Abstract

Background: Limited English Proficiency (LEP) patients can pose a challenge to the administration of healthcare, particularly in unpredictable environments such as the prehospital setting.

Methods: An online survey regarding EMS responses involving LEP patients was distributed to 521 credentialed EMS providers in Marin County (EMT and paramedic).

Results: There were 109 respondents (21% response rate). It was common for our providers to interface with patients who do not speak English as a primary language and in such situations there are a variety of approaches to translation. A minority of respondents reported frequent challenges in accessing translation services.

Ninety-two percent (92%) of respondents indicated that their agency did not have a specific policy on addressing language barriers with patients and only 16% indicated their agency has a dedicated means of interpretation. Google translate was the most commonly cited as the preferred tool.

A majority of respondents felt that language barriers frequently caused a challenge in obtaining an adequate history and 26.6% indicated that a language barrier frequently caused a challenge when they encountered a possible against medical advice (AMA) patient.

Respondents noted that language barriers usually did not cause a challenge in providing appropriate care including adequate pain control however 27.5% reported that they thought they frequently/somewhat frequently contributed to an on-scene delay and 16.6% indicated the same for a transport delay.

Over ¾ of respondents (77%) were interested in learning more about how other EMS providers approached language barriers. There were 61 qualitative responses to an invitation to share best practices in addressing language barriers in the prehospital settings and the common themes in these responses were technological improvements (e.g., iPad with interpreter), education (e.g., language training) and system-focused (e.g., EMS agency policy on approach to patients with language barriers).

Conclusions: Language barrier patients are common in the prehospital environment and they represent both the potential for pitfalls and also room for improvement in communication strategies.

Background

Patients with Limited English Proficiency (LEP) present significant challenges in healthcare delivery, particularly in dynamic environments such as prehospital settings. According to the Department of Justice, LEP individuals are defined as those for whom English is not the primary language and who have a limited capacity to read, speak, write, or understand English.¹ In 2022, 8.4% of U.S. households reported speaking English “less than very well,” with Spanish speakers comprising the largest group at 5.3%.

Notably, Executive Order 13166 (“Improving Access to Services for Persons with Limited English Proficiency”) mandates that all federally funded healthcare providers evaluate their policies to ensure meaningful access for LEP individuals.¹ However, knowledge gaps and unclear policy guidelines persist within emergency medical services (EMS).

LEP individuals often lack reliable access to essential services such as translation and interpretation, and research on the impact of this lack of access on their medical care—particularly in EMS and emergency department (ED) contexts—is limited.

Available literature reveals intriguing trends: paradoxically, while LEP patients typically have less access to primary and preventive care, they often receive more intensive care in acute settings.

A recent scoping review encompassing 137 studies found that LEP individuals are significantly less likely to have a regular source of care or receive preventive services, and they are more likely to forgo necessary medical attention.²

Additionally, they often experience dispatch delays for both Advanced Life Support (ALS) and Basic Life Support (BLS) services.³

Conversely, studies indicate that LEP patients are more likely to be admitted to the hospital after an ED visit and are at an increased risk of readmission within 30 days.^2,4 They also tend to receive additional interventions and diagnostics (e.g., laboratory tests, intravenous fluids, lumbar punctures, intubation) in prehospital and ED settings.^5-7

Despite, or perhaps due to, this more aggressive care approach, LEP patients are also more likely to leave the ED without being seen or to discharge against medical advice (AMA).⁸

Such disparities in care and outcomes underscore the necessity of understanding the barriers and facilitators affecting LEP patients across all healthcare settings. Notably, evidence regarding the specific challenges faced by prehospital providers in treating LEP patients remains scarce.

In response to these identified gaps in understanding, the Marin County (CA) EMS Agency developed a provider-facing survey aimed at exploring the challenges EMS providers encounter when treating LEP patients and identifying strategies for improvement.

This discussion will present the results of our survey study and contextualize them within the existing body of research on this critical issue.

