Non-English-Speaking Versus English-Speaking Patients in the Emergency Department? Ann Emerg Med 200;36:5(456-461).

Lindholm M, Hargraves JL, Ferguson WJ, Reed G. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med. 2012 Oct;27(10):1294-9.

Taylor DM et al. Variables associated with administration of analgesia, nurse-initiated analgesia and early analgesia in the emergency department. Emerg Med J. 2017 Jan;34(1):13-19.

Flores G. The Impact of Medical Interpreter Services on the Quality of Health Care: A systematic Review. Medical Care Research and Review, Vol. 62 No. 3(June 2005)255-299.

Mahmoud I et al. Satisfaction with emergency department service among non-English-speaking background patients. Emergency Medicine Australasia (2014)26, 256-261.

Bagchi AD et al. Examining Effectiveness of Medical Interpreters in Emergency Departments for Spanish-Speaking Patients with Limited English Proficiecy: Results of a Randomized Controlled Trial. Ann Emerg Med 2011(57)3:248-256.

Stowell JR, Filler L, Sabir MS, Roh AT, Akhter M. Implications of language barrier on the diagnostic yield of computed tomography in pulmonary embolism. Am J Emerg Med. 2018 Apr;36(4):677-679.

Yan Z et al. Yield of CT Pulmonary Angiography in the emergency department when providers override evidence-based clinical decision support. Radiology. 2017 Mar;282(3):717-725.

Blay N et al. Healthcare interpreter utilization: analysis of health administrative data. BMC Halth Serv Res. 2018 May 10;18(1):348.

Weise E. Demand Surges for Medical Translators at Medical Facilities. USA Today [serial on the internet]. 2006 July 20.

Patil S, Davies P. Use of Google Translate in medical communication: evaluation of accuracy. BMJ 2014;349:g7392.

Karliner LS, Perez-Stable EJ Gregorich SE. Convenient Access to Professional Interpreters in the Hospital Decreases Readmission Rates and Estimated Hospital Expenditures for Patients with Limited English Proficiency. Med Care. 2017 Mar;55(3):199-206.


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