Caring for LEP Populations in the ED: A Quick Guide

Limited English proficiency (LEP) is a federal term used to describe individuals who do not speak English as their primary language and have limited ability to read, speak, write, or understand English.¹ The U.S. Census Bureau defines those with LEP as individuals over age 5 who speak English “less than very well.”

Eight percent of the U.S. population (approximately 25.7 million people) had limited proficiency in English as of 2021. That number nearly doubled from the 1980s, when LEP individuals accounted for only 4.8% of the population.²

In the United States, the majority (62%) of individuals with LEP are Hispanic adults who speak Spanish as their primary language, and more than a fifth (22%) are Asian.³ The highest populations of LEP individuals traditionally have been found in 6 states: California > Texas > Florida > New York > Illinois > and New Jersey.

Although the distribution of LEP patients varies from region to region, language-concordant care is a prescient issue that affects all health-care systems.

Under Title VI of the Civil Rights Act, LEP individuals are entitled to language assistance when receiving any service, benefit, or encounter provided by facilities that accept federal dollars (including reimbursement via Medicare or Medicaid).⁴ National Culturally and Linguistically Appropriate Services Standards (National CLAS Standards) provide guidance to health-care and health-care-related entities on best approaches for implementing and monitoring services for LEP individuals. Federal requirements mandate that all recipients of federal funds achieve and adhere to these standards, which aim to advance health equity, improve quality, and reduce health-care disparities.⁵

EDs are critical entry points for establishing medical care in the United States for marginalized and immigrant populations. Some studies have shown, though, that LEP patients have lower rates of testing and procedures, shorter ED durations, less medication, and decreased frequency of intravenous placement compared to English-speaking patients (ESP).³

To prevent further delays to appropriate treatment and care, it is imperative to actively address issues specific to LEP individuals. Language and communication — including having appropriate language or translation services available when needed — are essential for effective medical care and disposition. By implementing standardized high-quality language services for our patients with LEP, we can improve quality of care and health outcomes for these individuals and communities.

Risk Factors, Clinical Outcomes
LEP is an important and frequently encountered social determinant of health in the emergency department. LEP patients face significant communication barriers, which often intersect with health literacy and other structural determinants of health. Individuals with LEP are more likely to be uninsured than their ESP counterparts. Despite increases in coverage after the passage of the Affordable Care Act of 2010, LEP patients remain 3 times as likely as ESPs to be uninsured.^6,7

Studies clearly demonstrate that LEP patients who are not provided interpreters receive markedly different medical management and care than ESPs in the ED.² LEP status is associated with increased risk of delayed presentations for strokes and heart attacks secondary to limited knowledge of pertinent warning symptoms. According to some reports, individuals with LEP have been found to have higher rates of diagnostic testing in the ED and higher rates of hospitalization,⁸ and LEP status is associated with longer length of stay and increased ED return visits when professional interpreters are not utilized at time of admission or discharge.^9,10

Additionally, language barriers place patients at increased risk for clinically significant adverse patient safety events. In an analysis of these adverse events, a majority were found to be secondary to communication errors and, in particular, errors of omission on behalf of patients or providers (for example, an omitted medication allergy disclosure from the patient or an omitted procedural risk from the provider that then becomes clinically relevant). Adverse events affecting those with LEP are associated with a higher incidence of physical harm and more severe levels of harm than those that occurred in the care of ESPs.^11,12

Bedside Awareness
As emergency physicians, we are charged with caring for diverse groups of patients, determining who is the sickest among them, and appropriately allocating our resources to screen for and treat life- and limb-threatening emergencies. As such, timely and accurate communication in emergency medicine is imperative, as it has a profound impact on our differential diagnoses and subsequent health outcomes.

