Language assistance for limited English proficiency patients in a public ED: determining the unmet need

Abstract Background Many patients who present to public Emergency Departments (EDs) have Limited English Proficiency (LEP). LEP patients have worse understanding of their conditions and high rates of ED recidivism. LEP patients are entitled to language assistance under Title IV of the 1964 Civil Rights Act. The objective of this study is to characterize the unmet need for language assistance in a public ED. Methods Retrospective chart review of 48 h of successive patient encounters in a public ED. Registration workers asked each patient their preferred language and whether they would like an interpreter. On recent implementation of a new electronic health record (EHR), however, providers were unable to see the responses recorded. When discovered, this created a natural experiment to compare patient request for language assistance with documented practice of the providers who were unaware of the patient’s stated preference at registration. The study was set in a public, urban ED, annual census of 50,000 visits, with language assistance services available 24/7 via video units and phone line. The subjects included all patients presenting to the ED for a 48-h period. Those with altered level of consciousness and those who left before being seen were excluded. Age, race, ethnicity, preferred language, preference for language assistance, status of the provider as certified bilingual, documentation of language assistance use, type of language assistance used (video, phone, bilingual staff or ad hoc) were captured. Descriptive statistics were used with proportions and 95% CIs to describe the unmet need. Results In total, 253 encounters met inclusion criteria. Mean age was 41 years, 201/253 (79.5%) were Hispanic or Latino, and 134/253 (53%) preferred to use a language other than English (97% Spanish, 2% Armenian and 0.8% Tagalog). Of the 110/253 (43%) patients requesting an interpreter, 12/110 (10.9%) were seen by a certified bilingual provider and 5/110 (4.6%) had written documentation by the primary provider that language assistance was used. The calculated unmet need for spoken language assistance was 93/110 (84.5%) of patients requesting language assistance or 93/253 (36.8, 95%CI 31–42.9%) of total ED patients. Conclusions In this public ED, there is a large unmet need for language assistance for LEP patients

Hospital and Health System-Level Interventions to Improve Care for Limited English Proficiency Patients: A Systematic Review.

Although federal legislation mandates the provision of qualified interpreters for limited English proficiency (LEP) patients, language services are consistently underutilized by health care providers even when readily available. The objective of this study was to systematically review the literature and summarize evidence for interventions at the hospital or health system level that improve communication with, quality of care for, or health outcomes of LEP patients.The literature was systematically reviewed according to PRISMA guidelines to answer the following question: "For patients with limited English proficiency, which interventions at the hospital or health system level will result in improved communication, quality of care, or health outcomes?"The search yielded an initial 16,686 references, 19 of which met the inclusion criteria. Baseline rates of language service utilization were extremely low and remained at low levels postintervention in multiple studies. Most studies focused on language service utilization, patient communication, metric tracking, and access to care, whereas few studies evaluated quality of care or health outcomes of LEP patients. Multifaceted interventions that include elements of administrative emphasis, process evaluation, and education appear to improve language service use and communication.This review revealed large gaps in the evidence to guide hospital and health system improvement strategies for LEP patient care. Given the large and persistent performance gaps in the provision of language assistance for LEP patients, hospitals, health systems, and granting agencies should invest in implementation and dissemination research focused on language service use

Hospital and Health System-Level Interventions to Improve Care for Limited English Proficiency Patients: A Systematic Review.

Although federal legislation mandates the provision of qualified interpreters for limited English proficiency (LEP) patients, language services are consistently underutilized by health care providers even when readily available. The objective of this study was to systematically review the literature and summarize evidence for interventions at the hospital or health system level that improve communication with, quality of care for, or health outcomes of LEP patients.The literature was systematically reviewed according to PRISMA guidelines to answer the following question: "For patients with limited English proficiency, which interventions at the hospital or health system level will result in improved communication, quality of care, or health outcomes?"The search yielded an initial 16,686 references, 19 of which met the inclusion criteria. Baseline rates of language service utilization were extremely low and remained at low levels postintervention in multiple studies. Most studies focused on language service utilization, patient communication, metric tracking, and access to care, whereas few studies evaluated quality of care or health outcomes of LEP patients. Multifaceted interventions that include elements of administrative emphasis, process evaluation, and education appear to improve language service use and communication.This review revealed large gaps in the evidence to guide hospital and health system improvement strategies for LEP patient care. Given the large and persistent performance gaps in the provision of language assistance for LEP patients, hospitals, health systems, and granting agencies should invest in implementation and dissemination research focused on language service use

A Pragmatic Assessment of Google Translate for Emergency Department Instructions.

