Impact of Telephone versus Video Interpretation on Parent Comprehension, Communication and Utilization in the Emergency Department: A Randomized Trial

Abstract

Importance

Consistent professional interpretation improves communication with limited English proficient (LEP) patients. Remote modalities (telephone and video) have potential for wide dissemination.

Objective

To test the effect of telephone versus video interpretation on communication as measured by diagnosis comprehension, lapses in interpreter use, quality of communication and interpretation, and healthcare utilization during pediatric emergency care.

Design

Randomized trial of telephone versus video interpretation. Investigators were blinded to interpretation modality during outcome ascertainment.

Setting

Free-standing, university-affiliated pediatric emergency department (ED)

Participants

Spanish-speaking LEP parents of pediatric ED patients. A convenience sample of 290 parents were approached, of whom 249 (86%) enrolled, and 208 (84% of enrolled) completed the follow-up survey (91 telephone arm, 117 video arm). Groups did not differ significantly by consent or survey completion rate, ED factors (e.g. ED crowding), child factors (e.g. triage level, medical complexity), or parent factors (e.g. birth country, income).

Intervention

Assignment to telephone or video interpretation for the ED visit, randomized by day

Main Outcomes and Measures

Parents were surveyed 1–7 days following the ED visit to assess communication and interpretation quality, frequency of lapses in interpreter use, and ability to name the child’s diagnosis. Two blinded reviewers compared parent-reported and chart-abstracted diagnoses and classified them as correct, incorrect, or vague. Length of stay (LOS) and charges were obtained from administrative data. Effect of interpretation modality assignment on outcomes was assessed using chi-squared and Student’s t-tests.

Results

Video-assigned parents were more likely to correctly name the child’s diagnosis than those assigned to telephone (75% vs 60%, p=.03), and less likely to report frequent lapses in interpreter use (2% vs 8%, p=.04). There were no differences in parent-reported quality of communication or interpretation, or in ED LOS or charges. Video interpretation was more costly (per-patient mean $61 vs $31, p<.001). Parent-reported adherence to assigned modality was higher for the video arm (93% vs 79%, p=.004).

Conclusions and Relevance

LEP families who received video interpretation were more likely to correctly name the child’s diagnosis, and had fewer encounters with frequent lapses in interpreter use. Use of video interpretation shows promise for improving communication and patient care.

Trial Registration

clinicaltrials.gov Identifier: NCT01986179

Introduction

In 2007, over 25 million people in the United States reported speaking English less than “very well.”¹ Language barriers in healthcare are associated with increased costs,² decreased satisfaction³ and adherence,⁴ and increased risk of harm.^5–7 Professional interpretation mitigates these effects ⁸ yet remains underutilized.^9–11 Consequently, limited English proficient (LEP) patients and families may receive care that is less safe and effective relative to English-speaking families.

Technological advances have increased access to telephone and video-based interpreters,¹² but use remains low: fewer than one in three LEP patient encounters receives any professional interpretation.^9–11 Reasons for underuse are multi-factorial, but cost, technical requirements, time constraints and providers opting to “get by” with non-proficient language skills contribute.^10,13–15 The methods available in a given setting and perceived barriers to accessing those methods likely influence consistent professional interpreter use, increasing the potential for ad hoc interpreter use or reliance on providers’ own non-proficient language skills. Such lapses in professional interpreter use increase the risk for miscommunication and patient harm.^5–7,16,17 For example, ad hoc interpreters made errors twice as often as professional interpreters,¹⁶ and 77% of their errors had potential clinical consequences.¹⁷ These consequences can be serious: compared to English speakers, LEP patients with an adverse event have been found to suffer physical harm nearly twice as often⁶ and to remain hospitalized twice as long.⁷

