Introduction

As of 2013, approximately 61.6 million individuals in the United States speak a language other than English at home. Of these individuals, about 41%, totaling 25 million people, are considered to have Limited English Proficiency (LEP), defined as anyone over the age of 5 who reports speaking English less than “well” or “very well” [1]. In the US, the population of individuals with LEP is estimated to be 8% of the total US population and continues to grow, having increased by 80% between 1990 and 2013 [1], with growth fastest in smaller metropolitan areas [2].

Language barriers profoundly affect the experiences that patients with LEP have with the healthcare system, impacting their relationships with care teams, ability to access care, understanding of their of illness, and ability to make informed decisions [3]. In the hospital, language barriers encountered by patients with LEP put them at risk for suboptimal communication especially in the ICU [4] [5]. Consequently, patients with LEP face significant disparities. Hospitalized patients with LEP are at a higher risk of adverse medical events [6], have less fully documented informed consent [7], longer hospital and ICU stays [8, 9], higher readmission rates [9,10,11], and increased ICU mortality rates [12]. At end of life, patients with LEP are more likely to receive mechanical ventilationand are less likely to receive a comfort measures order set [8].

Access to interpretation services in healthcare settings is legally required by the United States government [13]. Use of language services results in fewer clinically important interpretation errors, better quality of care, higher patient satisfaction, and shorter hospitalizations [14,15,16]. Previous literature describes patients with LEP receiving language services via in-person, phone-based, and video-based professional interpreters, as well as language-concordant clinicians [17,18,19,20]. Compared to the use of professional interpreters, care by a language-concordant clinician results in better outcomes for patients with LEP [18]. Amongst the interpretation modalities commonly used, in-person interpretation is preferred for important discussions with patients and families as in-person interpreters are not only able to provide verbatim interpretation, but also alert clinicians to health literacy challenges and function as cultural brokers [3] [21].

Unfortunately, when professional interpreters are not readily available, physicians often still resort to using ad hoc interpretation [22, 23], relying on their own limited language skills, other clinicians [24], family members [23, 25], smart phone translation apps [26], and even Google Translate [27]. These methods have been associated with poorer communication, clinical errors, family distress, and worse patient outcomes [9, 15, 25].

The COVID-19 pandemic has disproportionately affected racial and ethnic minorities in the US, many of whom have LEP [28, 29]. Since the start of the pandemic, hospitals have observed a significant rise in the percentage of patients with LEP or requesting interpreter services [30, 31]. During the COVID-19 pandemic, patients with LEP at the end-of-life were more likely to be Full Code and die after longer hospital stays [32, 33]. The serious nature of COVID-19 and associated high morbidity and mortality rates resulted in clinicians more frequently encountering scenarios that are at high risk of misunderstanding without professional interpretation, such as end-of-life and goals-of-care discussions [34]. Thus, COVID-19 has increased the need for strategies to effectively communicate with patients with LEP.

Unfortunately, the COVID-19 pandemic has impaired communication with patients with LEP in and out of the hospital. Outside the hospital, patients with LEP in the community faced challenges in accessing important healthcare information during the COVID-19 pandemic. Although Spanish is the most spoken language among those with LEP in the US, Spanish language content on COVID-19 from hospitals provided less accessible and less diverse content than the English language versions available [35,36,37].

While conditions in the hospital resulting from COVID-19 created challenges for effective communication with all patients, those with LEP were particularly affected in a variety of ways [38]. Despite increasing patient need, professional interpretation became more limited. Concerns about contamination, limited the use of phone and video-based interpretation [39, 40]. Concerns about COVID-19 transmission and limited PPE supplies reserved for clinical staff resulted in decreased availability of in-person interpretation at the bedside [28, 40]. To reduce infection risk and PPE use, clinicians spent less time in the rooms of patients infected with COVID-19, and may have incentivized physicians to “get by” with ad hoc interpretation methods [22]. For ICU patients, muffled voices under masks and background noise from intensive care units’ ventilators and other machines added additional communication challenges [39]. In addition to the above challenges, hospitals widely restricted visitors on inpatient units, resulting in family members being unable to be present at the bedside [41]. For patients with LEP, this limited their ability to have both clinical and non-clinical social interactions, resulting in isolation and distress [27, 42].

In this myriad of ways, language barriers exacerbated COVID-19-related health disparities [27]. Addressing these unique communication challenges posed by the COVID-19 pandemic is of utmost importance given the disproportionate impact of COVID-19 on Hispanic and other communities within the United States who may have language barriers.

