LEP patients best served with interpreter in ED

Data show fewer errors with interpreters

Hospitals that receive federal funds are required by law to offer language assistance to patients with limited English proficiency (LEP). There is good reason for such a requirement because census data suggest that more than 59 million Americans speak a language other than English at home, and more than 25 million have LEP. However, a new study suggests that the type of assistance provided can make a big difference in determining whether or not there are miscommunications that lead to clinical consequences.1

Researchers, led by Glenn Flores, MD, a professor and director of the division of general pediatrics at the University of Texas Southwestern Medical Center and Children's Medical Center of Dallas, scoured the audiotapes of 57 interactions involving LEP patients at two large pediatric EDs in Massachusetts. They discovered nearly 2,000 errors, 18% of which had potential clinical consequences. However, only 2% of these errors were associated with professional interpreters who had at least 100 hours of training. Interpreters with less training were associated with 12% of the errors, and ad hoc interpreters — typically family, friends, or staff who may be bilingual but have no training in medical interpretation — were associated with 22% of the clinically significant errors. The authors note that the error rate was, in fact, lower (20%) for patients who had no interpreters at all than for the patients who had ad hoc interpreters.

"We have shown in a number of studies that having no interpreters is suboptimal and having ad hoc interpreters is suboptimal because they don't have the training and they are not familiar with medical terminology," says Flores. Further, while it may be tempting to make use of a family member who is bilingual, this can present additional complications. "There can be embarrassing issues, particularly when you have a child interpreting for adults," explains Flores. "The adult may not want to talk about domestic abuse or drug abuse, and [he or she] may not want to talk about sexual issues, or depression."

Matthew Wynia, MD, director of the Center for Patient Safety at the American Medical Association and clinical assistant professor at the University of Chicago agrees, noting that the use of ad hoc interpreters is problematic in many respects. "If you use a family member or the janitor, or you just pull someone in who happens to speak the language but who doesn't have any training in how to be an interpreter, not only do you have some of the problems of confidentiality and professional ethics of interpretation, but you also have just plain quality control problems," says Wynia. "They can misreport what you say to the patient."

Identify patients with limited English

Communicating with the LEP population is challenging in all health care settings, but the ED has some unique characteristics that may heighten the risk for errors. "Even if you speak the same language as your health care provider, when things happen fast and people have serious issues, it can be hard to understand what is going on, so when you add a language barrier to the mix, it really magnifies the challenges," says Flores. Nonetheless, he stresses there are things that ED administrators can and should do to minimize the chances that language barriers will lead to errors.

The first and most important step, says Flores, is to make sure that LEP patients are identified when they present to the ED for care. One way to do this is by asking all patients what primary language is spoken in their home. In cases where English is not the primary language, patients should be asked to rate their ability to speak English: very well, well, not well, or not at all. "Anything less than 'very well' is classified as LEP, and these patients need an interpreter," says Flores. "Don't just ask them if they need an interpreter because you will miss a lot of patients who don't speak sufficient English."

Keep in mind that many critical health care communications occur throughout a patient's visit to the ED, not just while he or she is being seen by a physician. This is where many health care organizations drop the ball, says Flores, noting that interpreters are not always present when they need to be. "Some of the most important communications occur at the end of the visit when the nurse or a medical assistant is signing the patient out," he says. "Also, you can imagine trying to get someone to sit still during an MRI [magnetic resonance imaging] or to get them in the right position for a chest X-ray without an interpreter."

Written communications, such as prescriptions or patient instructions, need to be printed in the patient's preferred language as well. "Have an option on the prescription pad when you can check off Spanish or some other language that is prevalent in your area so that the pharmacist knows how to print the instructions," says Flores. "Also, make sure that you have all of your patient instruction materials printed out in the most common languages so that people really do understand what they are supposed to do after discharge."

There should be plans in place for phone communications involving LEP patients as well, advises Flores. "Make sure that when patients call on the telephone that there are multilingual operators and phone trees for making appointments and follow-ups," he says.

Wynia agrees, noting that if a patient who does not speak English calls in, it is the hospital's responsibility to get an interpreter on the line. "Many patients just don't call because they know an interpreter isn't readily available," he says. "This is also why patients tend to cluster in [health care] settings where interpreters are available or where the staff speak their language."

