Saturday morning quarterbacking is much easier than dealing with tricky situations at the time. It is well worth the time to think of the worst language support misses or mistakes you have heard of or experienced, and to design safeguards to prevent such situations from happening.
The bigger the language support toolbox of the organization, and the more easily staff and providers can find the toolbox and instructions on how to use them, the fewer language support disasters the organization will have.
First, we will present several real-life situations and the ways that well-prepared staff dealt with them. Further down, we will lay out the infrastructure elements that provide resilience to language support challenges.
Four Deaf patients presented at the Emergency Department on Friday evening at six pm, a historically difficult time to get an interpreter in-person or on VRI.
Fix: Requested in-person interpreters from agency, letting the dispatcher know that there are several patients and the interpreters will be asked to flow to where the most urgent activity is. Conducted serial triage of all four patients via VRI without terminating the VRI connection.
A pregnant woman from the Gambia, who speaks only Mandinka, is admitted for a month of ante-partum care with two high risk medical conditions. It is difficult to get a Mandinka interpreter even over the phone.
Fix: Had two or more OPI contracts and made a reservation for interpreting time as necessary. This was outside of normal office hours most days and required that the doctor agree to talk with the patient and her husband at 7 each evening. Checked with the local community to identify a health sciences student or health worker locally who could be trained as an informal interpreter just for this patient and only to facilitate communication of information at a basic register.
The staff Farsi interpreter was at home on maternity leave when a long-term elderly patient was admitted for end-of-life care. The interpreter wanted to assist with this patient but could not travel.
Fix: Used an instant-setup ZOOM account, which is secure, to connect the interpreter at home with the care team and patient on a large-screen PC wheeled into the inpatient room.
The VRI platform was down and clinics started calling in saying they could not communicate with their patients. Or the OPI (Over-the-Phone) call line was returning a busy signal, and staff become instantly panicked as doctor schedules were disrupted.
Fix: Executed an established protocol: Contacted the language company via backlines that were requested for just such an emergency. Got information about the cause of the outage and the estimated time of resolution. Transmitted this information, along with directions for operating through alternative networks to all staff groups affected, including receptionists, unit coordinators, and managers of clinics and floors.
The Spanish staff interpreter who has interpreted the memorial service for babies who die in the hospital every year was needed for a major sedated-awake surgical procedure the same day. She usually interpreted the service and read several poems in Spanish chosen by the chaplain.
Fix: The interpreter was given a copy of the chaplain’s remarks ahead of time, translates them into Spanish, and voice-recorded this plus the poems in Spanish. This voice recording was played at the memorial event.
The supervisor of the Cath Lab locked the video remote iPad in her office when she went home on Friday, as there were no more cases scheduled until Monday. Then an Arabic-speaking inpatient was sent down for an urgent procedure at 9 am on Saturday.
Fix: The Nurse Anesthetist brought an iPad over from the Pre-Surg area, which was quiet that morning.
The new Medical Assistant in Urology Clinic had no idea how to find the instructions on self-care in Russian for the patient, as requested by the doctor, and the rest of the staff have gone to lunch.
Fix: The Medical Assistant confessed to the doctor that he has no idea how to find the translation, thinking it is in some bottom-drawer archive in the clinic. The doctor, who wrote the set of instructions and worked with Interpreter Services to get it translated, showed the M.A. how to access all the translations for the entire organization on the Interpreter Services page of the intranet.
The main elevators are down during a long fire alarm and non-English-speaking patients are piling up in the elevator lobbies on all floors because they cannot understand the loudspeaker instructions to get to an alternative route.
Fix: Interpreter Services had seen this happen many times before and had prepared a placard for each elevator lobby with basic instructions in six languages, plus a diagram, of how to get to an alternative route.
The Medics bring in a semi-conscious, very unkempt man with Asian features who was found lying bleeding on a sidewalk, with no ID, with an unknown clinical situation, who mumbles agitatedly to himself in some unidentified foreign language.
Attempted fix: ED requested help from Interpreter Services to send staff interpreters from all available languages to identify his language need. This was not successful– the patient did not respond coherently to any of the interpreters. The patient also did not respond to a CDI, or Certified Deaf Interpreter, skilled in communicating with people having trouble with language expression or understanding. The patient remained a John Doe until he left AMA two days later, language group still unknown.
The Language Program Manager can prepare the organization for most unexpected contingencies by preparing the fundamental infrastructure and protocols and staff/provider training:
No one language agency can provide all the language coverage needed. Contract with at least two agencies for each modality: in-person, phone, and video remote. For sign language three or four agencies might be necessary. Authorize staff to access all of these agencies, in whatever order you dictate. If you get OPI (phone) over your video remote platform, also have the capacity to use real telephones to call other telephonic agencies. Lay out emergency operating protocols as part of the contracting discussions.
So that not all the laptops or iPhones or iPads go down at the same time for updates. Have some devices on flexible poles so that they can be positioned over a C-section patient or under a prone Interventional Radiology patient. Have some extra devices in a central location for deployment to unexpected events anywhere in the building, such as a patient locked into a bathroom stall.
