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Equity in Patient-Provider Communication: Improving the Identification of Limited English Proficient Patients in the Emergency Department

Background: Limited English proficient (LEP) patients are a high-risk population, with increased risk of readmissions, medication dosing errors, and serious adverse events Our ED used language services for only 2 5% of visits in fiscal year 2019 despite census data suggesting that approximately 10% of all Philadelphia children have at least one LEP parent Therefore, a higher proportion of ED visits might be expected to require language services Despite the known benefits of providing LEP patients linguistically-appropriate care, our ED had no standard process of proactively identifying LEP patients or documenting when language services were used We used quality improvement methodology to create a prospective and retrospective identification process that was timely, accurate, respectful, and actionable Our goal was to increase utilization of language services and improve post-hoc documentation of interpreter encounters, with a SMART AIM of increasing interpreter use documentation from a baseline of 37% to 50% after 6 months Methodology: We formed a multidisciplinary team, including physicians, nurses, child life specialists, registration staff from the ED, language services leadership, refugee health physicians from primary care, and patient/family representatives We created a process map to examine the disparate processes used to collect information about patient language After reaching a consensus to mandate preferred language identification during nursing triage, the team created a short screening question that was vetted through a bilingual patient/family representative A new section, specifically for language needs, was added to the electronic health record (EHR) triage navigator with the vetted question A 'yes' response to the question created an alert for anyone opening the chart, which presented information about how to obtain language services A 'yes' response also added a globe icon with the specified language to the ED track board and pre-populated the ED provider note with a template for documenting the interpreter encounter Multiple educational interventions and clinical supports were utilized to facilitate improved identification and documentation All clinicians were educated about the aforementioned changes through internal newsletters, huddles, and presentations at division-wide meetings Discussion: Since the EHR interventions went live in January 2020, documentation detailing interpreter encounters has increased from 37% to 6 1% compared to the baseline period (Figure 1) Utilization of language services has also increased from 2 5% of all visits to 3 7% (Figure 2) The success of these metrics can be attributed to our iterative steps to obtain buy-in from front-line providers There was a slowdown in progress coinciding with the COVID-19 pandemic, so repeat education will be needed after the pandemic recedes Conclusion: Implementation of a key stakeholder-informed standard process for obtaining LEP information shows early success in increasing rates of reported use and documentation Next steps include expanding the use of video interpreting and additional provider education