Episode #144 Keeping Patients with Limited English Proficiency Safe During Anesthesia Care

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Have you provided anesthesia care for a patient with limited English proficiency? Language barriers in healthcare are a big threat to patient safety. Today, we are talking about how we can keep patients with limited English proficiency safe during anesthesia care.

Before we dive into the episode today, we’d like to recognize Blink Device Company, a major corporate supporter of APSF. Blink Device Company has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Blink Device Company – we wouldn’t be able to do all that we do without you!”

Our featured article today is from the February 2023 APSF Newsletter. It is “Anesthesia Care for Patients With Limited English Proficiency” by Harrison Charwat and Meghan Lane-Fall. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well.

To kick off the show today, we are going to hear from one of the authors. I will let him introduce himself now.

[Charwat] “Hi, my name is Harrison Charwat and I’m a PGY one anesthesiology resident at the hospital of the University of Pennsylvania in Philadelphia, PA.”

[Bechtel] I asked Charwat what got him interested in this topic? Let’s take a listen to what he had to say.

[Charwat] “I started this project as a medical student. I had a clerkship experience where I was assigned to be the liaison for a patient on the wards with limited English proficiency because the medical student quote has the most time to spend with the patient. I had not heard of the patient’s primary language before and I was on hold for half an hour to connect with an interpreter.

This made me interested in learning more about the experience and processes involved in communicating with L E P patients. It also showed me the barriers in this process, especially practical limitations like time can generate gaps in care.”

[Bechtel] What a great way to start the show today and don’t worry we will be hearing more from Charwat in the future. Now, it’s time to get into the article. The authors introduce the scope of this threat to anesthesia patient safety since language barriers contribute to disparities in care and outcomes for patients that do not speak English well compared to English-speaking patients. The definition of patients with limited English proficiency or LEP from the US Department of Health and Human Services is: “those who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English.” There are five high-risk scenarios for LEP patients according to the Agency for Healthcare Research and Quality that include the following:

1. Medication Reconciliation
2. Patient Discharge
3. Informed Consent
4. Emergency Department Care
5. And Surgical Care.

Do these clinical scenarios sound familiar? They probably do since anesthesia professionals may have an important role in all of these high-risk scenarios. This is not the time to let down our guard since LEP patients are at increased risk for surgical delays, surgical infections, falls, pressure ulcers, and readmissions. Let’s start with some fast facts. There are over 7,000 languages recognized by linguists. There are 1,333 languages catalogued by the United States Census Bureau. The US Census Bureau also reports speakers from forty-two different language groups. Check out Table 1 in the article which reveals the top ten languages spoken by those who speak languages other than English at home in the United States as well as the number of speakers of each language in the United States in 2018 and the percent change for each language between 2010 and 2018. We are going to run through the top ten languages now.

1. Spanish
2. Chinese, including Cantonese and Mandarin
3. Tagalog
4. Vietnamese
5. French
6. Arabic
7. Korean
8. Russian
9. German
10. And Hindi.

As you can see from the second column, there are millions of people in the US who speak languages other than English in the home and these patients may present to a hospital in the United States for healthcare.

The authors remind us that it is vital to recognize the unique needs of patients who do not speak the most common language or languages in any given setting. This is true in the United States and around the world. In the United States, English is the de facto language of government, health care, and commerce. In 2019, almost a quarter of the US population reported speaking another language at home with 8.2% of the US population reported to have limited English proficiency. When we look at government programs in the US, there is the Title VI of the US Civil Rights Act of 1964 which requires recipients of federal financial assistance to work towards making their programs, services, and activities accessible by people with LEP. This is important in the healthcare setting since Federal financial assistance programs include the healthcare providers and hospitals who participate in CHIP, Medicaid, and Medicare. Thus, these hospitals must provide appropriate translation of written word and interpretation of spoken word.

There is a resource available for organizations and individual providers from the US Department of Health and Human Services that is a free online educational program which helps to assess the ability to provide care for LEP patients and offers education about the Health and Human Services Office of Minority Health Standards for Culturally and Linguistically Appropriate Services in Health and Health Care.

Let’s take a dive into important considerations for providing care for patients with limited English proficiency. First, clinicians must determine when interpretation services are needed. This is actually spelled out pretty clearly by the Joint Commission in this statement, “Because communication is a cornerstone of patient safety and quality care, every patient has the right to receive information in a manner he or she understands.” When it is time to use interpretation services, it  may be in person with a trained clinician or trained staff member or dedicated interpreter. Other options include partnering with a company for audiovisual or audio only trained interpreter services. Interpretation services should be used for all two-way communication with the patient. What interpretation resources are available at your institution? It is important to know what resources are available in your hospital and wherever you provide anesthesia care.