Understanding the relationship between interpretation modality, provider use, and patient and family outcomes is essential for optimizing strategies to improve communication and decrease the risks associated with failure to use professional interpreters. We aimed to determine the impact of telephone versus video interpretation on 1) parent comprehension (ability to name the child’s diagnosis), 2) parent-reported quality of communication and interpretation, and 3) frequency of lapses in professional interpreter use. We hypothesized that, because providers prefer video interpretation over telephone,¹⁸ they would use video interpretation more consistently, leading to fewer lapses in interpreter use, and therefore better parent comprehension and higher quality communication and interpretation. Secondary objectives were to compare length of stay (LOS), duration and cost of interpreted communication, and hospital charges by assigned modality. We hypothesized that video interpretation would be used more frequently at higher cost, but that LOS and hospital charges would not differ by group, consistent with previous studies comparing professional interpretation services.^19,20

Methods

Setting

This pragmatic randomized trial was conducted in the Seattle Children’s Hospital (SCH) emergency department (ED), a 38-bed pediatric ED staffed by nurse practitioners, residents, fellows and faculty physicians. In 2014, the ED had 38,954 visits; 20% involved LEP families. Language need was assessed at triage by asking parent preferred language for medical care.

Before the study, professional interpretation was available via in-person, video and telephone modalities. During peak census hours, a Spanish interpreter was present in the ED. All ED rooms were equipped with dual-handset, speakerphone-enabled telephones with 1-touch dialing to telephone interpretation. Five mobile consoles for video interpretation were also available throughout the ED. Families received one or more modalities during a visit based on provider preference and availability. Hospital policy prohibits providers from using non-native language skills for medical communication unless certified as proficient by the hospital through the Clinician Cultural and Linguistic Assessment, a validated, telephone-based test.²¹

Randomization

Randomization assigned a remote interpretation modality (telephone or video) to be used throughout the ED each day, assigned at the beginning of daily recruitment. Randomization by day occurred via sealed, opaque envelopes in blocks of 6, such that each set of 6 envelopes contained an even number of each modality, to ensure an even distribution over days of the week. After opening the envelope, the clinical research assistant (CRA) hung signs announcing the assigned modality on every ED patient room. Faculty and staff were asked to use the assigned modality with Spanish-speaking LEP families until the CRA could approach the family, unless in-person interpretation was clinically required. If a family declined to participate or was ineligible, providers could use any interpretation modality they chose.

Study Population and Recruitment

Recruitment took place from February to August 2014, 5–6 days per week (including one weekend day each week) from 2–10 pm, and concluded after reaching goal sample size.

Eligible families were Spanish-speaking parents and their child (<18 years old) presenting to the SCH ED for care and requesting Spanish interpretation. Only Spanish-speaking families were enrolled, as they comprise two-thirds of LEP families seen, and validated study instruments were only available in Spanish.

Families were ineligible if the child had a life-threatening emergency (triage level 1), the chief complaint indicated a psychiatric disorder or suspected abuse, or the family was roomed before the interpretation modality of the day was announced. Families were also ineligible if their ED provider deemed that care required in-person interpretation. Once enrolled, however, families were retained in the study even if a provider subsequently used a non-study interpretation modality, consistent with our intention-to-treat design. If siblings presented for care together, only the youngest child was eligible to avoid selection bias.

Data collection

Contact information was collected at enrollment. A telephone survey, administered by a Spanish-speaking CRA 1–7 days after discharge, asked the parent about parent characteristics (English proficiency using US Census categories,¹ highest education, family income, and previous experience with the child’s current condition), the quality of communication and interpretation received, how providers communicated during the ED visit, and the child’s discharge diagnosis. Measures are described below. If a parent could not be reached within 7 days or 10 telephone calls, their survey responses were considered missing.

ED visit information was captured at enrollment from the electronic medical record, including: triage acuity level, from 1 (life-threatening emergency) to 5 (anticipated need for limited to no work-up or intervention), as assigned by the triage nurse;²² day of the week; ED crowding using the routinely-calculated National Emergency Department Overcrowding Score (NEDOCS; range 0–200); and names of treating providers. Those names were compared to a list of certified Spanish-proficient clinicians, to determine which patients received some care by proficient providers. There were few Spanish-proficient faculty or staff, and because all ED patients also received care from multiple non-proficient nurses and providers, families receiving some care from a Spanish-proficient provider were included in the study.