So that the organization has some internal capacity to see patients directly using the patients’ own languages. This takes a great deal of pressure off of providing interpreter support for these encounters.
Create easily accessible repositories of devices, instructions, and materials, which everyone on the care team can access
Create and maintain a well-designed intranet page that has ALL the information needed for staff and providers and administrators to provide responsive language support at any time of day. List the locations of video and phone devices, so that if their own devices are not working, they can borrow from other units.
- Where are the ear covers for the Pocket Talkers and the interpreter earphones?
- Where are the charger stations?
- Where does one plug in the remote devices in the various sterile procedure areas?
- What steps to take to decontaminate devices after they have been in inpatient rooms?
- What are the access codes for phone and video agencies?
- In a pinch, can the nurse or doctor call the phone interpreter using her own phone?
- Where to take or report a broken device?
Encourage, right on the web page, that staff make a shortcut to this page on their own desktop.
Make these accessible on the intranet by title of the document as well as by keyword of the topic. If a receptionist needs HIPAA in Farsi, he should be able to find it on the Language Access page in a flash to download and print it. If the discharging nurse needs to send her patient home with instructions on care of an indwelling catheter in Korean, this should take mere seconds. If a patient needs Braille materials, how is that arranged for?
On disability, sensory deficit, and language support that staff do not usually know but may need to find out quickly:
- When can you use family to interpret—for instructions on how to get to the elevators, for a caution to not let the toddler jump on the chair, to report out the patient’s blood pressure today, to discuss cancer treatment options?
- What elements does your HC organization document: preferred spoken language; additional spoken languages; preferred written language; sensory deficit; needed accommodations…
- What is the difference between ASL, SEE, ASL Close Vision, CDI, and Tactile?
- What language support is needed for aphasia, or for deafness due to a brain tumor, or a blind person?
- When should an in-person interpreter be arranged for?
- How does a staff person or provider initiate or receive a phone call via Relay Operator?
- What are the key steps of working with a foreign language or ASL interpreter?
This FYI allows for training-on-demand. Staff who are successful in providing language support to their patients become more invested in their patients’ well-being.
Assure that no one person and no one department is a bottleneck for vital information, materials, or devices
Send out simple refresher instructions on all aspects of language support to unit managers, reception staff, unit coordinators, care coordinators and hospitalists on a regular basis, and invite them to forward to their teams. Provide a one-page laminated language support card for all unit secretaries and clinic receptionists to keep at their desks in a drawer. Everyone else asks them for help. Insist that language support devices be kept in unlocked cabinets in staff areas or in locked areas that all unit staff can access. Make sure that the units which need multiple devices have what they need. Maintain a fan-out email list that notifies all units with video or phone devices when there is going to be a large program update, so that they can plan for it and not get caught short with a device sidelined for an hour to download version 10.X.
Make sure that you and several people on each unit have all passwords associated with the particular devices they are using. If possible, use a computer management application which pushes out updates to all units at the same time from a central point, so that staff on the units do not have to deal with this
Assure that many layers of authority in the organization are confident on how to accomplish language support in a crisis
On each patient-facing unit there should be several internal layers of expertise on language support, such as the clinic or inpatient manager, the charge nurses or supervisors, and the leads. The Language Program Manager should solicit time on the agenda of nurse managers and clinic managers on a regular basis. Some doctors function very well as additional language support problem-solvers and early adaptors of new tech. External to the units, the Administrator-on-Call group should all be well-trained to solve difficult language support problems. One of them is on-call round the clock. Problems might be technical issues, resource issues such as permission to engage round-the-clock interpreters for a dying patient, or risk management issues, of which there are many. The AOC group should all have a good working relationship with the Language Program Manager and be able to consult with him or her as needed.
The Language Support Manager should be included on the Disaster Planning Committee. This assures that organizational resources are available during disasters to notify and communicate with non-English-speaking patients and communities.
Encourage and train staff to fluently use multiple modalities of language support, rather than to expect one-stop shopping
When a language support device or network goes down for whatever reason, staff and providers should immediately break down the needed communication into pieces and find alternate means to convey each of the pieces. Rather than delaying in triaging a patient at 2 am because the Triage VRI device was not charged, many different modalities can be brought to bear. This thinking process must be immediate, just as when the electricity goes off due to a major storm, and the generator comes on, and all staff shift to accomplish the most important tasks on auxiliary power. The parts of the Triage conversation that CAN be carried out with the help of phone, family, writing, pictures, or bilingual staff should be accomplished, so that care can be consented and started. The VRI machine should be plugged in. The AOC is called and asked to enter the locked ENT clinic so that the their VRI unit can be borrowed for a couple of hours. An email is sent to the off-duty ER manager to add charging of the ER VRI machines to the daily roster of tech duties.
Authorize and encourage coloring outside the lines to accomplish effective communication in unusual circumstances
Reward innovation. Recognize language support heroes by nominating them for organizational awards. Often it is young staff who lead in managing tech emergencies, and who lead in using tech to manage language support crises.