Professional translation services in the ED can reduce errors and prevent adverse events
Thrombosis, sclerosis, embolism-it might not require conjugating verbs, but medical terminology is a language in itself, one that often creates a barrier between physicians and patients. When the patient also doesn't speak English, communicating becomes an even bigger obstacle.
A recent study in the Annals of Emergency Medicine, "Errors of Medical Interpretation and Their Potential Clinical Consequences: A Comparison of Professional Versus Ad Hoc Versus No Interpreters," explores the medical errors fueled by language barriers in the ED. Study authors recorded audio of ED visits during 30 months in the two largest pediatric EDs in Massachusetts. Participants included Spanish-speaking limited-English-proficient patients, caregivers, and their interpreters.
Study authors noted 1,884 interpreter errors and concluded that professional interpreters were significantly less likely (12%) to cause errors than ad-hoc interpreters (22%) or no interpreters (20%).
What do these findings mean for your ED? Potentially, a lot. Non-English-speaking individuals are more at risk of having reduced access to healthcare, and thus are more likely to use the ED for emergency and routine care. In addition, the volume of patients that pass through the ED is inherently greater than the number of patients who are admitted to the hospital, so the need for capable translators is usually greatest in the ED. Understanding what medications a patient is taking or when he or she last ate may make the difference between a successful treatment or an adverse event.
Not having the appropriate translator services may also cost the hospital money. "When a non-English-speaking patient comes in and you can't understand what their chief complaint is, you are assuming the worst and tend to order more things, so your cost goes up. It makes sense to deter that cost and have services available," says Harvey Castro, MD, emergency physician at Quest Care Partners in Dallas/Fort Worth.
But the need for translators is different for every hospital. Some hospitals may only sporadically encounter patients who speak a foreign language, but it may be an everyday occurrence for other hospitals. Each facility must determine what translator services are appropriate to meet community needs. In general, hospitals have four options:
- Professional medical translators, who can provide their services either in person or over the phone.
- An ad-hoc phone-based translator service. The three-way phones allow both the physician and the patient to speak and listen to a translator, who may or may not be trained in medical terminology.
- Friends or family members of the patient.
- Nurses or other clinicians who are bilingual and can translate simple questions or requests.
There are pros and cons to each type of translator, and not all are appropriate in every circumstance.
Professional medical translators
Cambridge (Mass.) Health Alliance (CHA) has close to 100 FTE interpreters covering three hospitals and 20 clinics in the Boston area. About 40% of CHA's patients do not speak English; the most common foreign language is Portuguese, followed by Spanish and Haitian-Creole. "For the top dozen or so languages, we have interpreters available 24/7 to communicate either through a high-tech three-way phone or at the bedside," says Assaad Sayah, MD, medical staff president and chief of emergency medicine at CHA.
Generally, interpreters are available within 15 to 20 minutes, day or night. If a translator is needed more urgently, the physician or other caregiver can call the translator number and a dispatcher can connect him or her to an appropriate translator in minutes. All of CHA's interpreters must go through rigorous medical terminology training, and they must pass both written and spoken proficiency tests before they can begin assisting patients.
When shopping for a translator service, keep in mind that the Annals of Emergency Medicine study suggests requiring at least 100 hours of training for interpreters could significantly reduce interpreter errors, thus improving quality and patient safety.
If a patient requires an examination of a personal nature, the patient may choose to ask the interpreter to stand behind a privacy curtain. "However, I think it is important that the interpreter is in the room so that the patient can read the facial expressions and body language," says Sayah. "We try to be very culturally sensitive. At the end of the day, patients are forgiving when they know they are going to get medical care, and as long as you are respectful, they can usually get over that."
Tracy Sanson, MD, FACEP, associate professor of emergency medicine at the University of South Florida in Tampa, says that in-person translators are appropriate not only for the initial history and physical (H&P) examination, but also for the tough moments, such as delivering the news of an impending surgery, serious illness, or death. "We use our own translators in the hospital for those one-on-one, eye-connecting moments."
If your hospital experiences only a sporadic need for translation services, having FTE translators may not be the best option. Instead, your organization may benefit from an ad hoc phone service.
