Lan­guage li­a­bil­i­ties

To avoid er­rors, hos­pi­tals urged to use qual­i­fied in­ter­preters for pa­tients with limited English

Modern Healthcare - - NEWS - By Sabriya Rice

ASPANISH-SPEAK­ING MALE PA­TIENT EN­TERED THE EMER­GENCY DEPART­MENT at Anne Arun­del Med­i­cal Cen­ter in An­napo­lis, Md., in De­cem­ber 2012 suf­fer­ing from vom­it­ing, ab­dom­i­nal pain and short­ness of breath. Over two days in the hos­pi­tal, he had blood drawn, un­der­went an ab­dom­i­nal CT scan, re­ceived IV flu­ids and had a uri­nary catheter in­serted. But it’s pos­si­ble that he never fully un­der­stood that fluid was build­ing up in his ab­domen and lungs and that his con­di­tion could be fa­tal. Ac­cord­ing to a hos­pi­tal in­spec­tion re­port, no one dis­cussed his care plan with him in Span­ish, the only lan­guage he un­der­stood, un­til an hour and a half be­fore he died.

As the U.S. grows in­creas­ingly more lin­guis­ti­cally and cul­tur­ally di­verse, some safety ex­perts worry that health­care providers too of­ten are not mak­ing pro­fes­sional in­ter­preter and trans­la­tor ser­vices avail­able to pa­tients and families. In­stead, they fre­quently rely on non­pro­fes­sion­als, in­clud­ing pa­tients’ fam­ily mem­bers, who are not knowl­edge­able about med­i­cal ter­mi­nol­ogy. This in­creases the risk of med­i­ca­tion er­rors, wrong pro­ce­dures, avoid­able read­mis­sions and other ad­verse events. Nearly 9% of the U.S. pop­u­la­tion is at risk for an ad­verse event be­cause of lan­guage bar­ri­ers, ac­cord­ing to the Agency for Health- care Re­search and Qual­ity.

Most or­ga­ni­za­tions ad­vise against the use of a pa­tient’s fam­ily or friends, who can po­ten­tially do more harm than good. Bilin­gual clin­i­cal staffers also are dis­cour­aged from step­ping in if they have not been cer­ti­fied as med­i­cal in­ter­preters. But physi­cians and hos­pi­tal staff of­ten ig­nore th­ese poli­cies, typ­i­cally be­cause of time pres­sures, lack of knowl­edge about the avail­abil­ity of pro­fes­sional in­ter­preters, or pro­ce­dural difficulties in ar­rang­ing for in­ter­preters.

In a re­port pub­lished in May in the Jour­nal for Health­care Qual­ity, hos­pi­tal qual­ity and safety lead­ers, nurs­ing staff and in­ter­preters

re­counted prob­lems that arose when staffers tried to do with­out, of­ten be­cause they felt the wait for a pro­fes­sional in­ter­preter would de­lay needed care. The re­port found that med­i­ca­tion er­rors and lack of in­formed con­sent were more com­mon among pa­tients with lan­guage bar­ri­ers.

Ev­ery ex­pert in­ter­viewed by Mod­ern Health­care for this ar­ti­cle knew of at least one case where a hos­pi­tal re­lied on un­trained hos­pi­tal staff, or a pa­tient’s rel­a­tive or friend, even at hos­pi­tals with es­tab­lished in­ter­preter pro­grams. “Ev­ery­body has a story about some risky sit­u­a­tion where lack of ad­e­quate interpretive ser­vices put a pa­tient in harm’s way,” said Me­lanie Wasser­man of Abt As­so­ciates, a re­search and pro­gram im­ple­men­ta­tion firm based in Cam­bridge, Mass., who co-au­thored the jour­nal ar­ti­cle.

In one case, a clin­i­cian com­mu­ni­cated in French to a Haitian pa­tient who spoke only Cre­ole. Haitian in­ter­preters noted that in French, “es­tomac” means stom­ach, but in Cre­ole a sim­i­lar­sound­ing word, “lestomak,” can re­fer to the chest. Such con­fu­sion could lead to a pro­ce­dure on the wrong or­gan or other body part. “This is a po­ten­tially life-threat­en­ing er­ror,” Wasser­man said.