We can help reduce health inequities at the bedside for individuals with LEP by:

• Routinely screening for language preference in the health-care setting, and utilizing EMR systems to trigger the need for language interpretation on current and future visits. Do not assume that patients with LEP are equally comfortable discussing nuanced and complex topics about their health in English. Have a low threshold to inquire with any patient: “Is there a language other than English that you would prefer to speak in for this visit?”
• Clearly documenting the use of interpreter services in the HPI and subsequent progress notes. It is important to use interpreter services not just for the initial HPI, but also for reassessments, shared decision-making, disposition planning, procedural or blood consents, and goals-of-care discussions.
• Considering additional social determinants of health likely to impact LEP patients, as they are more likely to have poorer patient outcomes, difficulties accessing care, lack of insurance, and higher rates of ED return visits compared to their English-speaking counterparts.²

Key Actions
As emergency physicians, we can address these social/structural determinants of health by actively engaging in the following actions.

Ensure all patients with LEP receive official (either in-person or remote via video or phone) interpretation during ED visits. While this will require additional preparation and apparent delay upfront, it will assure the visit progresses smoothly with less risk for misunderstanding and adverse patient outcomes.

• Recognize when your own language abilities are limited. If you are not certified to speak medical terminology in a language other than English, do not attempt to provide care in that language. Your language skills will limit your ability to obtain an accurate history and provide appropriate care. You must be able to discuss complex and nuanced topics (e.g., sexually transmitted infections, new cancer diagnoses, breaking bad news) to ensure that your patient fully understands the treatment and plan.¹³
• It is not appropriate to assume that bilingual ED staff can provide accurate medical interpretation. For example, many individuals may feel confident speaking another language conversationally but lack the proficiency and vocabulary to discuss complex health topics and medical care.

Refrain from using family members or friends as interpreters. Preparation here is key! Quickly glance at any documented preference in your medical record before evaluating your patient, and show up at the bedside with your official interpretation modality ready.

• While often eager to assist, family members and friends likely do not possess the medical vocabulary or knowledge to discuss or describe medical events.
• Patients may be less likely to disclose sensitive components of their medical history (such as HIV status), sexual history, and pertinent social history (such as substance use or abuse, interpersonal violence, or concerns of forced labor/trafficking) if family is present.

Follow best practices for interpreter use. This includes:

• Always speak to your patient in the first person.
• Maintain your gaze on the patient and not the interpreter. This imitates having a 1-on-1 conversation with the patient.
• Speak in short sentences, and take breaks to allow the interpreter to convey everything you are saying. Empower your interpreter to notify you if they need the pace of the conversation modified.
• Brief your interpreter prior to sensitive discussions so they know the tone of the conversation. Examples of this might include a goals-of-care discussion, new HIV diagnosis, or the finding of a new malignancy.

Consider the effective use of interpreters as a procedure in which you can and should become very skilled and competent. Simulation can be an excellent educational tool that can help trainees and other members of your department learn how best to use in-person or remote interpreters in various clinical scenarios.

Provide language-concordant care plan updates. Use interpreters to discuss updates. Many LEP patients leave with a sense of not understanding what medical services were done for them. This should be just as important as gathering an HPI. If admitting the patient to the hospital, it is imperative that you share the plan and rationale in their language, employing teach-back methods to assess for understanding.

Use clear, simple-to-understand, vetted discharge instructions for common ED diagnoses. Know that translation applications such as Google Translate are inconsistent between languages and should not be relied on routinely for discharge instructions.¹⁴ If no other options are available, be aware that these applications are meant to work with simple sentences (e.g., a sentence with only 1 subject and 1 verb).

When prescribing medication, always write out medication instructions in the patient’s preferred languagein your discharge instructions. Most pharmacies do not collect primary language information and do not print medication instructions in a patient’s primary language.

Know that LEP patients have a higher chance of poor access to follow-up care and high rates of being uninsured. If close follow-up is required, inquire about insurance status, stating clearly that this is important for you to help them best navigate the health system. Be sure to involve patient navigators, care managers, or social workers early to help ensure adequate access to timely follow-up.