Interpreter phone lines offer advantages

The literature suggests that the best way to communicate with LEP patients is through a professional interpreter or a bilingual provider, says Flores. Consequently, he advises ED administrators to identify staff who are bilingual, consider providing bonuses to personnel who are fluent in other languages, and to do more outreach to and recruitment of bilingual personnel.

While some large EDs have professional interpreters on staff 24/7 who speak Spanish or another language that is prevalent in the community, this is not practical in many settings, and it is impossible to have interpreter coverage for every language in any case. In instances where in-person interpreters are not available, most EDs rely on language lines where they can access trained interpreters via the telephone. "Typically, there are two handset phones that people can use so that both the patient and the doctor can be on the line with the interpreter at the same time," explains Wynia.

The phone lines can be inconvenient and cumbersome to use. And, of course, a phone-based interpreter will not able to pick up on any non-verbal cues or facial expressions that the patient may exhibit, but there can be some advantages to this approach as well, says Wynia. "When people are on the phone they may be willing to say things to the interpreter that they might not be willing to talk about if the interpreter is standing in the same room with them," he says.

In fact, Wynia, who is an HIV specialist, experienced this type of situation firsthand with a patient who always refused the assistance of a live interpreter. "Whenever she came in she preferred to not have an interpreter at all, but if there was anything of importance we had to discuss, I would get an interpreter on the phone, and she was OK with that because that interpreter wouldn't know her," he explains. "She was more willing to have that conversation with an interpreter on the phone than she would with a live interpreter."

In a true emergency, Wynia acknowledges that there may not be time to bring in a live interpreter or establish contact with a phone-based interpreter. "In an ideal setting you will have a rapid response way of getting an interpreter there, but regardless, you have to put the patient first and not let the situation get out of hand. You do the best with what you've got," he says. "But that isn't the most common situation in the ED. Most of what we see in EDs is more urgent rather than emergent cases, and in an urgent case you probably can wait 15 to 20 minutes [to establish contact with an interpreter]."

Even in cases where it is inconvenient or inefficient to wait for the services of a professional interpreter, Wynia stresses that the data are very clear that this is a better option than doing without an interpreter or relying on an ad hoc or untrained interpreter.

A word about cost

Professional interpreters can add costs to any health care encounter, and currently only 13 states and the District of Columbia provide third-party reimbursement for interpreter services. While this is certainly an issue for hospital administrators, it should not be a factor for individual providers, stresses Wynia. "The physician who is making the decision on whether to call an interpreter does not face that cost," he says. "Physicians who are convinced that interpreters are important to providing quality care will use interpreters, and those who feel like the inconvenience overrides the relative improvement in quality of care may not use them. But I think you have to acknowledge that is a risky decision because God forbid something happens to a patient after they leave because they did not understand [patient instructions]."

Where costs can enter into the decision-making equation is if hospitals adopt methods or systems that are not very responsive, hard to use, or particularly inefficient. "If you have to wait a long time [for an interpreter], that will drive up the inconvenience factor," adds Wynia.

When contracting for the services of interpreters or interviewing candidates for interpreter positions, keep in mind that time spent in professional training is more important than years of experience. This, at least, is what Flores discovered in his study, and he believes it makes perfect sense. "If you never received any training, even if you were working on the job as an interpreter for 30 years, you were probably making the same mistakes over and over again," he says. "I think this really shows how important and powerful the training is."

Unfortunately, there is not yet a universal understanding of precisely what comprises a trained, professional interpreter, although there is a code of ethics for interpreter services which covers things like maintaining confidentiality, and interpreting exactly what the parties say, explains Wynia. Consequently, medical interpreter certification programs are not at a point where it is reasonable or practical for health care organizations to require that medical interpreters be certified. "The vast majority of interpreters aren't yet certified," he says. "They may have very good training, but there just weren't any national certification programs until about 18 months ago."


  1. Flores G, Abreu M, Barone C, et al. Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus ad hoc versus no interpreters. Annals of Emergency Medicine 2012 Mar 14. [Epub ahead of print]


  • Glenn Flores, MD, Professor and Director, Division of General Pediatrics, University of Texas Southwestern Medical Center and Children's Medical Center of Dallas, Dallas, TX. E-mail: Glenn.Flores@utsouthwestern.edu.
  • Matthew Wynia, MD, Director, Center for Patient Safety, American Medical Association, and Clinical Assistant Professor, University of Chicago, Chicago, IL. E-mail: Matthew.Wynia@ama-assn.org.