Survey of perioperative utilization of professional medical interpreters for limited-English proficient patients: Towards a framework for systems-level improvement

Introduction: Surgical patients in United States' hospitals have grown more linguistically diverse. However, professional medical interpreter (PMI) utilization remains inconsistent at many healthcare institutions for limited-English proficient (LEP) patients. Numerous studies demonstrate that inadequate perioperative access to PMI leads to worse care and outcomes for LEP patients. The perioperative setting presents unique challenges for providers in caring for LEP patients including obtaining informed consent, a transient team of multi-disciplinary providers, and the time pressure of operating room practice. Objective: Our study is the first to assess barriers to consistent PMI use in the immediate perioperative setting and to identify system-level approaches to improve PMI use. Method: We surveyed a multidisciplinary team of perioperative nurses, advanced practice providers, anesthesiology and surgical trainees and faculty on their personal practices and perceived barriers to PMI use. An anonymous online 13-question survey was used. Answer options included rank order, multiple choice, Likert scale, and free text. Survey data was analyzed using univariate statistics and stratified based on providers having received information on the Title VI Civil Rights Act of 1964 and their medical training status. Pearson's chisquared test was performed and odds ratios calculated to determine if these provider characteristics were associated with increased preference for PMI over bilingual staff and patients' family members for interpretation and with other LEP evidence-based care practices. Results: We received a total of 262 responses with a 28.3 % response rate. Among survey participants, 19.1 % of participants did not know where to find patients' language preferences in the electronic health record (EHR) and 69.8 % of participants did not know how to update language preferences in the EHR. When a bilingual staff was present, 31.0 % and 24.8 % of providers would forgo using video and phone PMI, respectively. Comparatively, trainees were more likely to use PMI instead of patients' family or bilingual staff. Providers who received training on the Title VI Civil Rights Act of 1964 were more likely to use PMI for interpretation and provide translated consent forms, and least likely to utilize patients' families for interpretation. Barriers to PMI use included difficulty obtaining video consoles or phones, long wait times for interpreters, unavailability of language, unfamiliarity with using video consoles or accessing interpreters, poor sound quality and internet connectivity issues. As many as 26 % of respondents cited time pressure for starting a surgical case as the reason for not using an interpreter. Discussion: Based on these survey results, we developed a framework for quality improvement initiatives to effect system-level change in similar high-output perioperative settings. This framework can be categorized into (1) process refinement and harnessing the EHR for identification and documentation of LEP status, (2) interdepartmental collaboration to address workflow constraints, technical issues and supply-demand mismatch, and (3) increasing awareness among leadership and providers about interpretation laws, cost reduction and improved outcomes with PMI use.