Terminology
The term “LEP” is not without criticism, and more people and groups are demanding a shift away from that term, especially as it relates to health care and research. Those who support a change in terminology feel that “LEP” reinforces negative stereotypes and may be seen as pejorative to members of that population. The push for change includes attempts by non-health-care-related entities, such as the American Communities Survey, to change “LEP” to “LOTE” (Language other than English). However, neither the U.S. Census Bureau nor the federal government has formally adopted new terminology; thus LEP remains the most widely used term.¹⁵

This article is part of an EMRA Social EM Committee initiative to disseminate information about social EM topics encountered in the emergency department. More information can be found in the EMRA MobilEM app’s Patient Conversation Toolkit, available for download via iTunes and Google Play.

References

1. U.S. Department of Justice, Civil Rights Division, Executive Order 13166 Limited English Proficiency Resource Document: Tips and Tools from the Field, pp. 10-11, (September 21, 2004). http://www.lep.gov/resources/tips_and_tools-9-21-04.htm Accessed on October 15, 2023.
2. Ramirez D, Engel KG, Tang TS. Language Interpreter Utilization in the Emergency Department: A Clinical Review. J Health Care Poor Underserved. 2008;19:352-362.
3. Haldar S, Pillai D, Artiga S. Overview of Health Coverage and Care for Individuals with Limited English Proficiency (LEP). Kaiser Family Foundation News. 2023. Retreived from https://www.kff.org/racial-equity-and-health-policy/issue-brief/overview-of-health-coverage-and-care-for-individuals-with-limited-english-proficiency/:~:text=Introduction,limited%20English%20proficiency%20(LEP).
4. U.S. Department of Health and Human Services, Office of Civil Rights. (2013). Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons. Retrieved from https://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/guidance-federal-financial-assistance-recipients-title-vi/index.html
5. U.S. Department of Health and Human Services, Office of Minority Health. (2016). National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Practical Guide to Implementing the National CLAS Standards. Washington DC. Retreived from https://www.cms.gov/Outreach-and-Education/MLN/WBT/MLN1857916-OMH-AHE/OMHAHE/ahe/lesson01/09/index.html
6. Lu, Tianyi and Rebecca Meyerson. Disparities in Health Insurance Coverage and Access to Care by English Language Proficiency in the USA, 2006–2016. 2020. Journal of General Internal Medicine, 35(2), https://link.springer.com/article/10.1007/s11606-019-05609-z.
7. Sifuentes, et al (2020). “The Role of Limited English Proficiency and Access to Health Insurance and Health Care in the Affordable Care Act Era,” Health Equity 4(1), https://doi.org/10.1089/heq.2020.0057
8. Schulson L, Novack V, Smulowitz PB, Dechen T, Landon BE. Emergency Department Care for Patients with Limited English Proficiency: a Retrospective Cohort Study. J Gen Intern Med. 2018;33(12):2113-2119. doi:10.1007/s11606-018-4493-8
9. Lindholm M, Hargraves JL, Ferguson WJ, Reed G. Professional language interpretation and inpatient length of stay and readmission rates. J Gen Intern Med. 2012;27(10):1294-1299. doi:10.1007/s11606-012-2041-5
10. 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. Med Care. 2017;55(3):199-206. doi:10.1097/MLR.0000000000000643
11. 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. Med Care. 2015;53(11):940-947. doi:10.1097/MLR.0000000000000422
12. Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60-67. doi:10.1093/intqhc/mzl069
13. Rosenthal A, Wang F, Schillinger D, Pérez Stable EJ, Fernandez A. Accuracy of physician self-report of Spanish language proficiency. J Immigr Minor Health. 2011;13(2):239-243. doi:10.1007/s10903-010-9320-1
14. Taira BR, Kreger V, Orue A, Diamond LC. A Pragmatic Assessment of Google Translate for Emergency Department Instructions. J Gen Intern Med. 2021;36(11):3361-3365. doi:10.1007/s11606-021-06666-z
15. Ortega, P., Shin, T.M. & Martínez, G.A. Rethinking the Term “Limited English Proficiency” to Improve Language-Appropriate Healthcare for All. J Immigrant Minority Health 24, 799–805 (2022). https://doi.org/10.1007/s10903-021-01257-w