Surgery Black Box – Patient Language Support Scenarios

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Consider the following patient language support scenarios:

Surgery & Patient Language Support Case Study 1

The interpreter schedulers had worked for weeks to find an ASL (American Sign Language) interpreter for a patient who was to undergo a colon resection for cancer. The Surgery schedulers do not generally provide the patient with the time of surgery until 4 PM the day before, but the Interpreter schedulers prevailed upon the surgeon to set a time and let the Surgery schedulers know that this time should be set for the patient. (It is impossible to secure an ASL interpreter at the last minute.) The patient was scheduled for 6:30 am to arrive at the pre-surg check-in desk, as was the ASL interpreter. The interpreter was scheduled for the usual 2 hours for pre-surg, 6:30 to 8:30 a.m. The interpreter was also scheduled from 12:30 to 2:30 p.m. for the recovery. He had accepted a different assignment across town for 10 to 11 a.m., allowing for plenty of wiggle room.

The emergency department, as is common, was quite busy the night before the surgery, and several patients had been admitted into inpatient beds from the ER, with emergency surgery scheduled for early the next morning. These cases were added onto the Surgery schedule overnight by the 24-hour Surgery Scheduling nurse group. By 4 a.m. all the cases on the checkerboard of scheduled morning surgeries began to be changed around. Nowhere on the Surgery scheduling board was it noted that the Deaf patient was deaf. Nor could the Surgery schedulers see that this patient was Deaf by looking at their caseload on the computer. Surgery Central does NOT use the EMR used throughout the system, which shows language need. They use the Surgery scheduling software, which has no variable or flag for language need.

The Deaf patient was postponed to an 11 am start. A phone call was made to the Deaf patient’s phone number at 4 a.m. to instruct the patient to NOW arrive at 9 am for pre-surg. The family did not answer the call because they were asleep, so a message was left. No call was made to the Interpreter Scheduling Office because no one even thought about the possibility of the need for language support.

The patient’s husband got the message of delayed start when he woke up at 5 am. The patient adjusted her arrival time to 9 am. She arrived at the pre-surg desk at 9 am. She was told that her interpreter came at 6:30 and was informed that the pre-surg was rescheduled to 9, when he would need to be on his way across town to the 10 am appointment. The interpreter left. He did leave a message for his agency to call the Interpreter Schedulers when they opened the office at 7 am. The Interpreter Schedulers got this message from agency and had now been trying to find a replacement interpreter since 7 am, with no success so far. The patient was offered video remote ASL support, but because she had left her glasses at home she had trouble seeing the interpreter on-screen. She was already worried about her diagnosis and her surgery, and now she was distracted by language support that was not effective. The patient could not understand why the hospital had messed up on taking care of her.

There are other, unfortunately common, misconnections that happen in the black box of the surgical episode. Take this for example:

Surgery & Patient Language Support Case Study 2

The patient speaks a foreign language difficult to find at short notice, and he is hard-of-hearing. He is elderly. He is not really sure what is going to happen today because his family has done all the arranging and agreeing to care for him in outpatient visits. His hearing deficit has accustomed his family to talk past him most of the time. Today, though, the 2-hour pre-surg prep time is specifically designed for the anesthesiologist and the surgeon to re-consent the patient and to answer his last-minute questions. But the interpreter does not arrive because the surgery has been moved up to an earlier time late last night, unbeknownst to the interpreter. So the pre-surg nurses bring in the telephonic interpreting equipment and wait 20 minutes for an interpreter of the patient’s rare language. But the patient has rarely used a phone in his life, and he is too hard-of-hearing to be able to converse via the phone interpreter. His family once again steps forward to talk with the doctors, thereby denying the patient his last chance to find out what will happen to him today, and why. His consent is not informed.

The Surgery Black Box can also short-circuit patient care by its English-only process of notifying patients when their case is set for. Patients are told to leave the entire day of surgery free, which means that their childcare arrangements and driver arrangements have to cover the entire day. The phone call the afternoon before surgery about when to arrive at the hospital the next day is conducted in English, or a message is left in English. If then the surgery time is moved, which happens often, the time change message left on the patient’s answering machine is in English, which the patient does not understand. So the patient might ignore it and come at the original time, or might be confused by the message and not know what to do. By that time the patient phone lines at the hospital are closed for the night. If the patient shows up too late or if he does not come at all because he thinks his procedure was canceled, the patient loses out on his surgery, everyone in his family loses a day of work, and the hospital loses big money on teams and equipment left idle.

Unrelated to scheduling, there are many ways in which a surgical team, which has never interacted with their particular patients before, might frighten a Deaf or blind patient because they do not realize that the patient is deaf or blind. A blind person does not know that there is someone in the room unless the person announces himself and explains what he is doing. He may be very startled when someone touches him or speaks next to him. He may become anxious because he hears commotion all around him but does not know that he is in a curtained alcove and has some privacy. A Deaf person does not know that someone is in the room unless he can see the person. If he is recovering on his side he may be startled by staff walking up behind him. A routine protocol to attach soft wrist restraints to a semi-sedated patient so that she does not move or pull at tubes can result in a terrifying inability of a Deaf patient to use her hands to sign.

The language program manager does well to build a relationship with the nursing leadership in the three areas of Surgery scheduling, Pre-surg, and Recovery. The manager should angle for opportunities to attend staff meetings of these groups, to discuss process gaps that language need patients routinely fall through. Some easy fixes could be put into place, but they must be advocated for by leaders within the surgical world.

Examples of Improvements for Patient Language Support

The white board with surgical cases of the next few hours on it could have language need added to it as a flag, as is the case for labile diabetics who cannot tolerate having their surg times moved around. This would prevent Deaf and other vulnerable language-need patients from changes in surgery time.

The letters LANG could be added to some field in the surgery database to indicate a language or disability flag, maybe at the end of the field for special room setup or at the end of the field for name of procedure. The surgical scheduling team would need to look at the intake paperwork from the surgeon’s office, which does usually have the language need on it, and transfer that into the surgical database.

A protocol to not move around the surgery times of patients needing interpreters could be implemented. If a surgery time has to be moved, the protocol should include checking for language need before making the call in English. The clerk making calls to patients about original or changed surgery check-in times should be trained in including a phone interpreter on the call.

For hard-of-hearing patients who need to use telephonic interpretation in the Surgery area, use a telephone with a headset connected to it for the patient. Conference in a different phone for the doctor or nurse to use on the call. Headsets allow the patient to hear and concentrate on the voice of the interpreter and permits the patient herself to communicate with the care team.

Laminated cards indicating that a patient has a language need or a sensory deficit can be clipped to the head of the bed or to the curtain of the surgical cubby.

The Interpreter Schedulers can fax the names of patients who cannot be moved due to difficult language needs to the Surgery Management desk with the white board just before leaving for the night, and this can be taped to the board for the night shift to see.

Inform the Anesthesia team ahead of a sedated-awake procedure to not restrict the hands of a Deaf patient to the extent that he cannot sign.

Please share your own experience in partnering with provider teams to solve persistent language support problems related to the Surgery episode.

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