Hospital administrative data provided patient age, insurance type, and gender. Medical complexity was determined with the Pediatric Medical Complexity Algorithm, which uses up to 3 years of International Classification of Diseases—9^th Revision (ICD-9) codes to classify children as having illness that is non-chronic, non-complex chronic, or complex chronic.²³

Patient utilization data included disposition (admission vs. discharge), ED LOS (electronically-captured time from registration to admission/discharge) and hospital charges. Telephone and video interpretation invoices documented duration and cost of remote interpretations. In several cases, parents reported receiving a remote modality but no billing record was found; these were treated as missing.

The child’s ED discharge diagnosis was abstracted from the ED clinician note by an investigator (KCL) blinded to study group assignment.

Survey Measures

To measure communication quality, we used the Consumer Assessments of Healthcare Providers and Systems (CAHPS) Child Visit Survey 2.0 communication composite (5 items), which has been positively associated with adherence and better overall care (see eAppendix).^24,25 These items have response options of no; yes, somewhat; or yes, definitely. CAHPS items were selected because they are widely used and have undergone extensive cognitive testing for item understandability and validation for use with both English and LEP Spanish-speakers.^25–31

Interpretation quality was measured using a 4-item composite and 3 additional questions, adapted from questions developed for a previous trial of interpretation methods that included Spanish-speakers (see eAppendix).³² Composite item responses were on a 4-point scale, from poor (1) to excellent (4).

The parent was also asked to name or describe the child’s ED discharge diagnosis, using medical or non-medical terminology.³³ Responses were recorded verbatim.

Parents were asked to report on the frequency (never, sometimes, frequently, or always) providers and nurses used the following methods to discuss medical information: professional in-person interpretation, telephone interpretation, video interpretation, use of a family member or friend to interpret (ad hoc interpretation), speaking in English without an interpreter, and speaking in Spanish without an interpreter.

Survey Measure Coding for Analysis

To analyze quality of communication and interpretation, top-box scoring was used,^34,35 which is useful for measures that exhibit ceiling effects. In top-box scoring, participants responding with the most positive response (e.g., yes, definitely) to all composite items were classified as reporting high-quality communication or interpretation; all others were categorized as reporting low quality. For each composite, if 2 or more items were missing, the composite was scored as missing.

Parent-reported diagnoses were compared to chart-abstracted discharge diagnoses by 2 investigators (KCL and CKG), blinded to group assignment. Using a previously described method,³³ authors independently classified each pair of diagnoses as correct, incorrect, or vague/incomplete, based on whether a follow-up provider would reasonably know the diagnosis based on the parent-provided information. For example, for a child with bronchiolitis, “a virus in the lungs” was considered correct, “a virus” vague, and “asthma” incorrect. Disagreements were reviewed until consensus was achieved. The weighted kappa statistic for inter-rater reliability was 0.51, indicating moderate agreement.³⁶ For analysis, responses were dichotomized as correct versus incorrect/vague/incomplete.

Parental report of ad hoc interpretation, English without an interpreter, and Spanish without an interpreter were coded as lapses in professional interpreter use. For the composite, “never” to all 3 categories was classified as “never”; “frequently” or “always” in any category was classified as “frequently”; and the remainder were grouped as “sometimes.” For patients with a Spanish-proficient provider (12.5%), reported Spanish use was not considered in composite coding, as we could not know whether the Spanish was used by the certified provider or another non-certified provider. In 3 cases, parents reported receiving more than one interpretation modality “always”—these responses were considered to represent poor question comprehension and were excluded from composite calculation.