Methods

Setting

Marin County is served by a fire-based EMS system with three receiving hospitals. The EMS system utilizes electronic patient care reporting using ImageTrend®(Lakeville, MN). The yearly volume of EMS transports is 17,000 per year.

Marin is a suburban area with some rural communities and a population of 262,321 residents, 49,410 of which are Hispanic or Latino residents. Over 20% (23%) of Marin households speak a language other than English at home, approximately half the average proportion in the state as whole.

Spanish is the most common non-English language at 11.9%, followed by 5.6% other Indo-European languages and 3.9% Asian and Pacific Islander languages. This makes English and Spanish Marin county’s two threshold languages. Significantly, just 5% of the Marin county population is without health coverage.⁹

Survey

Our survey was distributed to all 521 Marin County credentialed EMS providers in Marin County (EMT and paramedic) via an emailed online survey link (Google Forms). The survey was open from 1/25/23 to 2/28/23 with four email invitations, three of them weekly reminders.

The survey was voluntary and consent implied. Due to the de-identified nature of the survey, it was re-sent to all paramedics, but providers were instructed not to complete a second time. Respondents were entered into a raffle for $50 gift cards which were distributed to three people after the survey was closed.

Respondents reported what agency they represented, approximately what percentage of their EMS responses are for a patient who does not have English as their primary language, what tools their EMS crews use to obtain a history from a LEP patient, and if their agency has a policy or a specific service in regards to language interpretation.

Respondents then ranked the frequency they experienced different challenges when providing care for an LEP patient, including accessing interpretation services, obtaining an adequate history, providing appropriate care, on-scene delay and transport delays, preventing patients from leaving against medical advice, and providing adequate pain control.

Survey questions regarding the benefits, concerns, and situation-specific utility of EMS telemedicine were answered using a 5-point Likert Scale. Respondents were also asked if they would like to learn how other EMS providers in the county address the issue of language barriers and invited to share any of their own ideas as to how best care for LEP patients.

Results

There were 109 responses to the survey, which represented a 21% response rate. The responses were from providers from 13 distinct EMS provider agencies in Marin County.

Approximately 60% of respondents reported that the frequency of providing emergency care for LEP patients was between 5-25% of their total responses. 30% of respondents reported the proportion of total responses as being less than 5%, 6.4% between 25 and 50%, and 2.7% greater than 50%.

Providers reported a range of translation strategies for LEP patients, the most commonly used being patient family/friends (reported by 89% of respondents), EMS team interpreter (71%) and phone apps such as Google Translate (47%).

The self-reported frequencies of encountering various challenges when providing emergency care for LEP patients are shown in Figure 1.

Of particular note, 69% of respondents reported sometimes or frequently experiencing difficulty accessing translation services; 80% reported sometimes or frequently

experiencing a challenge obtaining an adequate history; 51% reported sometimes or frequently experiencing a challenge with an on-scene delay, and 35% with a transport delay.

Finally, 53.7% reported sometimes or frequently experiencing more handling possibly preventable against medical advice (AMA) patients.

Approximately a third of respondents reported believing it to be sometimes or frequently more difficult to provide appropriate care for LEP patients.

We received 61 optional qualitative responses to our survey. The thematic domains with examples are summarized in Table 1.

Theme	Example	Example
Better Technology/Services	“Use a similar product that the hospitals are using that allows us to “FaceTime” an on call translator via the EMS iPads”	“Having a phone service translation would be ideal. Usually we have to deal with Spanish, but we have no way of translating other services”
Education	“County wide paid for language training for EMS providers to become fluent in other languages to best serve the community”	“A “Spanish for first responders class” would be a great tool for the county to put on that would possibly encourage more providers to gain better skills in this often overlooked issue”
Clinical Judgement	“Higher index of suspicion with less available information. More likely to transport to ensure proper assessment and care can be provided”	“People are people. Regardless of what language they speak the body works the same, and there is much we can learn just by doing a good assessment. Detailed histories on more complex matters are tough, but usually we can get by”
On Scene Problem-Solving	“What we have found helpful is having the Pt. contact a friend or family by phone who we can put on speaker phone to help translate”	“Utilizing your resources, whether it be family, friends, or colleagues (FD or PD), to best provide service where there is a language barrier”
Mindset	“Respect”	“Patience and compassion”
Policy	“County policy for translation services that are easily accessible”	“Encourage and incentivize employees to learn and maintain proficiency in additional languages”

Responses highlighted several key areas related to technology, translation services, education, clinical judgment, on-scene problem-solving, mindset, and policy.

