Where: University of California, San Francisco (UCSF), Medical Center, a 600-bed teaching hospital.
The issue: Improving communication with patients who have limited English proficiency.
Health care facilities that receive federal funding are required by law to provide language access for patients who need it, but busy hospitals face the challenge of scheduling interpreters in all the necessary languages, said Leah Karliner, MD, MAS, an associate professor of medicine at UCSF. To solve this problem, her team tested the effects of installing dual-handset interpreter phones at every bedside in the hospital.
Studies have shown that use of a professional interpreter when there is a language barrier improves communication, patient satisfaction, physician satisfaction, and the quality of care delivered, she said. “Clearly, it's fundamentally important to speak to somebody in their own language when you are receiving information, giving information, and building rapport,” said Dr. Karliner.
About 15% to 18% of the hospital's patients have limited English proficiency, with Chinese and Spanish being the most common foreign languages, she said.
How it works
The phones enable quick, 24-hour access to remote professional medical interpreters, and the patient and clinician each use a handset to communicate in real time. About 200 languages are available. Prior to the intervention, the hospital relied on in-person staff interpreters, who could be scheduled on weekdays, as well as a few dual-handset interpreter phones that were brought into patients' rooms when necessary, said Dr. Karliner.
The intervention wasn't designed to supplant the staff interpreters, who remain available to schedule, she noted. Staff interpreters are especially helpful for events like large family meetings, which are plannable and amenable to in-person communication, Dr. Karliner said.
The idea behind the intervention was to make good communication with these patients an even easier process. “The phone is there reminding you that you need to get an interpreter for this patient, and you can push a button and get an interpreter and not have to wait,” she said, offering the analogy of prevalent hand hygiene stations in hospitals.
The research team conducted a pre-post intervention implementation study to test the effects of the phones on informed consent (i.e., patient-reported understanding of the reasons for and risks of their procedures and having all questions answered). The proportion of patients who met criteria for adequately informed consent was significantly higher in the post-implementation group than the pre-implementation group (54% vs. 29%), according to results published online in February by the Journal of General Internal Medicine.
A separate study, published in the March 2017 Medical Care, assessed the effects of the bedside phones on 30-day readmission rates for patients with limited English proficiency. Readmissions in this population significantly decreased from 17.8% in the 18 months prior to the intervention to 13.4% during the eight-month intervention period (July 2008 to March 2009).
During the intervention period, 28,284 minutes of interpreted calls at $0.99 per minute cost a total of $28,001, according to the study. With the reduction in readmissions, the researchers estimated a net savings of nearly $1.3 million over the eight-month time period.
Although the phones improve communication for patients with limited English proficiency, Dr. Karliner noted that they don't work as well for everyone, such as people who are confused, those who are hard of hearing, or those who have physical issues that preclude telephone use. They're also not ideal for large group conversations. “I think they're ideal for shorter, on-the-fly interactions, which a lot of hospital interactions are,” she said. “They're also really good for the middle of the night and times in the hospital when it's really hard to get [interpreters] there in person.”
Some broader challenges remain, such as written communication (e.g., discharge summaries) and the need for more bilingual physicians who can communicate clinically with patients, added Dr. Karliner. She speaks Spanish, she said, “but I don't speak Chinese or Russian or Vietnamese or Arabic. Anyone can walk in your door, and they do.”
The phones remain in use at UCSF, and the interpretation intervention could easily be adopted in other hospitals, she said. The hospital has a contract with a national vendor, who negotiated the per-minute rate and installed the phones free of charge, Dr. Karliner said. “So in terms of cost, you only pay if you need it, as long as you can get the vendor to give you the equipment for free,” she said.
In addition, hospitals with fewer patients who speak other languages can adapt the concept to meet their needs, Dr. Karliner said. “There are other ways to set it up if you have very low volume, where that phone goes with the patient the minute they're admitted, and it travels with the patient,” she said.