A subset of study encounters (n=50) were video-recorded. We validated parental ability to report interpretation modality by comparing parent report to observed use for the 29 video-recorded encounters for which a parent reported receiving a particular modality “always” (telephone=14, video=15). Parent report of “always” using a particular modality (e.g., video) was deemed correct if no other modality use was observed (e.g., telephone or in-person).

Analysis

All analyses were conducted as intention-to-treat, based on assigned interpretation modality. Patient, parent, and ED characteristics were examined using chi-square analysis and Student’s t-test by assigned study group to evaluate the effectiveness of randomization.

All outcomes were evaluated by assigned interpretation modality in bivariate analysis, using chi-square for categorical outcomes and Student’s t-test for continuous outcomes.

In a sensitivity analysis, multivariate logistic and linear regressions were used to evaluate relationships between study outcomes and assigned modality, controlling for baseline characteristics that were found to be unbalanced between groups after randomization. Based on the a priori analytic plan, characteristics that differed between groups with a P-value < .1 were included in the sensitivity analyses.

A priori power calculations determined that 208 completed surveys would provide >80% power to detect small to medium effects in communication²⁸ and interpretation quality,³² and medium to large effects in diagnosis comprehension³³ and lapses in professional interpretation.³⁷

This study was approved by the Seattle Children’s Hospital Institutional Review Board.

Results

During 25 weeks of enrollment, 336 Spanish-speaking families were screened, 290 (86%) were eligible, and 249 (86% of eligible) consented to participate (Figure 1). Consent rate did not vary by assigned modality, but eligibility did, with significantly more families deemed ineligible on telephone days (20% telephone vs 8% video, P=.001). The most common reason for ineligibility was provider report of clinical indications requiring in-person interpretation. Loss to follow-up was similar between groups (15% telephone vs 18% video, P=.58).

Figure 1. Study enrollment and retention.

CONSORT diagram of study enrollment and retention

Study groups were balanced with regard to ED, parent, and child characteristics (Table 1). The only difference approaching significance was parental report of “not speaking English at all” (18% telephone, 30% video, p= .07).

Table 1.

Participant Characteristics, based on assigned remote interpretation modality

	Telephone Arma	Video Arma	P-value
Patient characteristics
Male gender	57% (61/107)	53% (75/142)	.51b
Age (mean, SD)	5.5 (4.4)	6.1 (5.4)	.26c
PMCA
No chronic conditions	79% (84/107)	77% (110/142)	.64b
Non-complex chronic	12% (13/107)	10% (14/142)
Complex chronic	9% (10/107)	13% (18/142)
Private insurance	2% (2/106)	1% (1/142)	.34b
ED visit characteristics
Weekday ED visits	84% (90/107)	84% (116/138)	.99b
Triage level d
2	5% (5/107)	9% (13/142)	.52b
3	49% (52/107)	49% (7/142)
4	40% (43/107)	35% (49/142)
5	6% (7/107)	7% (10/142)
NEDOCS (mean, SD)e	62 (26)	60 (21)	.44c
Spanish-proficient provider	15% (16/107)	11% (15/141)	.31b
Admitted to hospital from ED	16% (17/107)	15% (21/142)	.81b
Parent characteristics
Parent reported previous experience with current medical problem	33% (29/89)	31% (35/114)	.94b
Parent born in Mexico	81% (73/90)	84% (97/115)	.54b
Parent years in US (mean, SD)	11.6 (5.3)	11.2 (4.5)	.56c
Parent speaks English
Not at all	18% (16/89)	31% (36/115)	.07b
Not well	64% (57/89)	58% (66/115)
Well	18% (16/89)	11% (13/115)
Parent highest education
8th grade or less	44% (39/89)	37% (42/114)	.29b
Some high school	24% (21/89)	31% (36/114)
Graduated high school or GED	19% (17/89)	24% (27/114)
Some college or more	13% (12/89)	8% (9/114)
Annual family income (US dollars)
<$15,000	22% (20/91)	23% (27/117)	.19b
$15–30,000	50% (45/91)	36% (42/117)
$>30,000	15% (14/91)	25% (29/117)
Did not respond	13% (12/91)	16% (19/117)