BackgroundBecause many hospitals have no mechanism for written translation, ED providers resort to the use of automated translation software, such as Google Translate (GT) for patient instructions. A recent study of discharge instructions in Spanish and Chinese suggested that accuracy rates of Google Translate (GT) were high.Study objectiveTo perform a pragmatic assessment of GT for the written translation of commonly used ED discharge instructions in seven commonly spoken languages.MethodsA prospective assessment of the accuracy of GT for 20 commonly used ED discharge instruction phrases, as evaluated by a convenience sample of native speakers of seven commonly spoken languages (Spanish, Chinese, Vietnamese, Tagalog, Korean, Armenian, and Farsi). Translations were evaluated using a previously validated matrix for scoring machine translation, containing 5-point Likert scales for fluency, adequacy, meaning, and severity, in addition to a dichotomous assessment of retention of the overall meaning.ResultsTwenty volunteers evaluated 400 google translated discharge statements. Volunteers were 50% female and spoke Spanish (5), Armenian (2), Chinese (3), Tagalog (4), Korean (2), and Farsi (2). The overall meaning was retained for 82.5% (330/400) of the translations. Spanish had the highest accuracy rate (94%), followed by Tagalog (90%), Korean (82.5%), Chinese (81.7%), Farsi (67.5%), and Armenian (55%). Mean Likert scores (on a 5-point scale) were high for fluency (4.2), adequacy (4.4), meaning (4.3), and severity (4.3) but also varied.ConclusionGT for discharge instructions in the ED is inconsistent between languages and should not be relied on for patient instructions

Barriers to the Right to Health Among Patients of a Public Emergency Department After Implementation of the Affordable Care Act

Purpose: Emergency physicians are witnesses to the impact of socioeconomic determinants of health on physical and psychiatric illness. Understanding structural barriers to the right to health (RTH) serves as a foundation for interventions to promote health equity. This study was performed to determine self-described barriers to fulfillment of the RTH among a public emergency department (ED) patient population. Methods: A convenience sample survey between June and August 2014 of 200 patients in public ED assessing demographic characteristics and desired assistance with 36 barriers to fulfillment of the RTH. Results: There was a high demand for specialty care (91%, 182/200), access to primary care (87.5%, 175/200), and access to health insurance (86%, 172/200). Undocumented residents were significantly more likely to cite health insurance as the most important area for assistance (p=0.04). Conclusion: Despite implementation of Affordable Care Act, access to health care and insurance were still perceived as the most important barriers among underserved patient populations, particularly undocumented groups

Provider perspectives on emergency department initiation of medication assisted treatment for alcohol use disorder.

BackgroundAlcohol use disorder (AUD) is ubiquitous and its sequelae contribute to high levels of healthcare utilization, yet AUD remains undertreated. The ED encounter represents a missed opportunity to initiate medication assisted treatment (MAT) for patients with AUD. The aims of this study are to identify barriers and facilitators to the treatment of AUD in the ED, and to design interventions to address identified barriers.MethodsUsing an implementation science approach based on the Behavior Change Wheel framework, we conducted qualitative interviews with staff to interrogate their perspectives on ED initiation of AUD treatment. Subjects included physicians, nurses, nurse practitioners, clinical social workers, and pharmacists. Interviews were thematically coded using both inductive and deductive approaches and constant comparative analysis. Themes were further categorized as relating to providers' capabilities, opportunities, or motivations. Barriers were then mapped to corresponding intervention functions.ResultsFacilitators at our institution included time allotted for continuing education, the availability of clinical social workers, and favorable opinions of MAT based on previous experiences implementing buprenorphine for opioid use disorder. Capability barriers included limited familiarity with naltrexone and difficulty determining which patients are candidates for therapy. Opportunity barriers included the limited supply of naltrexone and a lack of clarity as to who should introduce naltrexone and assess readiness for change. Motivation barriers included a sense of futility in treating patients with AUD and stigmas associated with alcohol use. Evidence-based interventions included multi-modal provider education, a standardized treatment algorithm and order set, selection of clinical champions, and clarification of roles among providers on the team.ConclusionsA large evidence-practice gap exists for the treatment of AUD with Naltrexone, and the ED visit is a missed opportunity for intervention. ED providers are optimistic about implementing AUD treatment in the ED but described many barriers, especially related to knowledge, clarification of roles, and stigma associated with AUD. Applying a formal implementation science approach guided by the Behavior Change Wheel allowed us to transform qualitative interview data into evidence-based interventions for the implementation of an ED-based program for the treatment of AUD

