ROUTINE patient situations can be supported by pre-established interpreting modalities which staff and providers use reflexively. For example, a clinic triages walk-in patients using double-handset OPI at the front desk, and uses video remote for both the rooming process and the physician interview. Certain written materials are available in pre-translated format.
Many patient encounters are not routine, however. Also, it is not just during conversations in the clinic that the patient requires communication support. A strong language support program provides a matrix of tools and methods that staff and providers can reach for to help them communicate with patients in unusual locations, to perform complex services, and to deal with rapidly changing or unusual patient needs.
If the patient is intubated and sedated, does anyone bother to interpret for the patient? If the patient is told to provide a clean-catch urine specimen in the bathroom, where the instructions are written in English on the wall, how does the Swahili-speaking patient figure out what to do? How do we give a Tibetan patient getting a chest X-ray the instruction to hold his breath, when there is no interpreter present?
Using a matrix of language support modalities within an encounter is a conceptual leap for staff, who often have several modalities available but who do not think of them as dynamically connected. The whole idea is to look at the patient’s condition and his present position in the care process to decide what elements of language support best fit his needs at that moment.
The concept of a language support matrix brings people with many different skills into the available toolbox for language support. Specialists in patient education, registration, medical records, telecom, and IT have something to contribute. As each staff member and provider cares for the patient, he or she can access many aids for effective communication.
A pregnant patient who has only lived in the United States for a couple of years walks into the clinic looking anxious and asking to be seen. Reception staff dial their OPI (over-the-phone) interpreter service and hand the patient her handset of a double-handset phone. The patient says that she feels very weak and dizzy, and that she was observed having a seizure at home that morning.
The patient is taken back to a room. A qualified bilingual medical assistant takes vitals, settles the patient, and prepares the room for an examination. The patient states that her mother and her male partner, neither of whom are presently in the city, will want to be informed about the situation once the doctor figures out what is going on. The medical assistant sets up a conference phone in the room. Throughout the several hours that the patient remains in the clinic, this bilingual staff person will check in on and care for this patient.
The doctor uses a video remote device to bring an interpreter onscreen into the encounter. In addition to the doctor, a medical student is present. The doctor uses VRI instead of phone interpreting for the interview and exam because the patient is very worried, she may have some confusion or language difficulties due to the seizure, and she could use the reassurance of a friendly interpreter face
The patient states that she was treated for seizures as a teenager in her home country but was not informed of her diagnosis. The provider wants to find out what her medical history is, so she makes an international phone call to the patient’s hospital where she was treated a decade ago. In anticipation of a technical doctor-to-doctor exchange, the clinic provider requests that the clinic’s preferred agency interpreter for that language be assigned to interpret for the call. The agency locates her and the interpreter calls in on her personal phone.
The hospital telecom office connects the provider in the exam room, and the interpreter on her personal phone, with the hospital in the foreign city. Telecom also assists by providing the foreign medical records office with the full international number to fax the documents to the treating provider.
These incoming medical records are scanned by the clinic administrative assistant, sent to the Interpreter Manager, and rushed electronically to the hospital’s translation agency, which prioritizes translation of the key elements of the documents, as circled on paper by the sending provider.
Once the international phone call is over, the preferred agency interpreter continues to interpret over the phone between the patient and the provider to make detailed plans for an observation admission today. The patient’s mother and partner are conferenced onto the call for a briefing by the doctor. The interpreter interprets for mom.
The medical assistant is tasked with making sure that the patient is registered for and knows how to use the patient portal, so that she can communicate easily with her care team from home once she is discharged. (On our wish list, the portal would have built-in pre-translated support for common requests and statements!) Qualified bilingual staff or providers will interact in future directly with the patient’s communications via the portal.
The clinic arranges for the interpreter to come in-person for doctor rounds tomorrow morning, when the patient’s partner will also be present. He speaks English, but the patient will converse with her care team via the interpreter, not via her partner.
As she is admitted to the ante-partum unit, the patient receives a packet of admission documents in her language, which includes the hospital menu, information about services and resources for inpatients, a language card with useful expressions in both English and the foreign language, Patient Rights and Responsibilities, dual-language Power of Attorney and Advance Directive forms. Because these latter forms are in dual-language format, they can be scanned into the medical record once the patient completes them.
During the night, inpatient nurses use both phone and video remote to respond to the patient’s call bells and to explain what medication they are delivering.
During rounds in the morning, after imaging and lab tests are back, the doctor uses 3D models of the brain and the uterus to explain the patient’s condition to her and her partner. As the partner asks the provider questions in English, the interpreter interprets their conversation to the patient. Self-care instructions are provided in both languages, as the partner reads English only. As the patient collects her new discharge meds from the hospital pharmacy, labeling on the bottle is in her language.
Each clinical and administrative unit will need a different set of communication tools for its dynamic communication matrix. The interpreter manager can learn what these needed tools are by asking the staff on each unit about their worst experiences of not being able to communicate with various parties in the past. Ask staff what tools or assistance they wish they could just reach out and have available for various communication situations.
For example, some technical tools, such as a tall VRI stand with long, moveable arms which can hold a VRI screen upside down over a patient lying flat, may only be necessary in certain units, and may be shared amongst those units. Some specialized tools and materials are needed for patients who are Deaf, blind, children, restrained, neurologically compromised, aphasic, demented, disabled, intubated, in infection precautions, or in a mixed language group setting.