SD indicates standard deviation; PMCA, Pediatric Medical Complexity Algorithm²³; ED, emergency department; NEDOCS, National Emergency Department Overcrowding Score; GED, general equivalency diploma

^aDenominators vary by characteristic, as some are derived from hospital administrative data and some required survey completion

^bChi-squared

^cStudent’s t-test

^dTriage level assigned in ED to indicate illness severity. Patients with triage level of 1 (highest acuity) were not eligible to participate

^eNEDOCS score indicates ED crowding relative to staff and rooms available and was recorded at the time of family enrollment in the study

Parent-reported adherence to study modality varied significantly by assigned group, with greater use of the assigned modality on video days (93% vs 79%, P=.004), and greater use of the non-assigned remote modality on telephone days (34% vs 15%, P=.002) (Figure 2). In our internal validation comparing parent report to the video-recorded encounters, parents who reported “always” receiving a particular modality were correct in 86% of cases (25/29).

Figure 2.

Parent-reported frequency of communication methods by study arm. Only Frequently/Always responses shown for assigned remote modality; all others show Frequently/Always and Sometimes. Opposite remote modality indicates use of telephone for video-assigned families, and use of video for telephone-assigned families.

Parents assigned to video interpretation correctly named their child’s diagnosis significantly more often than parents assigned to telephone interpretation (75% vs 60%, P=.03; Table 2; Table 3). Over one-third (37%) of parents in each group reported “never” experiencing a lapse in professional interpretation, with no between-group difference. Telephone-assigned parents were significantly more likely to report “frequent” lapses in professional interpretation, though overall levels were low (8% vs 2%, P=.04). Groups did not differ with respect to parent-reported quality of communication or interpretation. ED LOS for admitted and discharged patients, ED charges, and minutes of remote interpretation received did not differ between groups. Mean charges per patient for video interpretation were twice those for telephone interpretation ($61 vs $31, P<.001).

Table 2.

Outcome measures, by assigned remote interpretation modality

	Telephone Arm	Video Arm	P-value
Survey-based measures	% (n)	% (n)
Diagnosis comprehension	60% (52/87)	75% (85/114)	.03a
Frequent lapses in professional interpreter usec	8% (7/91)	2% (2/117)	.04a
No lapses in professional interpreter usec	37% (34/91)	37% (43/117)	.93a
High quality communicationd	83% (74/89)	87% (101/116)	.43a
High quality interpretationd	47% (42/89)	50% (58/116)	.69a
Would recommend modality to a friend	78% (70/90)	85% (98/116)	.22a
Would recommend interpreter to a friend	93% (83/89)	92% (105/114)	.76a
Interpreter listened carefully	98% (86/88)	96% (109/114)	.42a
Adherence to assigned modalitye	79% (68/86)	93% (106/114)	<.001a
Utilization measures	Mean (SD)	Mean (SD)
ED LOS for discharged patients, minutes	168 (83) (n=90)	162 (94) (n=121)	.61b
ED LOS for admitted patients, minutes	290 (114) (n=17)	310 (109) (n=21)	.59b
ED medical charges, US dollarsf	$1290 (956) (n=106)	$1245 (982) (n=142)	.72b
Billed minutes of assigned modality	36 (24) (n=101)	37 (22) (n=138)	.76b
Billed minutes of any remote modality	40 (27) (n=101)	39 (22) (n=138)	.68b
Charges for assigned interpreter modality, US dollarsf	$31 (20) (n=101)	$61 (36) (n=138)	<.001b

^aBased on chi-squared

^bBased on Student’s t-test

^cCommunication without professional interpretation is a composite of parent responses regarding frequency of provider use of the following: ad hoc interpretation, English without an interpreter, and Spanish without an interpreter (unless a patient’s provider was certified proficient in Spanish)

^dScored using top-box scoring, in which encounters receiving the most positive response for all questions within the composite (see Appendix for text of questions) are scored as high quality, and all others are scored as not high quality

^eBased on parent report of receiving the assigned interpretation modality “frequently” or “always”

^fInterpretation charges are not billed to families and are not included in the ED medical charges

Table 3.