The objective of this narrative review was to assess the existing literature and lay media for strategies and interventions employed by hospitals to provide interpreter services and support communication with patients with LEP hospitalized during the COVID-19 pandemic.

Methods

Literature Search

Given the gap in our knowledge about interventions implemented during the COVID-19 pandemic to better communicate with patients with LEP, we elected to perform a narrative review. The purpose of a narrative review is to evaluate the landscape of publications on a topic and identify gaps. To do so, we designed a search strategy built around limited English proficiency (LEP), COVID-19, and inpatient medicine. The following databases were used to search for articles in peer-reviewed journals: APA PsycInfo (1806 to November 2021), EBM Reviews—Cochrane Central Register of Controlled Trials (October 2022), EBM Reviews—Cochrane Database of Systematic Reviews (2005 to November 9, 2022), Embase (1974 to November 11, 2022), Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily (1946 to November 11, 2022). To expand the search, Ebsco Megafile (2020–2022) was used to search for articles in the lay media.

This search strategy was designed and conducted by an experienced librarian (LP) with input from the paper’s principal investigators (CY, AB). Database subject headings and keywords in the title and abstract were used to search for interpretation strategies during the COVID-19 pandemic for non-English speaking hospitalized patients. The complete strategy listing all terms and combinations used is listed in the Appendix. This review was exempt from Institutional Review Board review as it reviews previously published data.

Selection Criteria

Each title, abstract, and full-text article was reviewed independently by the study authors (CY, AB). Articles were included if the following criteria were met: (1) the article was from an English-speaking country where not speaking English is a challenge (2) the article described or assessed a novel intervention or strategy implemented during the COVID-19 pandemic to address language barriers faced by patients and families with LEP (3) the intervention or strategy was deployed in an inpatient setting (e.g., inpatient hospital unit, intensive care unit).

Data Synthesis and Analysis

We descriptively summarized and qualitatively synthesized the data, categorizing the types of interventions implemented and any described outcomes.

Results

Literature Profile

The initial search yielded a total of 43 articles in peer-reviewed journals and 18 articles in the lay media. Following a review of the 61 titles and abstracts and applying our inclusion and exclusion criteria, 6 articles were included for full text review. After full text review, we included the 6 articles, all from peer-reviewed journals (see Table 1). In total, 55 articles were excluded, most because they did not describe an intervention or strategy and/or were not implemented in inpatient settings.

Table 1 Summary of articles describing interventions to address language barriers during the COVID-19 pandemic
Full size table

Of the included articles, four articles were based in the United States,one in the United Kingdom, and one in Canada. The interventions described in the articles fall into one of three categories: (1) interventions that increased the accessibility of language-concordant care (2) interventions that increased the accessibility of professional interpretation and (3) interventions to improve family communciation and understanding. Three articles fall under the first category, two under the second, and one article falls into the third.

The languages spoken by the patients with LEP were specified in five of six articles. In those five articles, patients in Knuesel et al. (2021) [31],Herzberg et al. (2022) [43] and Alvarez-Arango et al. (2021) [44] spoke Spanish, while the patients in the articles by Wachtl et al. (2021) [45] and Kwok et al. (2021) [24] spoke a diverse set of languages, ranging from Bengali, Hindi, and Urdu to Mandarin, Cantonese, and Punjabi. Mulpur et al. (2021) [40] likely served patients who spoke a diverse set of languages as well, though the languages were unspecified. Kwok et al. (2021) [24] and Alvarez-Arango et al. (2021) [44] quantify the total number of patients with LEP who were served by the interventions, while the other articles do not.

Category 1: Increasing Accessibility of Language-Concordant Care

Three articles—Knuesel et al. (2021) [31], Herzberg et al. (2022) [43], and Alvarez-Arango et al. (2021) [44] leveraged bilingual staff at their hospitals to increase the accessibility of language-concordant care as more patients with LEP were hospitalized during the COVID-19 pandemic [31]. (2021)The articles describe two different approaches to engaging Spanish speaking clinicians and/or staff to support frontline healthcare teams.

Spanish Language Care Group (SLCG)

Knuesel et al. (2021) [31] describe the process of developing the Spanish Language Care Group (SLCG) at a large tertiary care center in the US. Study authors describe assembling Spanish-speaking physicians from an existing registry that identified clinicians with multilingual skills to address the increased number of hospitalized Spanish-speaking patients. SLCG leaders then collaborated with leadership from the inpatient medicine surge team and the Center for Diversity and Inclusion to develop a staffing strategy, assigning SLCG providers to shifts in the ED, inpatient medical units, and ICU to assist provider teams with language interpretation and other clinical tasks. Knuesel et al. (2021) [31] report “overwhelmingly positive feedback” [31] from the teams who were assigned SLCG clinicians and SLCG physicians themselves.

