Episode #230 Bridging Communication Gaps: Ensuring Safe Anesthesia Care for Patients with Limited English Proficiency

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. Today, we are talking about a threat to anesthesia patient safety related to communication failures. Did you know that patients with low English proficiency experience less patient-centered care, use health care less frequently, and have an increased risk of adverse events in the health care setting? In addition, there are multiple high-risk situations that are associated with worse outcomes in patients with low English proficiency that may involve anesthesia professionals. These include medication reconciliation, hospital discharge, obtaining informed consent, emergency department care, and perioperative surgical care. Stay tuned as we discuss these threats as well as considerations for improved communication and anesthesia patient safety for patients with low English proficiency.

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 October 2024 APSF Newsletter. It is “Tailoring Perioperative Care for Patients with Low English Proficiency” by Yasuko Mano and colleagues. To follow along with us, head over to APSF.org and click on the Newsletter heading. The first one down is the current Newsletter. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well.

We have exclusive content from one of the authors to help kick off the show today. Here she is now.

[Mano] “Hello, my name is Yasuko Mano and I’m an anesthesiology resident at Northwestern Memorial Hospital. I graduated from the Keck School of Medicine of the University of Southern California, and that is where I completed this research project.”

[Bechtel] the first question I asked Mano is, why do you feel so passionate about this topic. Let’s take a listen to what she had to say.

[Mano] “So I come from a background where neither of my parents or really anybody in my family speaks English as their primary language. I happen to be born in the States, so that’s why I feel comfortable speaking, but the entire time that I’ve lived in The US or in any other English-speaking country,  I’ve always felt as if my family wasn’t receiving the best care that they could have. I felt like we were receiving disparate care, even if that wasn’t the intention of the health care facilities or the health  care system to do so. And that’s why I became interested in trying to bridge those gaps that exist between patients with language barriers and the health care system that primarily really revolves around English speaking patients. So that’s why I kind of wanted to do this research project. And I felt really passionate enough to get involved in this QI initiative.”

[Bechtel] We will be hearing from Mano again. We are really excited to hear more about this project and get into the article. So, here we go!

Anesthesia professionals are familiar with using in-person, telephone, or video interpreters during the perioperative period to help improve communication and ensure high quality and safe anesthesia care for patients with low English proficiency. Many hospitals have increased the availability of interpreter services, but there are still gaps in the perioperative period where communication failures can impact patient care. If we follow a patient along their perioperative journey, we can see that there are times when language interpreter services are not used, not available, or difficult to use. It starts with the initial check-in and rooming process in the preoperative clinic area. Sure, once the surgeon or anesthesiologist arrives after the patient has been roomed, interpreter services are available and frequently used, but this is not always the case before this time point. Another critical time is after the patient has been moved to the operating room during induction and emergence from anesthesia. The authors of the article identified these gaps in interpreter services during the perioperative period and developed a quality improvement initiative with a focus on structural changes in the preoperative and intraoperative areas designed to improve communication between patients and the anesthesia care team.

We are going to go through this quality improvement project now. The team started by tackling the problem in the preoperative clinic space from when the patient is first introduced to the anesthesia team to start laying the foundation for a strong patient-anesthesia professional relationship with a welcome message and an individualized greeting. Check out Figure 1 in the article for an example of the translated, laminated welcome message and visit description that is provided for patients with low English proficiency during the immediate check in process. The welcome message was designed to outline the workflow and purpose of the visit and to reassure the patient that their health history, preoperative instructions, and questions would be discussed in their preferred language. Here is the welcome message that was translated by medical professionals who are native speakers:

“Welcome to the preoperative clinic. Please fill out the forms as best you can. If unable, return them to the front desk. We can complete them together with a translator. Once roomed, we will go over the forms, instructions, testing (if needed) and answer your questions in with a translator. We will bring the patient to the room first and return for any visitor or family member if needed.”

Translations of this message were available in the top 10 most encountered foreign languages in their patient population. For an example of the message, check out Figure 2 in the article.

Each patient’s chart also included laminated cards that identified the patient’s language as a visual indicator to all health care staff of the patient’s primary language spoken. On the back of these cards, there were printed phonetic pronunciation of how to say “Hi my name is (and then the staff name) and “Mr./Mrs. (patient name) to the preoperative clinic, please” in each of the 10 languages accordingly. The purpose of this card was to have the staff great, introduce themselves, and call for patients in their native language. Then, after rooming the patient, the card would be available on the patient’s chart to the rest of the preoperative clinic team to greet the patient in their native language. Check out Figure 3 in the article for a sample of the front and back of this card.

Another important component of this project was to decrease preoperative anxiety and strengthen the physician-patient relationship on the day of surgery. This involved explaining to the patient that while the in-person or video interpreter would not be accompanying the team into the operating room, the team had several key phrases in the patient’s preferred language for when they are going under and waking up from anesthesia. To accomplish this, the team created a badge card linguistic tool which listed phonetic pronunciations of how to say the following:

• Breathe
• Surgery is finished
• Pain?