Let’s take a look at this patient safety VIP on the healthcare team, the trained interpreter who must speak English, the desired language, and understand the medical terminology in both languages. Training includes 40-120 hours of training prior to starting. This training is critical since untrained interpreters make twice as many errors as trained interpreters.

How should the interpretation services be used during anesthesia care? The first step is for the health care professional to let the interpreter know what to expect from the encounter before initiating the conversation with the patient. You might say, “Hi, my name is Dr. Bechtel. I am an anesthesiologist, and I will interviewing a patient about their medical history with a brief physical exam and going over the consent for anesthesia before taking the patient to the operating theatre for surgery.” The next step is to have the conversation directly with the patient, not with the interpreter. Finally, at the end of the conversation, the interpreter will provide either their name or ID number for documentation.

Check out the recent APSF twitter feed for examples of suboptimal interpretation options. These include the patient’s family members, other staff members with limited fluency or medical language, Google Translate, or “just winging it.” The use of the patient’s family members is an attractive option since they are in the room, are familiar with the patient, and it is free. Do not be tempted though since most family members are not trained interpreters, may not be familiar with the medical terminology, and there may be concerns about confidentiality. Plus, family members may not translate everything you say or may change the information or may participate in the conversation rather than acting as the interpreter. This is a significant threat to the patient’s individual autonomy and ability to provide informed consent. Another situation is when a minor child accompanies their parent with limited English proficiency. Once again, due to family dynamics, limited medical knowledge, and overall situation, it is not appropriate for children to be used as interpreters except for emergencies. There may be a policy that allows patients to request a family member to be the interpreter. It is important to ensure that this is an appropriate request and does not compromise the patient’s autonomy. In addition, professional interpretation services should be offered for every patient who presents with LEP, but patients may elect not to use these services as well.

The authors highlight three foundational principles of providing care for LEP patients. We are going to review these now. First, patients with limited English proficiency may be conversant in simple English, but will still need interpretation services to provide adequate understanding of their healthcare which may include the surgical procedure and anesthetic. Second, a patient’s ability to speak and understand English has no relationship with their intelligence or medical knowledge. What if you, as an anesthesia professional or healthcare professional, needed emergency care and could not communicate directly with the healthcare team due to a language barrier? The third principle is that every patient has the right to communicate directly with the healthcare team. There may be a push for increased efficiency during the perioperative period, but providing care for LEP patients requires extra time with minimal distractions. Here are some strategies that may help maintain these principles:

Keep the remote interpretation service device at the patient’s bedside.

Review your institution’s policies on interpretation services to help with questions from family members

Pre-schedule in-person interpretation if possible. This is especially helpful for family meetings or other pre-planned conversations.

This is a call to action to create partnerships between patients and members of the healthcare team to streamline care for LEP patients to provide efficient and safe care that meets the needs of this vulnerable group.

Going forward, clinicians are likely to see an increasing number of patients with limited English proficiency. Keeping these patients safe during anesthesia care requires having a plan in place for effective communication that reduces the strain on the provider so that there is less running around trying to find the remote interpretation device in the preoperative holding area during a busy day in the operating room and more time to build and maintain a strong relationship with the patient. Trained interpretation staff are vital members of the health care team and can help to ensure that patients are informed throughout their medical journey while maintaining their autonomy. The author’s leave us with this call to action that I am going to read now.

“Providing interpretation services for patients should be considered an aspect of providing the compassionate patient-centered care to which clinicians aspire.”

[Bechtel] Before we wrap up for today, I also asked Charwat what he hopes to see going forward. Here is his response.

[Charwat] “In order to serve our patients, we need to understand who they are now and who they will be in the future. We are seeing more patients with limited English proficiency and it is important to have plans in place for how to best address these communication challenges. I hope this article opens up new discussion within departments and practices for how they’re caring for L E P patients on an individual and systems level.”

[Bechtel] Thank you so much to Charwat for contributing to the show today and thanks to our listeners for tuning in. If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

For more anesthesia patient safety content, we hope that you will check out the newest February APSF Newsletter, share the Anesthesia Patient Safety Podcast with your colleagues, consider donating to the APSF and supporting our mission, and connect with us on Twitter by following us @APSForg.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2023, The Anesthesia Patient Safety Foundation