Patient Safety Tip of the Week
September 12, 2017 Can You Hear Me
Now?
When we first
started this column the title was intended to be “Translation Barriers and
Patient Outcomes”. But as we progressed we realized that not only are language
barriers problematic for patient outcomes and safety, but hearing impairment
that interferes with effective communication is equally problematic.
The original article
by Squires et al. (Squires
2017) found that for limited English proficiency patients, only 20% of home
health visits were language concordant. The study suggests that home health
care services may not be meeting the demand for language services, perhaps
predisposing to suboptimal patient outcomes.
Then another recent
study (Karliner
2017) sought to determine if
increasing access to professional interpreters improves hospital outcomes for
older patients with limited English proficiency (LEP). Karliner
and colleagues explored the impact of a dual-handset interpreter telephone at
every bedside on a medicine floor of an academic hospital. They found a
significant decrease in observed 30-day readmission rates for the LEP group
during the 8-month intervention period compared with 18 months preintervention, 17.8% vs. 13.4%. The improved readmission
outcome for the LEP group was not maintained during the subsequent postintervention period when the telephones became less accessible.
There was no significant intervention impact on length of stay but the
intervention proved to be cost-effective. After accounting for interpreter
services costs, the estimated 119 readmissions averted during the intervention
period were associated with estimated monthly hospital expenditure savings of
$161,404.
A previous study (Nápoles 2015)
had shown that inaccurate language interpretation in medical encounters is
common and more frequent when untrained interpreters are used compared to
professionals in-person or via videoconferencing.
Hospitals, of course, must provide interpretation services
to meet Joint Commission (and other regulatory body) requirements. But also
included in those requirements are the need to provide similar services for the
deaf or hearing impaired patient. It was shortly after the above articles that
we saw that a federal appeals court has paved the way for patients to sue a
hospital for not taking steps to assure they understood what was happening to
them when they got medical treatment (Musgrave
2017). “In the lawsuit, patients described how scared and confused they
were when doctors and nurses used gestures or passed notes to them to explain medical
procedures. The medical professionals apparently resorted to such methods
because of the failure of a video system the hospital uses to communicate with
the deaf. Instead of hiring sign language interpreters to come to the hospital,
the hospital uses a service where interpreters at remote locations are beamed
onto a TV screen. But, patients said, the image is often blurry. Or, they said,
the screen goes blank. Sometimes medical professionals didn’t know how to
operate it.”
Hospitals must provide signing services for the deaf and,
just like language interpreters, those who sign need to be trained to deal with
medical terms and concepts. But the problem goes well beyond those with
significant hearing loss. Even minor degrees of hearing loss may impair
communication between healthcare professionals and patients.
The problem was really emphasized by a recent article in
JAMA Otolaryngology-Head & Neck Surgery (Cudmore
2017). Cudmore and colleagues conducted
semi-structured interviews on 100 adults age 60 and older. Of the 100, 57
reported having some degree of hearing loss. 43 of the 100 reported mishearing
a physician or nurse in a primary care or hospital setting (this did not vary
by age group). They identified several themes (in order of frequency): general
mishearing, consultation content, physician-patient or nurse-patient
communication breakdown, hospital setting, use of language, selective deafness.
Some patients especially noted problems with similar
sounding words. Others complained that the physician or nurse did not look at
them while talking (we’ll bet some of these patients were lip reading) and
others complained the healthcare professional spoke too fast or in too low a
volume.
The accompanying editorial (Weinreich
2017) notes patients with hearing loss are missing instructions,
missing diagnoses, and missing medication information. Weinreich
notes that, in addition to physicians speaking too quickly or quietly,
background noise may cause patients to miss messages. She notes we need to know
when our patients have hearing loss and change how we communicate with hearing
loss patients. She notes we need to:
- Speak louder
- Speak slower
- Type/write for clarity
when necessary
- Take time with patients
- Use temporary
amplification when necessary
Last of all, don’t
assume that what is heard is actually understood. A recent article (Ginsberg
2017) noted an anecdote that
was recently shared with the CreakyJoints
community: a patient was diagnosed with rheumatoid arthritis and prescribed
methotrexate. The doctor told her that she "can't" get pregnant while
taking methotrexate. The patient apparently took her doctor literally and grew
lax in her contraceptive use, simply because she was following his orders. Obviously,
the physician meant "you shouldn't get pregnant," not "you can't
get pregnant." (because methotrexate may cause
birth defects, as well as other problems). That emphasizes the concepts of “hear
back” and “teach back” which we have stressed in our columns on health literacy
and numeracy. (“Hear back” is obviously also critical in communication between
healthcare professionals).
So if you are a hospital or similar medical facility, make
sure you use professional interpreters and signers and meet or exceed the
requirements of the regulatory bodies. In all healthcare settings you need to
assess whether your patients have hearing impairment (some of us won’t admit
it!). Use some of the techniques noted above in the Cudmore
and Weinreich articles. And, perhaps most
importantly, use hear back and teach back to make sure your patients truly
understand what you are trying to communicate to them.
Some of our other
columns on health literacy and numeracy:
June 2012 “Parents'
Math Ability Matters”
May 7, 2013 “Drug
Errors in the Home”
November 2014 “Out-of-Hospital
Pediatric Medication Errors”
January 13, 2015 “More
on Numeracy”
August 2017 “More
on Pediatric Dosing Errors”
References:
Squires A, Peng TR, Barrón-Vaya Y,
Feldman P. An Exploratory Analysis of Patient-Provider Language-Concordant Home
Health Care Visit Patterns. Home Health Care Management & Practice 2017; First
Published March 9, 2017
http://journals.sagepub.com/doi/abs/10.1177/1084822317696706?journalCode=hhcb
Karliner LS, Pérez-Stable EJ, Gregorich SE. Convenient Access to Professional Interpreters
in the Hospital Decreases Readmission Rates and Estimated Hospital Expenditures
for Patients With Limited English Proficiency. Medical
Care 2017; 55(3): 199-206, March 2017
Nápoles AM, Santoyo-Olsson
J, Karliner LS, Gregorich
SE, Pérez-Stable EJ. Inaccurate Language Interpretation and Its Clinical
Significance in the Medical Encounters of Spanish-speaking Latinos. Medical
Care 2015; 53(11): 940-947
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610127/
Musgrave J. Deaf patients get go-ahead to sue Boynton’s
Bethesda hospital. Palm Beach Post 2017; May 3, 2017
Cudmore V, Henn P, O’Tuathaigh CMP, et al. Age-Related Hearing Loss and
Communication Breakdown in the Clinical Setting. JAMA Otolaryngol
Head Neck Surg 2017; Published online August 24, 2017
http://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2649281
Weinreich HM. Hearing Loss and
Patient-Physician CommunicationThe Role of an
Otolaryngologist. JAMA Otolaryngol Head Neck Surg 2017; Published online August 24, 2017
http://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2649280
Ginsberg S. Say What? Dangers of Miscommunicating. When
miscommunication means life or death. MedPage Today
News 2017; June 11, 2017
http://www.medpagetoday.com/rheumatology/generalrheumatology/65928
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