These translations were available in the top ten foreign languages encountered at the author’s institution. Medical professionals who are native speakers in these languages created the translations and the cards were distributed to all anesthesia care team members. Feedback on the use of these badges was encouraged. Check out Figure 4 in the article for an example of the Language Badge Translation Card. This resource provided a way for anesthesia professionals to encourage deep breaths on induction and emergence and in recovery to facilitate preoxygenation and improve postoperative ventilation. Being able to communicate that the surgery is finished helps the anesthesia care team to be able to reorient patients after emergence and provide some reassurance. By using the badge, anesthesia professionals are able to better assess patient pain in the operating room which helps to minimize untreated or undertreated postoperative pain. This quality improvement initiative improved communication with patients with low English proficiency during critical parts of perioperative care with a few key words or phrases in the patient’s preferred language. Figure 5 in the article provides a visual representation of the results of this intervention.

The authors assessed their quality improvement initiative with a five-point Likert scale questionnaire for patients and clinical staff for patient satisfaction and overall feedback. And here are the results: Spoiler alert, they were very positive.

• 53 patients completed the survey with 89% giving a 5 out of 5 response that they strongly agreed that the implemented greeting and message was a positive experience and made them feel welcomed.
• 4% responded with a 4 out of 5 and 7% with a neutral response of 3 out of 5. There were no responses which indicated a negative impact of their experience.
• 56 members of the preoperative clinic and anesthesia care team completed the survey with 88% responding 5 out of 5 that the language tools were helpful and made a positive impact on patient interactions. 12% responded with a 4 out of 5.
• The big takeaways from this project include the following:
• It is feasible to introduce structural changes to address language barriers in the perioperative setting at low cost. The total cost of this intervention for the laminated welcome messages, chart cards, and badges was less than $250 for the anesthesia department. No outside funding or personnel were needed.
• This initiative can be implemented quickly. The author’s experience was that it took a few months to receive approval from the institutional review board, prepare translations, laminate, print, and distribute materials.
• It is possible to facilitate improved communication on emergence in patients with low English proficiency which is a critical time when the degree of English proficiency may be even lower than their preoperative state.

This is an exciting patient-centered initiative that helps to build stronger relationships between patients and the entire anesthesia care team throughout the perioperative period.

Is this something that you want to implement at your institution? The authors provide several barriers to implementation of this initiative that include the following:

• Finding medical professionals to complete the translations.
• Orientation of the health care staff to the new badges, cards, and welcome messages.
• Keep in mind, that after addressing these barriers, the remainder of the process went smoothly.

The orientation involved a brief, 30 minute, in-person training to review the new workflow and practice using the greeting cards and badges. In addition, the authors were able to use in-house health care staff to complete the translations of the top ten translations, but other options include using paid medical translation services. For patients who do not speak one of the top ten languages, an interpreter was available for their clinic visit and there are plans to include these languages in future steps of the initiative.

The big takeaway here is that similar improvements in the experience for patients with low English proficiency is feasible for most perioperative settings. This is a rare innovation in healthcare that is easy to implement with minimal additional resources required and can be customized for each institution based on patient demographics. Plus, there are huge benefits when it comes to improved communication during critical parts of the perioperative care period.

Going forward, the authors plan to increase the number of languages represented in the initiative, increase the variety of phrases used intraoperatively, and increase the accessibility of these translations such as through digital technology keeping in mind the limitations of digital literacy. The authors conclude that the structural changes that they made had a positive impact om the patient experience for those with language barriers leading to improved communication and stronger relationships between anaesthesia professionals and their surgical patients. There is a call to action to improve the perioperative care of low English proficiency surgical patients one step at a time by identifying the barriers they face and tailoring their care to bridge those gaps.

Before we wrap up for today, we are going to hear from Mano again. I also asked, what do you hope to see going forward? Let’s take a listen.

[Mano] “The final question that I’ll be answering is, what do you hope to see going forward?  So going forward, I and I’m sure the rest of the team in this research project would agree that we hope to see more languages being represented in the PERI operative. Setting I want every patient, no matter what cultural background or language they speak to feel like they can comfortably receive non disparate care in the health care system, especially in a really scary time when they might be getting surgery or going through anesthesia.

And I think in terms of next steps, like we want more than just the top 10 commonly spoken languages to be represented at Keck Hospital. We want anybody from any country to be able to come to the hospital and feel like they would be able to get the quality of care that any English-speaking patient would be able to get and feel comfortable asking and getting their questions answered as well.”

[Bechtel] We are so excited about this exciting initiative and would love to see more institutions implement similar programs.

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.

Are you attending the 78^th Postgraduate Assembly in Anesthesiology on December 6-9^th? If you are going, we hope that you will attend the APSF Panel: Medication Errors in the Perioperative Environment – Exploring the Role of Human Factors. For more information, head over to APSF.org and click on the Conferences and Events heading. The first one down is Upcoming Events featuring the APSF. I will include a link in the show notes as well.

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

© 2024, The Anesthesia Patient Safety Foundation