Frequency of diagnosis categories for enrolled patients, with example parent- and clinician-reported diagnoses for the most common categories. Categories are listed in order of descending frequency.

Diagnosis categorya	N (%)	Example parent and clinician diagnoses
		Codeb	Parent-reported diagnosisc	Clinician diagnosisd
Viral gastroenteritis	24 (12)	Correct	A virus causing diarrhea and vomiting	Viral gastroenteritis
		Vague/Incomplete	A little air and fluid in the stomach. They did some tests and gave some medicines and the pain went down little by little	Viral gastroenteritis with possible mesenteric adenitis
		Incorrect	Inflammation in the appendix	Diarrhea and resolved abdominal pain, due to likely viral gastroenteritis
Viral respiratory infection	24 (12)	Correct	It was an infection by a virus and it would probably continue to bother her for 44 to 72 hours, but they couldn’t give antibiotics	Viral upper respiratory infection
		Vague/Incomplete	It was like dehydration, it wasn’t serious	Fussiness due to upper respiratory tract infection
		Incorrect	It was a bacteria that was going to go away in 2 weeks	Viral pharyngitis
Injury	23 (11)	Correct	He has a sprained ankle	Sprained ankle
		Vague/Incomplete	Muscle pain	Foot sprain
Viral illness--unspecified	18 (9)	Correct	He had a virus which caused stomach pain	Fever, abdominal pain, and rash, likely due to a virus
		Vague/Incomplete	They did x-rays, blood tests, and an ultrasound which all came out well but the blood test came back a little high	Fever, abdominal pain, sore throat, and mouth sores, likely coxsackie virus, with concern for pancreatitis
		Incorrect	Pneumonia	Vomiting in the setting of a likely viral infection
Rash	14 (7)	Correct	He had allergies, but they didn’t figure out to what, but he got a lot of hives on his body	Urticaria without a clear trigger
		Vague/Incomplete	Allergies	Urticaria, likely due to recent virus
		Incorrect	Something like a virus in his throat and that what he had on his skin is like fever--I don’t know--and that it was because he went swimming in the lake	Streptococcal scarlet fever and cercarial dermatitis (swimmer’s itch)
Other:
Closed head injury	8 (4)
Skin/soft tissue infection	8 (4)
Otitis media	7 (3)
Abdominal pain	6 (3)
Asthma	5 (2)
Other diagnoses	57 (28)

^aDiagnosis categories are for presentation purposes only and were not used in the analysis; in the analysis, parent-reported diagnoses were compared to the more detailed clinician diagnoses, as listed in the table

^bBased on whether a follow-up provider would likely know the clinician diagnosis from the parent’s report, as determined by 2 investigators blinded to study group.

^cRecorded verbatim in Spanish during the telephone follow-up survey and translated into English by a bilingual investigator, then verified by a bilingual research assistant. Analysis was conducted by bilingual investigators, with both English and Spanish versions visible. Several responses were edited for brevity.

^dAbstracted from the clinician note in the medical record by an investigator blinded to study group

In the multivariate sensitivity analyses, controlling for the only unbalanced baseline characteristic (parent-reported English proficiency), the relationships between study arm and outcomes remained unchanged (data not shown).

Discussion

In this pragmatic randomized trial comparing telephone and video interpretation, video interpretation led to better parental ability to name their child’s diagnosis and a lower likelihood of frequent lapses in professional interpreter use. Study groups had comparable parent-reported communication and interpretation quality, ED LOS, charges, and minutes of remote interpretation. This suggests that video interpretation may improve parental comprehension and decrease opportunities for medical errors, ultimately improving healthcare outcomes. From the perspectives of family experience and ED flow, however, both remote modalities worked well.