Herzberg et al. (2022) [43] describe the same intervention but from the perspective of a physician in the SLCG. The study authors describe the appreciation they received from patients, patients’ families, and clinicians as well as the example that the intervention set for other hospitals locally and nationally.

Juntos Consult Service

Alvarez-Arango et al. (2021) [44] describe the creation of a consultative service at a large tertiary care center in the US in response to rising numbers of Spanish-speaking patients. The service, called Juntos, comprised of Spanish-speaking staff who indicated certified Spanish proficiency and a willingness to be deployed to COVID units. Volunteers staffed the Juntos service from 7am to 7 pm 7 days per week during the peak of COVID-19 admissions, followed by 8am to 5 pm from Monday to Friday after the peak. The Juntos consult service was available to all inpatient teams, including from the ICU and labor and delivery. Surveys were sent to all individuals placing Juntos consults as well as all Juntos volunteers. The survey showed that the majority of referrals stemmed from the medical and ICUs. Satisfaction with the program was high overall, with 85% of individuals placing consults reporting being very satisfied with the care delivered and 71% of Juntos volunteers reporting being very satisfied with their experience. [44]

Category 2: Increasing Accessibility of Professional Interpretation

Two articles – Mulpur et al. (2021) [40] and Kwok et al. (2021) [24]—describe approaches that use technology to increase the accessibility of professional interpretation given the challenges that the COVID-19 pandemic posed to in-person interpretation.

Wearable Technology Connection to Phone Interpretation

Mulpur et al. (2021) [40] describe an approach where the phone number for telephone interpretation was programmed onto Smartbadge wearable technology already worn by clinicians. Clinicians were then able to verbally request professional telephone interpreter services while at the bedside, which would seamlessly emanate from the speaker on the Smartbadge. As a result of this intervention, Mulpur et al. (2021) [40] reported that the number of minutes of telephone interpretation doubled between the first and second quarters of 2020 and clinicians reported an increased sense of connectedness with patients due to the interpreter’s voice seeming to originate from their chest.

Interpreter on Wheels

Kwok et al. (2021) [24] describe a trial of an “Interpreter on Wheels” (IOW), an electronic tablet mounted on a rolling stand with an audio and visual interpretation service. The tablet was available to Emergency Department staff in the hopes of decreasing the use of bilingual staff as ad hoc interpreters by increasing accessibility of professional interpreters. During the two month trial, Kwok et al. (2021) [24] reported 477 virtual interpretation encounters in a variety of languages, most commonly Mandarin and Cantonese. Staff and patients expressed satisfaction, rating the device a cumulative 4.43/5. However, Kwok et al. (2021) [24] were unable to determine the impact of the IOW on the frequency of bilingual clinicians being used as ad hoc interpreters during the trial period.

Category 3: Improving Family Understanding

Wachtl et al. (2021) [45] describe the implementation of an animated patient education video in two London National Health Services (NHS) hospitals aimed at increasing families’ understanding of mechanical ventilation and its risks, benefits, and alternatives in the setting of pandemic visitor restrictions. Developed to serve both English-speaking and non-English speaking families now separated from loved ones in the ICU by COVID-19-related visitor restrictions, the animated video was made available in English, as well as the four most spoken non-English languages by patients served by the regional NHS Trust—Bengali, Hindi, Turkish, and Polish. In total, 45 English-speaking and 26 non-English speaking families were included in the intervention. The investigators conducted surveys of the families’ self-reported understanding of mechanical ventilation before and following implementation of the intervention. The study authors found that the 20 English-speaking and 12 non-English speaking families surveyed after implementing the intervention reported increased understanding of mechanical ventilation and its risks, benefits, and alternatives, but no change in their levels of anxiety.

Discussion

The purpose of this narrative review was to identify the strategies and interventions described in the literature to address the unique communication challenges faced by hospitalized patients and their families with LEP during the COVID-19 pandemic.

