BACKGROUND: Access to written hospital discharge instructions improves caregiver understanding and patient outcomes. However, nearly half of hospitals do not translate discharge instructions, and little is known about why. OBJECTIVES: To identify barriers to and potential strategies for translating children's hospital discharge instructions. METHODS: We conducted a mixed-methods, multimodal analysis. Data comprised closed-and open-ended responses to an online survey sent to Children's Hospital Association language services contacts (n 5 31), an online environmental scan of Children's Hospital Association translation policies (n 5 22), and county-level census data. We examined quantitative data using descriptive statistics and analyzed open-ended survey responses and written policies using inductive qualitative content analysis. RESULTS: Most survey respondents (81%) reported having a written translation policy at their hospital, and all reported translating a subset of hospital documents, for example, consent forms. Most but not all reported translating discharge instructions (74%). When asked how inpatient staff typically provide translated discharge instructions, most reported use of pretranslated documents (87%) or staff interpreters (81%). Reported barriers included difficulty translating uncommon languages, mismatched discharge and translation time frames, and inconsistent clinical staff use of translation services. Strategies to address barriers included document libraries, pretranslated electronic health record templates, staff-edited machine translations, and sight translation. Institutional policies differed regarding the appropriateness of allowing interpreters to assist with translation. Respondents agreed that machine translation should not be used alone. CONCLUSIONS: Children's hospitals experience similar operational and organizational barriers in providing language-concordant discharge instructions. Current strategies focus on translating standardized documents; collaboration and innovation may encourage provision of personalized documents.

OBJECTIVES: Patients and families preferring languages other than English (LOE) often experience inequitable communication with their health care providers, including the underutilization of professional interpretation. This study had 2 aims: to characterize resident-perceived communication with families preferring LOE and to evaluate the impact of language preference on frequency of resident interactions with hospitalized patients and families. METHODS: This was a cross-sectional study at a quaternary care children’s hospital. We developed a questionnaire for residents regarding their interactions with patients preferring LOE. We concurrently developed a communication tracking tool to measure the frequency of resident communication events with hospitalized patients. Data were analyzed with logistic and Poisson regression models. RESULTS: Questionnaire results demonstrated a high level of resident comfort with interpretation, though more than 30% of residents reported “sometimes” or “usually” communicating with families preferring LOE without appropriate interpretation (response rate, 47%). The communication tracking tool was completed by 36 unique residents regarding 151 patients, with a 95% completion rate. Results demonstrated that patients and families preferring LOE were less likely to be present on rounds compared with their counterparts preferring English (adjusted odds ratio, 0.17; 95% confidence interval [CI], 0.07–0.39). Similarly, patients and families preferring LOE were less likely to receive a resident update after rounds (adjusted odds ratio, 0.29; 95% CI, 0.13–0.62) and received fewer resident updates overall (incidence rate ratio, 0.45; 95% CI, 0.30–0.69). CONCLUSIONS: Hospitalized patients and families preferring LOE experience significant communication-related inequities. Ongoing efforts are needed to promote equitable communication with this population and should consider the unique role of residents.

OBJECTIVE: Patients with limited English proficiency (LEP) benefit from the appropriate use of medical interpreters. A multidisciplinary quality improvement team sought to improve communication with patients with LEP within a pediatric emergency department (ED). Specifically, the team aimed to improve the early identification of patients and caregivers with LEP, the utilization of interpreter services for those identified, and documentation of interpreter use in the patient chart. METHODS: Using clinical observations and data review, the project team identified key processes for improvement in the ED workflow and introduced interventions to increase identification of language needs and offer interpreter services. These include a new triage screening question, an icon on the ED track board that communicates language needs to staff, an electronic health record (EHR) alert with information on how to obtain interpreter services, and a new template to prompt correct documentation in the ED provider’s note. Outcomes were tracked using statistical process control charts. RESULTS: All study measures met special cause for improvement during the 6-month study period and have been sustained during surveillance data collection. Identification rates for patients with LEP during triage increased from 60% to 77%. Interpreter utilization increased from 77% to 86%. The documentation of interpreter use increased from 38% to 73%. CONCLUSION: Using improvement methods, a multidisciplinary team increased the identification of patients and caregivers with LEP in an ED. Integration of this information into the EHR allowed for the targeted prompting of providers to use interpreter services and to correctly document their use.

It isn't a good fit." The patient, a child who had fled armed conflict and persecution, had been diagnosed with a severe behavioral health problem. The family was overwhelmed. On behalf of the family, we sought help from multiple behavioral health services and heard the same thing: "Therapy won't work with an interpreter." "We don't know how to complete intake for a child who doesn't speak English." "We can't start treatment until we hire a bilingual therapist." Our health system failed this family, and the social and emotional consequences were devastating.In retrospect, we should not have been shocked. Since entering health care, we have been aware that children and adolescents with limited English proficiency (LEP) have been subtly and less subtly deterred from seeking mental and behavioral health care by the health system itself. Despite federal regulations rooted in the Civil Rights Act that require recipients of Medicaid or Medicare to take reasonable steps to address language barriers, children with LEP are nonetheless stymied while seeking routine outpatient services for conditions such as depression, when trying to enroll in early intervention services for children with disabilities, and when seeking help for addiction. In general, the barriers that patients face are rooted in good intentions. One health care professional has never been trained to work with children with LEP and feels that someone with more experience would offer better care. Another with strong beliefs in evidence-based therapies is reluctant to treat because "we don't know if these therapies are effective with interpreters." Other barriers are more prosaic or are simply oversights. One clinic is contracted for inperson but not telephonic interpretation and thus is unable to schedule appointments because office staff cannot talk to parents on the phone. Another program developed a protocol for communicating with parents with LEP but not with children with LEP.Our anecdotal experiences are consistent with research on access to mental and behavioral health care for patients with LEP across North America. 1 Sentell et al 1 found that among adults with LEP in California, the odds of receiving needed mental health services were less than half those of English-proficient adults, even after adjusting for insurance status. Similarly, Fortuna et al 2 found that among immigrant Latino adults who had been exposed to political violence in their home countries, English proficiency was associated with mental health service use in the prior 12 months. Although most research has focused on adults rather than on children, a large study from Canada found that among children and adolescents referred for mental health care, patients with

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