Many respondents recommended implementing a tablet-based system similar to that used in local EDs, which would allow providers to access real-time video interpretation services. Additionally, several participants advocated for a county-run education program aimed at training providers to effectively communicate in the county’s other threshold language, Spanish.

Respondents also emphasized the need for caution when caring for LEP patients, citing the challenges posed by limited information. They stressed the importance of conducting thorough physical assessments to ensure comprehensive care. Another suggestion was the development of a countywide policy or set of guidelines regarding interpretation services to provide greater clarity in practice.

Finally, many responses underscored the significance of providers adopting a compassionate, patient, and respectful mindset when interacting with LEP patients.

Discussion

This qualitative study examined how EMS personnel in Marin County provide care for patients with LEP and the challenges they face in delivering prehospital care. A survey was distributed to all EMS departments in the county, yielding 109 responses (21% response rate) from 13 different agencies.

The majority of respondents reported that at least 5% of their EMS calls involved LEP patients. Key challenges identified included difficulty accessing interpretation services, obtaining comprehensive medical histories, on-scene delays, and managing patients who may leave AMA.

A recent qualitative study involving 39 EMS providers in King County, Washington, an LEP-dense urban area reported similar challenges.10 Notably, providers highlighted ineffective interpretation, cultural differences, distrust, high-stress situations (e.g., violent incidents), unclear acuity of conditions, and provider bias as barriers to delivering care for LEP patients.

Participants indicated that they often transported LEP patients to hospitals regardless of illness severity due to concerns about miscommunication and unrecognized health issues, revealing a disparity in care compared to EP patients.

Respondents mentioned strategies for improving care for LEP patients, including utilizing on-scene interpreters, relying on objective clinical findings, making conservative treatment and transport decisions, and fostering trust with patients.

They emphasized the importance of educating both LEP communities and EMS providers, as well as organizing community- EMS interactions to build trust and understanding.

Our research in Marin County validates and expands upon the findings from King County. Despite the distinct demographic context, we identified many of the same challenges and themes noted in the earlier study.

The issues reported in an urban environment were echoed in our wealthier, suburban setting, suggesting that language barriers are significant and problematic across various geographic and demographic contexts.

This implies a need for broad efforts to address these challenges, particularly in areas with high immigrant populations, where primary language often serves as a proxy for immigrant status.^11,12

Immigrants frequently experience reduced access to primary care, making them a vulnerable group for poor health outcomes.

Our findings align with existing literature indicating that LEP patients may be at risk of receiving either inadequate care or excessive interventions due to language barriers. Some respondents noted that LEP patients are more likely to decline transport AMA, while others suggested that, if transported, additional care and diagnostics might be performed due to communication challenges.

Prior investigation indicated that English proficient patients tend to report higher satisfaction with their triage experiences, while Spanish-speaking patients often feel misunderstood by nursing staff.¹³

This highlights the critical need for adequate translation and interpretation services to facilitate effective communication with LEP patients.

Moreover, LEP patients experience a higher rate of adverse events due to communication failures compared to their EP counterparts (52.4% vs. 35.9%).¹³ In hospital settings, several studies have found that LEP patients are more likely to be admitted after an ED visit or to be readmitted within 30 days, indicating disparities in outcomes following emergency care.²

Several respondents suggested developing a county-wide policy to assist EMS providers in addressing the challenges associated with caring for LEP patients. These recommendations were forwarded to the local EMS policy and procedure committee, leading to the

implementation of a new policy in April 2024. This policy provides non-binding guidance that highlights high-risk scenarios involving LEP patients (e.g., AMA situations) and outlines a hierarchy of recommended interpretation options.