Anti-immigrant Rhetoric and the Experiences of Latino Immigrants in the Emergency Department

Introduction: Anti-immigrant rhetoric and increased enforcement of immigration laws have induced worry and safety concerns among undocumented Latino immigrants (UDLI) and legal Latino residents/citizens (LLRC), with some delaying the time to care.1 In this study, we conducted a qualitative analysis of statements made by emergency department (ED) patients – a majority of whom were UDLI and LLRC – participating in a study to better understand their experiences and fears with regard to anti-immigrant rhetoric, immigration enforcement, and ED utilization.Methods: We conducted a multi-site study, surveying patients in three California safety-net EDs serving large immigrant populations from June 2017–December 2018. Of 1684 patients approached, 1337 (79.4%) agreed to participate; when given the option to provide open-ended comments, 260 participants provided perspectives about their experiences during the years immediately following the 2016 United States presidential election. We analyzed these qualitative data using constructivist grounded theory.Results: We analyzed comments from 260 individuals. Among ED patients who provided qualitative data, 59% were women and their median age was 45 years (Interquartile range 33-57 years). Undocumented Latino immigrants comprised 49%, 31% were LLRC, and 20% were non-Latino legal residents. As their primary language, 68% spoke Spanish. We identified six themes: fear as a barrier to care (especially for UDLI); the negative impact of fear on health and wellness (physical and mental health, delays in care); factors influencing fear (eg, media coverage); and future solutions, including the need for increased communication about rights.Conclusion: Anti-immigrant rhetoric during the 2016 US presidential campaign contributed to fear and safety concerns among UDLI and LLRC accessing healthcare. This is one of the few studies that captured firsthand experiences of UDLI in the ED. Our findings revealed fear-based barriers to accessing emergency care, protective and contributing factors to fear, and the negative impact of fear. There is a need for increased culturally informed patient communication about rights and resources, strategic media campaigns, and improved access to healthcare for undocumented individuals

Impact of a novel, resource appropriate resuscitation curriculum on Nicaraguan resident physician’s management of cardiac arrest

Purpose: Project Strengthening Emergency Medicine, Investing in Learners in Latin America (SEMILLA) created a novel, language and resource appropriate course for the resuscitation of cardiac arrest for Nicaraguan resident physicians. We hypothesized that participation in the Project SEMILLA resuscitation program would significantly improve the physician’s management of simulated code scenarios. Methods: Thirteen Nicaraguan resident physicians were evaluated while managing simulated cardiac arrest scenarios before, immediately, and at 6 months after participating in the Project SEMILLA resuscitation program. This project was completed in 2014 in Leon, Nicaragua. The Cardiac Arrest Simulation Test (CASTest), a validated scoring system, was used to evaluate performance on a standardized simulated cardiac arrest scenario. Mixed effect logistic regression models were constructed to assess outcomes. Results: On the pre-course simulation exam, only 7.7% of subjects passed the test. Immediately post-course, the subjects achieved a 30.8% pass rate and at 6 months after the course, the pass rate was 46.2%. Compared with pre-test scores, the odds of passing the CASTest at 6 months after the course were 21.7 times higher (95% CI 4.2 to 112.8, P<0.001). Statistically significant improvement was also seen on the number of critical items completed (OR=3.75, 95% CI 2.71-5.19), total items completed (OR=4.55, 95% CI 3.4-6.11), and number of “excellent” scores on a Likert scale (OR=2.66, 95% CI 1.85-3.81). Conclusions: Nicaraguan resident physicians demonstrate improved ability to manage simulated cardiac arrest scenarios after participation in the Project SEMILLA resuscitation course and retain these skills