Prior to the COVID-19 pandemic strategies beyond language interpretation to support patients with LEP have included specific clinic days with language-congruent clinicians [46], huddles between clinicians and interpreters [47], continuing education sessions on caring for patients with LEP [48], electronic apps for health promotion and communication providers [49], and chronic disease education via group video visits by community health workers [50]. Most interventions described in the literature occur in non-hospitalized patients, such those seen in outpatient clinics or through community outreach [46, 49, 51]. However, these strategies may not be applicable when caring for individual patients in higher-acuity settings, such as those who are hospitalized or in ICU. Finally, few communication strategies have been described for communicating with patients with LEP regarding critical illness and end-of-life care [52], unfortunately more prevalent during the COVID-19 pandemic.

Overall, the five interventions described in the six articles all report positive outcomes and are generally replicable, though would likely require significant resources to sustainably serve the needs of all patients with LEP, regardless of primary language. The interventions described by Mulpur et al. (2021) [40] and Kwok et al. (2021) [24] are the most sustainable strategies as they require one-time investments in technologies. In addition, these interventions also provide better access to language services for all patients with LEP, regardless of primary language.Conversely, Wachtl et al. (2021) [45] made the video animation available in 4 languages and it might require significant resources to make the animation available in several other languages. Both the Spanish Language Care Group (SLCG), as described by Herzberg et al. (2022) [43] and Knuesel et al. (2021) [31], and the Juntos consult service, as described by Alvarez-Arango et al. (2021) [44] relied on Spanish-speaking staff. The former embedded clinician volunteers with frontline medical teams while the latter created a consult service that could be utilized as needed by any inpatient team [31, 43, 44]. Compared to the setup of the Juntos consult service, the setup of the SLCG likely allowed for more immediate language assistance while potentially requiring more volunteer time.

While care by language-concordant clinicians is optimal, resulting in better outcomes for patients, there are many challenges facing this kind of intervention [18]. First, there will certainly remain a shortage of language-concordant clinicians for patients in the foreseeable future. Studies have shown that the most commonly spoken languages among clinicians and medical trainees in the United States do not align with the most commonly spoken languages by patients with LEP. This is true for both the regions in which they practice and in the US as a whole [53,54,55]. Second, Spanish-fluent staff were available to assist other medical teams only as a result of pandemic-related disruptions of their typical clinical work. In the case of the Spanish Language Care Group, the bilingual clinicians were available while their typical clinical activities were suspended by the COVID-19 pandemic [31]. Once normal hospital operations and academic activities began to return, the Juntos consult service began to struggle with coverage, as volunteers had to meet their clinical responsibilities while also covering the Juntos pager [44]. Finally, given the limited number of bilingual staff available, interventions that utilize these individuals’ unique language skills perpetuates the so-called minority or cultural tax. This tax, as described by Alvarez-Arango et al. (2021) [44] describes the increased frequency of which minority staff, trainees, and faculty face additional, often uncompensated, duties and responsibilities to advance an institution’s diversity, equity, and inclusion work.

Some limitations of this narrative review include the following. First, as with all narrative reviews, we depend on our search strategy to capture relevant articles. To maximize the chances of capturing all relevant articles, we worked with an expert librarian to develop the comprehensive search strategy and broadened the search beyond academic articles to include published perspectives and articles in the lay media. While we are confident that our expert librarian captured the pertinent articles, it is possible that in the limited time since the search was finalized in November 2022, additional articles have since been published that were not included. Second, despite our broad search strategy, this narrative review captured few relevant articles, particularly original research articles. As COVID-19 has disrupted research in other fields [56], it is possible that the burdens that COVID-19 placed on healthcare systems in the US and beyond limited the ability for systems to develop, implement, assess and document novel interventions in the academic literature, while coping with the patient care demands placed upon clinicians during the pandemic.

New Contribution to Literature

Our narrative review is the first to describe communication strategies directly implemented to address the unique communication challenges posed by COVID-19 for hospitalized patients with LEP.

This narrative review shows that there are a few novel strategies described in the literature that were used to address the unique communication challenges faced by patients with LEP during the COVID-19 pandemic. In the interventions that were described, the outcomes of the interventions, while seemingly positive, were not systematically measured, making the overall impact of the intervention difficult to evaluate. In addition, the ability of the interventions to scale up to address all patients with LEP, regardless of primary language, and to remain feasible beyond the initial surges of the COVID-19 pandemic are somewhat questionable. Future research should focus on developing strategies to improve communication with patients with LEP in pandemic conditions (e.g., with high patient volume, PPE shortages, limited family visits) that can serve all patients with LEP and can be maintained over longer periods of time. Given the increasing population of patients with LEP, this area of research remains a challenge and a priority.