Adaptations to Interpreter Services for Hospitalized Patients During the COVID-19 Pandemic

To the Editor:

Coronavirus disease 2019 (COVID-19) has caused unprecedented changes in how health care institutions care for patients, disproportionately impacting the provision of health care among vulnerable populations. Furthermore, COVID-19 has highlighted health and health care disparities among minorities,¹ many of whom have language barriers or limited English proficiency (LEP).¹

Patients with LEP are defined as individuals who do not speak English as their primary language and have a limited ability to read, write, speak, or understand English.² A mandate compels US institutions accepting federal funding to provide interpretation services to patients with LEP enhancing bidirectional communication to mitigate disparities during health care interactions.³ It is vital during COVID-19 when populations with LEP are at increased risk of hospitalization to bolster trustworthy and accurate interpretation.

Mayo Clinic Rochester (MCR) needed to preserve personal protective equipment for frontline clinicians during COVID-19; therefore, in-person interpretation for patients with confirmed COVID-19 or COVID-19 rule-outs (positivity uncertain) was discontinued. Mayo Clinic Rochester continued normal interpreter practice for non–COVID-19 patients.

MCR is one of three institutions in the United States with an established program for providing complex care to international patients. Therefore, global travel restrictions impacting international patients’ ability to reach the United States substantially impacted MCR’s usual inpatient population. Additionally, with increasing COVID-19 regional referrals, MCR admitted larger numbers of Spanish-speaking patients with severe COVID-19.⁴ Similar to other institutions, MCR could not meet the demand for Spanish interpretation and increasingly adopted outside telephone and video interpretation to meet language needs (using programs such as Language Line and Insight).⁵

Before COVID-19, fixed tablets were installed in high-acuity patient rooms such as in the intensive care units, emergency department, and some acute care units to facilitate video consultations (using a program such as Intouch).⁶ Although not previously implemented, with COVID-19, video-enabled interpretation using Intouch was integrated into interpretation services connecting remote interpreters to inpatients. If an Intouch screen was not available in the patient’s room, interpreters connected via other applications such as Zoom or Insight to patient and family smartphones or hospital iPads.

With visitor restrictions, patients with LEP are isolated and susceptible to poor communication and lack of advocacy at the bedside while hospitalized. The role of the interpreter may assume broader significance including as an advocate, cultural broker, or simply a language-concordant person with whom a patient with LEP can relate more easily.⁷ Without being present, it is challenging for an interpreter to do this. To compound the issue of remote interpretation, it is also likely that with severe and critical illness admissions related to COVID-19, interpreters were required to conduct especially challenging conversations to guide complex decision-making and therapeutic management.

Several ethical considerations deserve attention. In-person interpretation is considered superior by most, especially during critical and serious illness conversations. Much work has examined clinician duty of care during pandemics. Although they are members of the health care team, interpreters do not have the same duty of care; however, they do have other ethical obligations to patients. Institutions have a responsibility to address the language needs of patients with LEP while simultaneously ensuring the safety of their employees, including interpreters. Empirical work to explore patient, caregiver, clinician, and interpreter experiences during COVID-19 would be helpful as institutions evaluate their responsibilities, quality of care, and systems issues that may impact the delivery of effective language services to patients with LEP.