As discussed in a recent editorial by former US Surgeon General, Dr. Richard Carmona, communication barriers faced by non-English speaking patients leads to disparities in access to preventive services and an increased reliance on emergency services [8
]. Even one year after the enactment of state legislation that mandates the right to a medical interpreter, we found that utilization among ED patients with limited English remained low.
In our sample of Boston EDs, 11% of patients had significant identifiable language barriers, but only 15% of these patients received services of a professional medical interpreter. The assessment for use of interpreter and significant language barriers appeared more extensive by interviewers than by the judgment of treating clinicians. The utilization of interpreter services in ED-based studies prior to passage of the medical interpreter law was 12–15%, which suggests that access did not improve with enactment of this legislation [6
]. However, we did find clear variation by site in need and use of professional interpreters, which indicates that some hospitals may have adapted differently to the legal requirement.
The ability of providers to accurately ascertain information and patients to fully understand diagnosis, risks and benefits, and instructions is especially important in the ED environment, where patients are faced with complex medical decisions in the face of illness or injury. Indeed, Bernstein, et al. found that compared to non-English speaking patients who did not receive interpreter services, those who received interpreter services had higher rates of primary care follow-up, lower rates of return ED visits, and lower charges in the 30 days following the index ED visit [7
]. These data suggest that the ability communicate instructions and transition to outpatient care is enhanced by use of professional interpreters.
Health care professionals, most often physicians, accounted for nearly half of personnel, who interpreted for the clinical visit. Although the ability to communicate with these patients was likely better than those who did not have any interpreter, Moreno et al. [9
] found that one-quarter of designated dual-role staff interpreters had insufficient language skills. Since much of observed staff-performed interpretation was provided on an informal basis without any formal designation, we would expect that access to adequate language skills was even lower.
Additionally, for one-third of our patients with language barriers, friends or family members provided interpretation for the ED clinical care. Rosenberg et al. [10
] found that professional interpreters performed better than family members at ensuring accurate information transfer and maintaining interview efficiency. These qualities are specifically important in the ED, where accurate and efficient communication is necessary to ensure timely diagnosis and appropriate treatment. Of particular concern is that one-third of friend/family interpreters were <18 years old. We would expect that communication via these children and adolescents would be further limited and lead, on average, to compromised quality and patient safety.
This study has several potential limitations. The sites were geographically limited, and our sample had lower racial/ethnic diversity compared to many urban EDs. However, we would anticipate even higher interpreter need in more diverse ED populations. The sampling strategy and the presence of non-respondents may bias observed estimates and associations. However, the potential for this bias is minimized by consecutive sampling during data collection days and the overall high response rate. Research personnel determined need for interpreter, but they were not formally trained in this assessment and other factors, such as patient mistrust, may have influenced the ability to assess true language barrier. Although presence of the study may have influenced use of interpreters for clinical care, most research interviews were performed by bilingual study staff, which limits potential for such bias. Finally, lack of professional interpreter use does not necessarily mean that it was not offered. Patients may have preferred to use friends or family members as interpreters.