Many hos­pi­tals con­tract with com­pa­nies pro­vid­ing in­ter­preters, and most have dis­cour­aged the use of chil­dren as in­ter­preters for their par­ents. While most hos­pi­tals have es­tab­lished at least phone-based in­ter­pre­ta­tion ser­vices, it is not un­com­mon for hos­pi­tals in large ur­ban ar­eas such as San Fran­cisco, Hous­ton or Mi­ami to have more com­pre­hen­sive in­ter­pre­ta­tion and trans­la­tion pro­grams.

But re­searchers re­main con­cerned about in­con­sis­tent mon-

itor­ing and re­port­ing of lan­guage-re­lated er­rors. They say it’s dif­fi­cult to as­sess how well providers are ad­dress­ing the is­sue, es­pe­cially since pa­tients with limited English pro­fi­ciency are less likely than U.S.-born English speak­ers to call out er­rors when they oc­cur.

“This is an area where you see some of the worst pa­tientsafety prob­lems,” said Dr. Glenn Flores, direc­tor of pe­di­atrics at the UT South­west­ern Chil­dren’s Med­i­cal Cen­ter in Dal­las, who stud­ies lan­guage bar­ri­ers.

In a 2012 An­nals of Emer­gency Medicine study an­a­lyz­ing au­dio record­ings from vis­its at two large pe­di­atric emer­gency de­part­ments in Mas­sachusetts, Flores and his col­leagues found thou­sands of what they deemed in­ter­pre­ta­tion mis­takes, even among pro­fes­sional in­ter­preters. Th­ese in­cluded in­ter­preters omit­ting, adding or sub­sti­tut­ing words, adding their own per­spec­tives, or us­ing id­ioms, words or phrases that didn’t ex­ist in the pa­tient’s lan­guage. Of th­ese in­ci­dents, 18% had po­ten­tial clin­i­cal con­se­quences. Mis­takes were less fre­quent among pro­fes­sional in­ter­preters who had at least 100 hours of train­ing.

Em­ploy­ment of in­ter­preters and trans­la­tors is pro­jected to grow 46% by 2022, driven by large in­creases in the num­ber of non-English-speak­ing peo­ple in the na­tion, ac­cord­ing to the U.S. Bureau of La­bor Statis­tics. The num­ber of peo­ple speak­ing a lan­guage other than English in U.S. homes climbed 158% in the past two decades, a 2013 cen­sus re­port found.

The Joint Com­mis­sion re­quires hos­pi­tals to pro­vide pro­fes­sional in­ter­pre­ta­tion ser­vices to ev­ery pa­tient who needs it. It also re­quires writ­ten ma­te­ri­als be tai­lored to pa­tients’ age, lan­guage and abil­ity to un­der­stand. HHS’ Of­fice of Mi­nor­ity Health up­dated its Na­tional Stan­dards for Cul­tur­ally and Lin­guis­ti­cally Ap­pro­pri­ate Ser­vices last year, to help hos­pi­tals com­ply with Ti­tle VI of the Civil Rights Act and the Amer­i­cans with Dis­abil­i­ties Act.

Laws on lan­guage

In ad­di­tion, ev­ery state has laws on lan­guage ac­cess in health­care set­tings. Thir­teen states and the District of Columbia di­rectly re­im­burse providers for lan­guage ser­vices used by pa­tients on Med­i­caid and the Chil­dren’s Health In­sur­ance Pro­gram. “The fact that states can pay di­rectly for in­ter­preters is a great op­por­tu­nity to help hos­pi­tals meet fed­eral re­quire­ments and help them off­set the costs,” said Mara Youdel­man, man­ag­ing at­tor­ney for the Na­tional Health Law Pro­gram.

Hos­pi­tals in ru­ral ar­eas face par­tic­u­lar chal­lenges, said Dr. El­iz­a­beth Ja­cobs, as­so­ciate vice chair for health ser­vices re­search at the Univer­sity of Wis­con­sin at Madi­son. The largest rate of in­crease of peo­ple with limited English pro­fi­ciency is in ru­ral ar­eas be­cause re­cent im­mi­grants of­ten seek agri­cul­tural and other man­ual la­bor jobs in ru­ral ar­eas and small towns, she noted.

Some hos­pi­tals have staff or con­tract in­ter­preters for lan­guages com­monly spo­ken in their com­mu­ni­ties, while oth­ers pro­vide in­ter­pre­ta­tion through off-site ser­vices by video or phone. Ser­vices of­fered in-per­son and via video are of­ten pre­ferred, as they al­low in­ter­preters to pick up on non­ver­bal cues that may be cul­ture-spe­cific.

