ED providers might be tempted to rely on family members to interpret for patients with limited English proficiency, but this practice is problematic, both clinically and legally.1,2 “Family members are not trained interpreters, and you have no idea what they are saying. If using a healthcare-certified interpreter, you are assured of the accuracy,” says Breena R. Taira, MD, MPH, CPH, FACEP, associate professor of clinical emergency medicine at Olive View-UCLA Medical Center.

One time, Taira walked by a patient’s room and heard an ED provider say, “You have a problem with your liver.” A family member then interpreted this statement in Spanish as “You have a problem with your kidney.”

“From a medical/legal standpoint, to be assured of the accuracy of your communication, you need to use tools that are reliable and accurate,” Taira says. Fortunately, most EDs maintain robust interpreter services to assist with verbal communication. However, most do not offer any translator services for assisting with written communication. Not surprisingly, ED providers turn to automated translation software, such as Google Translate. “We see people using this because there is a gap in what hospitals typically provide,” Taira says.

Providers are trying to do the right thing — provide patients with written discharge instructions in their native language. “But machine translation is not ready for prime time in the ED,” Taira laments.

Accuracy of Google Translate is inconsistent among languages and should not be relied on by ED providers, according to a recent study.3 Taira and colleagues assessed the accuracy of Google Translate for 20 frequently used phrases in ED discharge instructions in seven languages. Translation accuracy rates varied depending on the language. “It’s not for medical use, and it’s not necessarily accurate,” says Taira.

Google Translate uses an algorithm that improves over time, but it relies on crowdsourcing feedback to do so.4 Even for commonly used languages with a high accuracy rate (e.g., Spanish or Chinese), accuracy of medical instructions is questionable. “All it takes is one acronym or proper noun to throw the meaning off,” Taira warns.

ED patients could receive discharge instructions that are wildly inaccurate. Researchers found translation errors, such as “Your Coumadin level was too high today,” translated in Chinese as “Your soybean level was too high today.” If the ED does not make a certified translator available for discharge instructions, Taira recommends writing the instructions in English so the ED provider knows they are accurate. Then, go to the bedside with a certified interpreter who gives the patient instructions verbally. The patient will not have written discharge instructions in their native language. “But at least you know that the information is being conveyed accurately,” Taira adds.

As for verbal interactions, professional interpreters in the ED improve communication beyond just word-for-word translation.5 Researchers observed six English-proficient and nine limited English-proficient patients in the ED. Phone-based interpreters missed some information because of a lack of visual cues. “We also observed instances where telephone-based interpreters had trouble hearing or interpreting the names of local clinics,” says Natalie Benda, PhD, a postdoctoral associate at Weill Cornell Medicine in New York.

Consistent use of interpreters in the ED is another legal concern. Professional interpreters are used inconsistently during pediatric ED visits.6 “Professional interpretation is underused in spite of federal mandate and local regulations requiring its use for families with a language other than English,” says K. Casey Lion, MD, MPH, assistant professor of pediatrics at the University of Washington School of Medicine.

Interventions to improve interpreter use to date in the ED “have not been terribly effective, with fewer than half of healthcare encounters that should use an interpreter actually doing so,” Lion reports.

To understand this in greater detail, Lion and colleagues recorded 50 pediatric ED visits and analyzed 312 communication events. Overall, professional interpreters were used for 36% of communications. “We should be concerned by how low interpreter use was at an institution with a strong commitment to language access,” Lion reports. “Also, everyone was likely on their best behavior, as they were being video-recorded.”

Interpreters were used most often to obtain medical histories (89% of the time). Interpreters were used least often for medication administrations (8% of the time) and for procedures (11% of the time). That is a safety concern. “There is the potential for serious errors and patient harm if the patient or parent are not able to ask questions in the moment,” Lion warns.

If the ED provider thinks the interaction will be brief (e.g., quickly checking a vital sign), it is easy to rationalize that it is not worth the hassle to find an interpreter. “When no interpreter is used, parents are left with no way to express concerns, share relevant information, or ask questions while things are being done to their child,” Lion notes.

For example, a parent might mention to a nurse that the volume of medicine given looks different from what they give at home, or report a medication allergy. Still, finding an interpreter in the ED can be difficult, time-consuming, or complicated. Lion and colleagues identified some barriers: cannot find a video console or speakerphone, technical difficulties, needing a password to unlock a tablet or computer, or the time it takes to provide all the necessary information to the interpreter. “Each of these things may be a small annoyance on its own, but they add up,” Lion observes.

Video interpreter units in every room, quick connections, reliable Wi-Fi without dropped calls, and an easy login process all help. “Even small changes in the barriers to accessing an interpreter can translate into big differences in use,” Lion offers.

EDs that make these changes can reduce risks, both in terms of malpractice and patient safety. Patients with limited English proficiency are known to experience higher rates of serious adverse events and medical errors.7 Failure to use interpreters could be why. “This should be a priority for improving patient safety and decreasing the risk of communication-related lawsuits in the ED,” Lion says.

REFERENCES

  1. Ramirez D, Engel KG, Tang TS. Language interpreter utilization in the emergency department setting: A clinical review. J Health Care Poor Underserved 2008;19:352-362.
  2. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res 2007;42:727-754.
  3. Taira BR, Kreger V, Orue A, Diamond LC. A pragmatic assessment of Google Translate for emergency department instructions. J Gen Intern Med 2021; Mar 5. doi: 10.1007/s11606-021-06666-z. [Online ahead of print].
  4. Castelvecchi D. Deep learning boosts Google Translate tool. Nature. Sept. 27, 2016.
  5. Benda NC, Bisantz AM, Butler RL, et al. The active role of interpreters in medical discourse - An observational study in emergency medicine. Patient Educ Couns 2021 May 24;S0738-3991(21)00384-0. doi: 10.1016/j.pec.2021.05.029. [Online ahead of print].
  6. Lion KC, Gritton J, Scannell J, et al. Patterns and predictors of professional interpreter use in the pediatric emergency department. Pediatrics 2021;147:e20193312.
  7. Khan A, Yin HS, Brach C, et al. Association between parent comfort with English and adverse events among hospitalized children. JAMA Pediatr 2020;174:e203215.