Ad-hoc over-the-phone translators
Most hospitals are equipped with translator phones. These special phones have two headsets so that both the physician and the patient can listen and speak to a translator, who is connected through a dispatcher. Translators may or may not be trained in medical terminology depending on the company providing the service. Over-the-phone translator services can connect physicians and clinicians to a translator within minutes, although it may take longer to find a translator proficient in a rare dialect.
Having a professional translator during the H&P is crucial. "The danger is that you don't work a patient up for the right thing-you think they are there for diarrhea, but they are there primarily for chest pain," says Castro. For some hospitals, the over-the-phone service is the best option to ensure proper communication.
Friends or family members
The general rule of thumb is that friends and family of the patient should only be used to translate non-medical issues. For example, a son can relay his mother's address, the name of her doctor, what she ate earlier in the day, and whether she is still in pain. However, the son should not be asked to translate a medical diagnosis or medication names.
Castro says that having family members translate can be a double-edged sword. On the one hand, a family member may be able to offer a physician insight into the patient's condition, but on the other hand, family members sometimes have a tendency to cover up the patient's symptoms. "Whereas if the interaction was translated on the phone, you would just take it for what it is. Unfortunately, because of the litigious world we live in, if that family member didn't translate correctly and I missed a diagnosis, in theory I would be liable, which is why the hospital has subscribed to that service," Castro says.
CHA has a policy to prevent friends and family members from translating. "The only way that we will use an interpreter that comes with the patient is if the patient refuses the offer [for one of our translators] and signs a waiver. It is a good policy because laypeople may not be able to translate the medical jargon. Also, family members tend to interpret their own way or summarize or make assumptions," says Sayah.
Sanson agrees that friends and family should not translate during the H&P, but they can be handy when it comes to simple communications, such as relaying directions to the radiology department or a request for juice. "I think that it is the responsibility of the patient to bring someone who can translate," she says.
Bilingual medical personnel
Although an over-the-phone translator service is invaluable, Sanson says setting up a phone call can take five to six minutes, which is onerous when you simply want to ask if a patient is still in pain or say that he or she can eat now that the tests are complete. Bilingual medical personnel, who are not necessarily trained translators but who can translate simple instructions, can help keep the patient flow moving. "It could prevent a patient from standing over in x-ray because they are not able to say to someone, 'I'm finished and I need to go back.' "
Bilingual medical personnel can also fill in the gaps where a phone service is not ideal. For example, it's pretty tricky to wield a phone during a pelvic examination, says Sanson. In such cases, a professional translator or a bilingual clinician is your best bet.
"In the hospital, we have a handful of trained translators, but if you are in the ED and there are several people who need translating, we may not be able to get the translator from across the hospital, which is why other caregivers are often used," says Sanson.
Bridging the gaps
Physicians are often not trained to communicate using a translator; it is a skill many learn on the job. "It can be difficult when you are trying to do something quickly," says Sanson. Just as you wouldn't rush through communication with a child or an elderly person with a receptive deficit or cognitive impairment, physicians shouldn't rush through communications with non-English-speaking individuals, even when a translator is present.
"It is something we learned in general that works across all of our communications, not just with a translator," Sanson says.
Physicians must pause to allow the translator to relay messages to and from the patient, repeat back what they heard to ensure they understood the patient correctly, and keep cultural differences in mind. For example, a hand gesture may have a completely different meaning to a patient from another country.
Some physicians may be able to translate on their own. For example, Castro is fluent in both English and Spanish, and since the majority of his non-English-speaking patients speak Spanish, he rarely needs a translator. Sanson, on the other hand, knows enough Spanish for simple communications such as saying hello and asking if a patient is pregnant, but requires a translator for the H&P. It's up to each physician to make the call as to when a translator is necessary.
"The emergency room is a catch 22-to some degree, it is all in the history, so if you miss some critical piece of information, you will make a mistake. On the same token, if someone comes in clutching their chest, you can work up a diagnosis. You have to know what medications they already take, but for the most part, you are going to take care of business even if they can't speak. In a true emergency where the person is unconscious, that is what we specialize in," says Castro.