The Of­fice of Man­age­ment and Bud­get in 2002 es­ti­mated that U.S. hos­pi­tals’ an­nual costs for pro­vid­ing in­ter­preter ser­vices was $78 mil­lion for in­pa­tient vis­its, $12 mil­lion for out­pa­tient vis­its and $8.6 mil­lion for emer­gency depart­ment vis­its. An Amer­i­can Med­i­cal As­so­ci­a­tion sur­vey found that costs of $150 or more for in­ter­preter ser­vices of­ten ex­ceeded a physi­cian’s pay­ment for the visit, pre­sent­ing what the AMA called a “sig­nif­i­cant hard­ship” for prac­tices.

David Fet­terolf, pres­i­dent of Stra­tus Video, which of­fers pro­fes­sional in­ter­pre­ta­tion ser­vices via video, said his com­pany’s pro­fes­sional in­ter­preter ser­vice costs about $1.50 a minute. Stra­tus uses an iPad, of­ten at­tached to an IV pole, that can be wheeled into a pa­tient room; within 30 seconds a cer­ti­fied in­ter­preter is avail­able on­line.

Such charges can quickly add up, but many say it is a nec­es­sary ex­pense. “We have quite a de­mand,” said Dar­rin Bear­den, in­ter­pre­ta­tion ser­vices co­or­di­na­tor for North­side Hos­pi­tal in At­lanta. The hos­pi­tal has an av­er­age of 230 in­ter­pre­ta­tion en­coun­ters daily, with about 83,000 to­tal in­ter­ac­tions in 2013. The hos­pi­tal started us­ing Stra­tus in 2012 to sup­ple­ment other in­ter­preter ser­vices it of­fers, in­clud­ing qual­i­fied med­i­cal in­ter­preters on staff and tele­phone ser­vices.

Lost in trans­la­tion

But there is plenty of ev­i­dence that con­tin­ued gaps in in­ter­pre­ta­tion are lead­ing to ad­verse out­comes. A study pub­lished in June in the Amer­i­can Jour­nal of Man­aged Care found that pa­tients whose pri­mary lan­guage was not English were sig­nif­i­cantly more likely to have mul­ti­ple 30-day read­mis­sions at a Los An­ge­les hos­pi­tal. Pa­tients speak­ing Rus­sian, Farsi and Span­ish each rep­re­sented about 5% of pa­tients with three or more hos­pi­tal stays between July 2009 and De­cem­ber 2010, the study found.

A Na­tional Health Law Pro­gram study an­a­lyz­ing 35 claims filed in four states between Jan­uary 2005 and May 2009 for one li­a­bil­ity in­surer found the in­surer paid $2.3 mil­lion in dam­ages or set­tle­ments and $2.8 mil­lion in le­gal fees for cases where the provider failed to of­fer a pro­fes­sional in­ter­preter. Among the cases stud­ied, five pa­tients died and oth­ers suf­fered per­ma­nent dam­ages, such as leg am­pu­ta­tions and or­gan dam­age.

Re­searchers urge hos­pi­tals to more closely track the num­ber of limited English pro­fi­ciency pa­tients and the in­ci­dents of er­rors as­so­ci­ated with th­ese pa­tients. Aswita Tan-McGrory, deputy direc­tor of the Dis­par­i­ties Solutions Cen­ter at Mas­sachusetts Gen­eral Hos­pi­tal, Bos­ton, said hos­pi­tals should fo­cus their at­ten­tion on high-risk sit­u­a­tions for in­ter­pre­ta­tion prob­lems, such as med­i­ca­tion rec­on­cil­i­a­tion, dis­charge in­struc­tions, in­formed con­sent, emer­gency vis­its and sur­gi­cal care.

Some ex­perts say stan­dard­iza­tion of train­ing and cer­ti­fi­ca­tion for med­i­cal in­ter­preters would re­duce clin­i­cal er­rors re­lated to in­ter­pre­ta­tion. The Na­tional Board of Cer­ti­fi­ca­tion for Med­i­cal In­ter­preters, based in Salem, Mass., and the Cer­ti­fi­ca­tion Com­mis­sion for Health­care In­ter­preters, based in Wash­ing­ton, of­fer pro­grams test­ing in­ter­preters’ knowl­edge and skills, set ethics codes and pro­vide guide­lines on stan­dard op­er­at­ing pro­ce­dures. The cer­ti­fi­ca­tion com­mis­sion said it has cer­ti­fied more than 1,600 in­ter­preters since it was founded in 2009.