Several respondents identified technological solutions as a powerful approach to mitigating language barrier challenges. Shortly after the completion of our survey, one local EMS provider agency implemented tablet-based audio/visual language line services, reporting successful integration and functionality.

With the rapid advancement of artificial intelligence, a wide range of cost-effective video and audio interpretation options are becoming available to providers. Additionally, agencies can anticipate increased regulation and scrutiny regarding their translation and interpretation tools.

For instance, California Assembly Bill 1638, passed in 2023 and effective January 1 2025, mandates that counties provide threshold language access in all public and patient-facing communications, including websites and protocols.

This survey study has several limitations. First, it was conducted in a geographically restricted area and focused on only two threshold languages.

In regions with a higher proportion of LEP patients or a greater variety of threshold languages, the challenges faced by EMS may be more pronounced. Consequently, the findings may not be generalizable to other locations.

Second, as a survey study, our results may be influenced by various biases. There may be social desirability bias, where respondents could have overestimated the frequency of their interactions with LEP patients or the challenges encountered, in order to align their responses with the study’s focus.

Furthermore, the voluntary nature of survey participation introduces selection bias; those who chose to respond may have had stronger opinions about the difficulties of caring for LEP patients or may have had more frequent interactions with this population. The 21% response rate further suggests potential limitations, as respondents may differ in their perspectives from non-respondents

Conclusion

While our study provides a rough idea of common challenges caring for LEP patients in Marin County, a next step could be conducting an objective study investigating these challenges.

Over a set period of time, EMS personnel could log every response that involves a LEP patient, and record whenever a challenge, in regards to accessing translation

services, obtaining an adequate history, providing appropriate care, on-scene delay, transport delay, handling a possibly preventable AMA patient, and providing adequate pain control is experienced is present.

We would then be able to get a concrete sense of what the greatest differences in care between EP and LEP patients are. Following that, the County could implement proposed solutions (ie, instituting video call interpretation devices in EMS vehicles) one at a time and record how such solutions impact the frequency of experiencing these various challenges. Investigation could then be done in regards to how this affects outcomes for LEP patients.

References

1. US Department of Justice. https://www.justice.gov/crt/executive-order-13166.

2. Twersky SE, Jefferson R, Garcia-Ortiz L, Williams E, Pina C. The impact of limited English proficiency on healthcare access and outcomes in the US: a scoping review. Paper presented at: Healthcare2024.

3. Meischke HW, Calhoun RE, Yip M-P, Tu S-P, Painter IS. The effect of language barriers on dispatching EMS response. Prehospital Emergency Care. 2013;17(4):475-480.

4. Rawal S, Srighanthan J, Vasantharoopan A, Hu H, Tomlinson G, Cheung AM. Association between limited English proficiency and revisits and readmissions after hospitalization for patients with acute and chronic conditions in Toronto, Ontario, Canada. Jama. 2019;322(16):1605-1607.

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9. US Census Bureau. https://data.census.gov/profile/Marin_County,_California?g=050XX00US06041. Accessed 9/7/24.

10. Stadeli KM, Sonett D, Conrick KM, et al. Perceptions of prehospital care for patients with limited English proficiency among emergency medical technicians and paramedics. JAMA Network Open. 2023;6(1):e2253364-e2253364.

11. Shelley D, Russell S, Parikh NS, Fahs M. Ethnic disparities in self-reported oral health status and access to care among older adults in NYC. Journal of Urban Health. 2011;88:651-662.

12. Ponce NA, Hays RD, Cunningham WE. Linguistic disparities in health care access and health status among older adults. Journal of general internal medicine. 2006;21(7):786-791.

13. Balakrishnan V, Roper J, Cossey K, Roman C, Jeanmonod R. Misidentification of English language proficiency in triage: impact on satisfaction and door-to-room time. Journal of immigrant and minority health. 2016;18(2):369-373.