Helping Non-English Speakers Navigate Emergency Departments

Study by RWJF Scholar finds video-interpreting may reduce number of Spanish-speaking patients who leave emergency departments against medical advice.

    • October 17, 2011

For a non-English-speaking patient entering an emergency department, getting care can be daunting and even overwhelming. Health care providers may order extra tests or hold these patients longer than they normally would to ensure they get a full understanding of the patients' health problems. Frustrated and confused, limited-English proficient patients often end up leaving emergency departments against medical advice.

"As a physician, I was shocked that limited English-proficient patients were getting care in a setting where they didn't understand what was going on," says Robert Wood Johnson Foundation (RWJF) Clinical Scholar (1996-1998) Elizabeth A. Jacobs, MD, MPP. "There are risks associated with patients not understanding what's happening in a medical encounter, which are only compounded by a language barrier. If patients can't get or convey complete information, they are at risk for medical errors that are dangerous and costly."

Having an effective interpretation system for these patients can vastly improve the process, she says. In fact, health care organizations that receive federal funds are required to provide interpreter services for limited-English proficient patients.

Video-interpreting over the Internet—which allows the interpreter, patient and health care provider to see each other even when the interpreter is not physically present—is an efficient means of delivery interpreter services. With this type of system, an interpreter can be located within minutes of a request for almost any language, visual cues can aid understanding, and the rapport of a face-to-face interaction can be maintained.

But does this type of system, proven to foster better communication in an emergency department, impact care outcomes?

Jacobs and her colleagues, Paul C. Fu, Jr., MD, MPH, and Paul J. Rathouz, PhD, looked for answers in their study, which was published online on October 18, 2011, in the journal Health Services Research. It is part of a special issue on "Bridging the Gap Between Research and Health Policy" that features research articles from current and former RWJF Clinical Scholars. The print edition will be published in February 2012.

Jacobs and her colleagues compared two hospitals—one in rural northern California, and one in urban southern California—that are similar in size and mission. At each location they studied the six-month period before implementation of a video-interpreting system, and a six-month period after its use had been well-established.

Using hospital electronic health records and billing data, they tracked information about Spanish- and English-speaking patients who had entered the emergency department for abdominal or chest pain: the number of tests ordered, the time spent in the emergency department, hospital admission rates, and whether the patient left against medical advice. They calculated the changes in outcomes for Spanish-speaking patients before and after the implementation of the video system, in comparison with a control group of English-speaking patients.

For both language groups, the mean time spent in the emergency department, the number of tests ordered and hospital admission rates decreased after implementation of the video-interpreting system. However, because there was not a statistically significant difference between the findings for the limited English-speaking and English-speaking groups, the researchers could not conclude that the video-interpreting system was the primary reason for these changes.

"Given the nature of ED [emergency department] practice … there are many other factors that influence our outcomes that likely had a stronger influence on what happens in the ED than accurate communication between clinician and patient," they wrote. "In hindsight, we may have found a more significant impact if we examined measures that were dependent on the patient's understanding, such as comprehension and adherence to communicated follow-up."

There was, however, a difference in the number of patients leaving the emergency department against medical advice. While there was no difference at the urban hospital, after implementation of the video-interpreting service rural hospital saw a significantly smaller portion of Spanish-speaking patients leave before receiving appropriate care compared to English-speakers.

Although the video systems did not demonstrate a statistically significant impact on the outcomes studied, it "does not mean they have not had a significant impact on the hospitals, clinicians, and patients that use them," the authors wrote.

"Providing interpreter services is a basic standard of care," Jacobs says. "Patients should receive care in a language they can understand," and a video-network is an efficient, cost-effective way to provide adequate, equal access to care.

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