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Patients with Limited English Proficiency Pose Risks

By Stacey Kusterbeck, Special for

Derick Jones, MD, MBA, and colleagues set out to learn if there are important care gaps for patients who visit the ED and do not speak English as a first language.

Researchers analyzed 745,464 ED visits, including 27,906 visits by patients with limited English proficiency (LEP). The authors compared the ED visits to determine if there were disparities in irregular departures and return visits 72 hours later and seven days later, or disparities in the disposition at the time of return visits.

Investigators found no extra return visits or irregular departure patterns among LEP patients compared to those proficient in English. However, more LEP patients were admitted to the hospital at return ED visits. “Important considerations for ED providers are to use best practices in translation workflows to assist in communication with these patients and consider some of the socioeconomic and insurance differences between limited English proficiency and English-proficient patients,” offers Jones, an emergency medicine specialist at the Mayo Clinic.

Patients with LEP “are at inherent risk when they present to an ED in the U.S. where English is most commonly spoken,” says Jay Brenner, MD, FACEP, medical director of the community ED at SUNY Upstate Medical University in Syracuse, NY.

In multiple well-publicized cases, LEP patients have experienced bad outcomes traced to misunderstandings or mistranslations of their history or symptoms. This issue has been a concern for emergency medicine providers for decades.

In a 1980 case, friends accompanying an 18-year-old unconscious Spanish-speaking patient told healthcare providers the patient was “intoxicado,” which the emergency physician misunderstood as “intoxicated." In fact, the friends were trying to convey that the patient had ingested something that made him sick.

The patient was experiencing an acute subdural hematoma, and intervention was delayed. All parties settled a subsequent lawsuit for $71 million. “It is critical to provide professional interpreter services for all languages commonly spoken in your patient population,” Brenner emphasizes.

Even though this episode happened decades ago, Brenner believes a similar case could occur in an ED today. Ad hoc interpreters are known to pose a legal risk because of the likelihood of misunderstandings. Frequently, though, ED patients still request that a family member serve as an ad hoc interpreter. “This should be done only in extreme circumstances, with great caution, because medical terminology may be challenging to be understood,” Brenner warns.

Hospital employees might serve as interpreters, but they should do so only if they are fluent, well-trained, and certified. “Otherwise, this practice could also lead to misunderstandings and legal risk,” Brenner notes.

LEP patients pose some unique liability risks for emergency medicine providers, according to Ryan M. Shuirman, JD, an attorney in the Raleigh, NC, office of Cranfill Sumner. The patient’s inability to understand questions asked, or the patient’s inability to convey information on symptoms or the history of present illness “can be a significant obstacle to ED providers in the process of gathering history and understanding the full context surrounding the patient’s presentation,” Shuirman explains.

Sometimes, emergency medicine providers are presented with similar obstacles when managing unconscious patients who are brought to the ED. “However, there can be confusion and misuse of descriptors in conversations with non-English speakers that could derail well-meaning efforts to understand more about a patient’s chief complaint,” Shuirman says.

For example, emergency clinicians might not be able to obtain accurate information on allergies for LEP patients. “This could lead to significant patient morbidity, just as it would with an unconscious patient,” Shuirman reports.

For ED leaders, finding enough multilingual staff to translate for LEP patients often is an uphill battle. One possibility is for administrators to recruit triage staff who speak languages most commonly spoken about patient populations that present EDs often. “It is unclear that the standard of care requires multilingual staff or requires the implementation of translator services when non-English speakers present to the ED,” Shuirman offers.

Rather than a fixed rule, the volume of patients who are non-English speakers, and the location of the ED, are crucial factors in determining the standard of care. “With an uptick in corporate negligence claims, at least in North Carolina, we can anticipate that hospital administrators will come under some scrutiny of how much consideration they have paid to this issue, and what efforts they have made to identify communication gaps to better care for the patient population they serve,” Shuirman predicts.

For more on this and related subjects, be sure to read the latest issues of ED Management.