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Three Part Question

Do [pediatric emergency department patients and their families who require a professional interpreter] have similar [rates of resource utilization] [compared to an English-speaking cohort]?

Clinical Scenario

A 12-year-old Vietnamese speaking female with a complicated past medical history presents to the emergency department (ED) with complaints of dizziness. History and physical exam are obtained from the patient and her family using a professional interpreter. You wonder how using an interpreter impacts ED utilization (incidence and costs of diagnostic testing, admission rate, and length of ED visit).

Search Strategy

Medline 1966-07/21 using PubMed, Cochrane Library (2021), and Embase
[(exp emergency medical services OR exp emergency department OR exp emergency services) AND (translating OR communication barriers)]. LIMIT to children and English language.

Search Outcome

93 studies were identified; three studies addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hampers LC, et al. Nov 2002 USA	4146 children, aged presenting to the ED with fever, vomiting, or diarrhea; 550 families did not speak English	Prospective cohort study	Incidence and costs of diagnostic testing, admission rate, use of intravenous hydration, and length of ED visit	Cases with an interpreter showed no difference in test costs, were least likely to be tested, more likely to be admitted, and no more likely to receive intravenous fluids, but had longer lengths of visit.	No standardized method to determine level of English proficiency
Hartford EA, et al 2019 Nov-Dec USA	51,826 patients seen in Seattle Children’s Hospital ED from Oct 2015 to Dec 2016, divided into English Proficient (EP) and Limited English Proficient (LEP)	Retrospective cohort study	Frequency of interpreter use for LEP patients	Interpreter use for families who preferred a non-English language was 45.4%	Determination of interpreter use was based on ED documentation; providers may have used an interpreter but not documented it in the chart.
			Admission rates, and transfer to the ICU within 24 hours of admission.	LEP patients who did not receive interpretation were less likely to be admitted than EP patients (OR 0.69, 0.62–0.78). Patients of LEP families, with or without interpretation, were more likely to be transferred to the ICU within 24 hours of admission than patients of EP families
Zamor R, et al. Jan 2020 USA	13,612 pediatric patients less than 2 years old diagnosed with bronchiolitis. Famalies preferred language was English or Spanish with requested use of an interpreter.	Retrospective cohort study	Frequency of chest x-rays and bronchodilator orders	Spanish-speaking families were more likely to have chest x-rays (35.8% versus 26.7%); no difference in bronchodilator orders	Single center study and only evaluating encounters where Spanish speaking families requested an interpreter. Information and selection bias given it is retrospective.
			Other diagnostic test (ex. labs), medication orders (ex. antibiotics) and disposition.	Spanish-speaking families were more likely to have complete blood counts and blood cultures ordered.

Comment(s)

Pediatric patients and their families with Limited English Proficiency (LEP) are at risk for disparities in the healthcare they receive, including during visits to the emergency department. Communication during these encounters may be done with a bilingual provider, an ad-hoc interpreter (family member, friend, or other staff), professional interpreters (via in-person, telephone, video methods), or no interpreter use at all. Use of an interpreter can lead to improved communication, but limited information exists related to resource utilization and potential financial benefits of using an interpreter with a LEP patient and family. These studies showed that care for LEP patients may include increased resource utilization, admission rates, transfer rates to ICU after admission, and more-limited communication at time of discharge. There is some evidence showing these differences in care result in higher financial expenditure and poorer patient and family satisfaction related to the encounter. Most data do show an overall improvement in care when a professional interpreter or bilingual physician is used, but interpreter use can be limited depending on hospital resources, presenting complaint, acuity, and how busy the ED at the time of evaluation. More research is needed to investigate the impact of interpreters on patient care as many communities are becoming more lingually diverse.

Clinical Bottom Line

Pediatric patients and their families with Limited English-Proficiency seen in the emergency department have increased resource utilization and discrepancies in their care compared to English-speaking cohorts. Their care may be improved by use of a professional interpreter, though use is limited due to multiple factors.

References

1. Hampers LC, McNulty JE. Professional interpreters and bilingual physicians in a pediatric emergency department: effect on resource utilization Arch Pediatr Adolesc Med 2002 Nov;156(11):1108-1113
2. Hartford EA, Anderson AP, Klein EJ, Caglar D, Carlin K, Lion KC. The Use and Impact of Professional Interpretation in a Pediatric Emergency Department Acad Pediatr 2019 Nov-Dec;19(8):956-962
3. Zamor R, Byczkowski T, Zhang Y, Vaughn L, Mahabee-Gittens EM. Language Barriers and the Management of Bronchiolitis in a Pediatric Emergency Department. Acad Pediatr 2020 Apr;20(3):356-363.