Our finding that video interpretation led to greater diagnosis comprehension suggests that communication may be more effective when the interpreter, family, and provider can see one another, allowing the interpreter to understand and relay non-verbal aspects of the encounter, and better approximating the experience of in-person interpretation. However, comprehension was low in both groups, demonstrating the need for ongoing improvements to communication, beyond selection of interpretation modality. The diagnosis concordance rates in this study were similar to those we described among LEP parents of hospitalized children,³³ but lower than those reported in a previous ED-based study,³⁸ possibly due to methodological differences in determining concordance.

The lack of a difference by study modality in parent-reported communication and interpretation quality may in part be due to the known tendency among Hispanics to prefer extreme Likert-scale responses, leading to ceiling effects.³⁹ However, use of top-box scoring should mitigate those effects. Thus, the lack of difference may alternatively reflect that both telephone and video methods work equally well from families’ perspectives, and that professional interpretation itself is the crucial element.

In nearly two-thirds of study encounters, parents reported at least some lapses in professional interpretation. While the practice of “getting by” without professional interpretation is common,^15,40 the high rates we observed were unexpected in a study of interpreter modalities and are concerning. Video interpretation led to fewer lapses in interpreter use, which may explain the better parent comprehension and may have implications for patient safety, given the link between language barriers and serious safety events.^5–7 The reduced lapses with video interpretation may be due to provider preference for this modality.¹⁸

Cost remains an important consideration when addressing language needs in healthcare settings. We found no difference by assigned modality in ED LOS, charges, or minutes of remote interpretation. Video interpretation was approximately twice as expensive; nevertheless, the relatively small difference between groups ($30/patient) may be a good investment to improve parent comprehension and lower the risk of communication-related adverse events.

This study was strengthened by its pragmatic design, assessing effectiveness of remote interpretation in real-world circumstances. The randomization to study condition by day approximated the conditions in most clinical settings, where a single remote modality is available, and providers decide how to communicate with families within those conditions. The study also included a wide range of nurses and providers with varying experiences with interpreter modalities, along with patients and families with diverse conditions and health care experiences. The study design and liberal inclusion criteria enhance the generalizability of the findings. Our use of diagnosis comprehension as an objective outcome of communication reduced the risk of response bias due to social desirability.

This study has some limitations. As a single-institution study, results may have been influenced by institutional culture or hospital facilities (e.g., the telephone and video equipment). Interpreter modalities were provided by different vendors, with separate professional interpreter networks. However, both vendors employ >100 Spanish interpreters, using similar hiring processes and criteria (based on review of the companies’ websites and personal communications with managers), which decreases the chance of systematic differences. Differences in provider-reported eligibility on telephone compared to video days may reflect provider dislike for telephone interpretation, leading providers on telephone days to declare a patient ineligible so they could use an alternate method. However, study groups were well-balanced, so eligibility differences were unlikely to have impacted our results. We could not blind clinical staff or families to assigned study group, but investigators were blinded during outcome ascertainment. Finally, we gathered some demographic information, such as English proficiency, from parent survey responses. Multiple caregivers are often present during pediatric ED visits and characteristics of caregivers not surveyed may have been unbalanced between groups. However, the child’s primary caregiver was surveyed most often and their personal experiences and attributes are most likely to impact the child’s care.

Assignment to video interpretation led to improved diagnosis comprehension among parents of children treated in a pediatric ED. Video-assigned families were also less likely to report frequent lapses in professional interpreter use. Parent-reported communication and interpretation quality, ED LOS, and charges did not differ by interpretation modality, suggesting that both work well for families and for patient flow. While video interpretation was more expensive, its use led to better parent comprehension and may decrease the risk for communication-related safety events. Expanding access to video interpretation may improve the quality and safety of care for LEP patients and families.