Interpretation use for consent to hip fracture surgery in patients with limited English proficiency

INTRODUCTION

Patients cannot provide informed consent for complex medical interventions, such as surgery, without professional interpretation when there is language discordance between the patient and clinician.¹ However, patients with limited English proficiency (LEP) rarely receive interpretation, even when such services are readily available.² Instead, clinicians often rely on ad hoc interpretation performed by a patient's family, friends, or other health professionals.³ Ad hoc interpretation is associated with clinically relevant omissions and errors when compared with professional interpretation.^{4, 5}

Language discordance in the surgical setting is not well studied. A limited body of literature demonstrates that compared with patients who are English proficient, patients with LEP and hip fracture do not experience longer lengths of stay, increased in-hospital mortality, or greater readmissions.^{6, 7} However, little is known about the use of interpretation in consent for surgery. We examined the use of professional interpretation for informed consent in patients with acute hip fracture and LEP.

METHODS

This retrospective study included all patients with LEP aged 50 years or older discharged with hip fracture between January 1, 2015, and January 1, 2018. We used International Classification of Diseases, 10th revision codes to identify patients with a most responsible discharge diagnosis of hip fracture. Patients with a non-English language listed as their preferred language were considered to have LEP. We excluded cases where hip fractures were managed nonoperatively and where we were unable to identify who signed the consent form. Consent forms have space to record the name and signature of the patient, the signature of a substitute decision-maker, and the name and signature of a professional interpreter. Telephone interpreters provide an interpreter identification number, and institutional policy requires that the interpreter identification number be recorded on the consent form. In-person interpreters write their name and sign the consent form.

Telephone interpretation is available 24/7 and in-person interpretation during business hours.

We reviewed charts to determine the proportion of patients who signed their own consent form and had documented use of (1) professional interpretation, (2) ad hoc interpretation, or (3) no interpretation.

University Health Network's Research Ethics Board approved the study.

RESULTS

We identified 553 hip fracture cases, and of these, 134 (24.2%) had LEP. Seven (5.2%) cases were excluded because they were managed nonoperatively and no consent form was signed, and one (0.7%) was excluded because we were unable to identify who signed the consent form. The final cohort totaled 126 hip fractures occurring among 122 unique patients (four patients fractured both hips during the study period). The mean age was 83.6 years (± 8.4), 85 (69.7%) patients were women, and 21 (16.7%) had a Charlson Comorbidity Index score of ≥2 (Table 1).

TABLE 1. Baseline characteristics (N = 122)

• ^a n = 126 hip fracture cases.

• ^b Three cases consented to hip fracture surgery on admission, but subsequently had a non-operative plan of care established.

• ^c The Charlson Comorbidity Index assigns a score measuring comorbidity; a higher score indicates a greater likelihood of death from comorbid disease.

• ^d n = 126 hip fracture cases.

In 67 (53.2%) cases, the substitute decision-maker signed the consent form on behalf of the patient. In 59 cases (46.8%), the patient signed their own consent form. Professional interpretation was used in obtaining informed consent in five (8.5%) of 59 cases. Ad hoc interpretation was used in 20 cases (33.9%), and 34 (57.6%) had no interpretation.

DISCUSSION

We found that at an institution with robust access to professional interpretation, only 8.5% of patients with LEP who signed their own consent form for hip fracture surgery received professional interpretation for informed consent. The majority of patients with hip fracture (57.6%) had no documented use of any interpretation.

Many factors may contribute to low use of professional interpretation in the surgical setting. A patient's English proficiency may be judged sufficient for consent. Hip fracture protocols also encourage expedited surgery and surgeons may prioritize “door-to-operating room (OR)” time over use of interpretation. A patient's English proficiency may be judged sufficient for consent. Ease of access to professional interpretation is an important facilitator of its use, and surgeons report using ad hoc interpretation if wait times for professional interpretation are greater than 15 min.⁸

Many institutions, like ours, have policies requiring the use of professional interpretation for informed consent. However, policies are weak levers in motivating change. A multipronged intervention including education, automated electronic medical record (EMR) alerts, and improved access to telephone interpretation was associated with increased use of professional interpretation.⁹ Installing dual-handset interpreter phones at the bedside increased the use of interpretation for informed consent in patients undergoing nonsurgical procedures from 29% to 54%.¹⁰

Our study has several limitations. First, not all patients with a non-English preferred language have LEP. Some patients may prefer a particular language but are proficient in English. Second, we relied on hospital consent forms to determine if interpretation was used. It is possible that interpretation use was not documented. Third, the majority of patients in our study had a substitute decision-maker consent on their behalf. We were unable to determine if these patients were truly incapable or if surrogates were used for expediency. Fourth, we did not have data on important patient characteristics such as level of education or relationship of the substitute decision-maker to the patient. Finally, this was a single-center study.

In conclusion, we found that professional interpretation was rarely used for patients with LEP consenting to hip fracture surgery. Clinicians and institutions must engage in serious quality improvement efforts to ensure that older adults with LEP can engage in the informed consent process.

ACKNOWLEDGMENTS

CONFLICT OF INTEREST

Dr. Cram is supported in part by a grant from the U.S. National Institute of Aging (R01AG058878) and through a salary award from the University of Toronto Department of Medicine. The remaining authors report no conflict of interest.

AUTHOR CONTRIBUTIONS

All authors conceived and designed the study. JM and SR led the data collection and drafted the manuscript. All authors critically revised the manuscript for important intellectual content.

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