Ex­perts say hos­pi­tals also need to do a bet­ter job of in­form­ing staff that pro­fes­sional in­ter­preter ser­vices are avail­able. Even those with es­tab­lished in­ter­pre­ta­tion pro­grams still ex­pe­ri­ence prob­lems.

In the 2012 in­ci­dent at Anne Arun­del Med­i­cal Cen­ter, which has a pro­fes­sional in­ter­preter pro­gram, emer­gency depart­ment nurses had in­di­cated the pa­tient was “Span­ish­s­peak­ing only.” But there was no record that an in­ter­preter was called dur­ing the ad­mis­sions process. Dur­ing the pa­tient’s first day, he signed a treat­ment con­sent form printed in English, and at one point his daugh­ter acted as in­ter­preter.

It can­not be de­ter­mined whether the pa­tient or his providers would have done any­thing dif­fer­ently if a pro­fes­sional Span­ish-speak­ing in­ter­preter had been used through­out his hos­pi­tal stay. But one thing is clear: The pa­tient “was not able to take part in de­ci­sions about his own treat­ment be­cause his need for a trans­la­tor was not iden­ti­fied,” the hos­pi­tal in­spec­tion re­port con­cluded.

Anne Arun­del Med­i­cal Cen­ter de­clined to com­ment on the case, cit­ing fed­eral pri­vacy law. But Vic­to­ria Bay­less, the hos­pi­tal’s pres­i­dent, said her fa­cil­ity uses a va­ri­ety of com­mu­ni­ca­tion mech­a­nisms to meet the needs of limited English pro­fi­ciency pa­tients, in­clud­ing per­sonal one-on-one in­ter­pre­ta­tion, video con­fer­enc­ing and tele­phone ser­vices. “We re­main fo­cused on con­tin­u­ing to im­prove our care and ser­vice in this re­gard,” she said in a writ­ten state­ment.

In an­other re­ported in­ci­dent, Wash­ing­ton Ad­ven­tist Hos­pi­tal in Takoma Park, Md., ac­knowl­edged that its pol­icy was not fol­lowed in March when a Haitian pa­tient who spoke Cre­ole was ad­mit­ted but no pro­fes­sional in­ter­preter was pro­vided dur­ing her in­pa­tient stay. In­stead, the pa­tient’s daugh­ter pro­vided in­ter­pre­ta­tion.

Mar­cos Pes­quera, ex­ec­u­tive direc­tor for Ad­ven­tist Health­care’s Cen­ter for Health Eq­uity and Well­ness, could not say why the hos­pi­tal’s staff did not use pro­fes­sional in­ter­preters in that case. But he noted the hos­pi­tal has more than 150 em­ploy­ees who are qual­i­fied in­ter­preters, and also has con­tract in­ter­preters speak­ing more than 200 lan­guages, in­clud­ing Cre­ole, via tele­phone ser­vices and video tech­nol­ogy. Ad­ven­tist has since re­vamped ef­forts to ed­u­cate staff about the avail­abil­ity of pro­fes­sional in­ter­pre­ta­tion ser­vices. “If the provider has the per­cep­tion that ac­cess­ing the re­source is hard, they are less likely to use it,” he said.

Univer­sity of Wis­con­sin’s Ja­cobs said long waits and other ac­cess is­sues in get­ting a pro­fes­sional in­ter­preter are dis­in­cen­tives for busy clin­i­cians and other hos­pi­tal staffers. “So they go with the eas­i­est thing to do at the mo­ment—their own limited lan­guage skills, a fam­ily mem­ber, or who­ever hap­pens to be ac­ces­si­ble,” she said. They “don’t read­ily rec­og­nize the im­pact it can have.”


Lu­cia Con­tr­eras of Riverdale, Md., talks with Bertha Cas­tril­lon, cul­tural di­ver­sity li­ai­son at Wash­ing­ton Ad­ven­tist Hos­pi­tal. The hos­pi­tal has more than 150 em­ploy­ees who are qual­i­fied in­ter­preters and has con­tract in­ter­preters speak­ing more than 200 lan­guages.

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