Qualitative/Quantitative/Mixed Methods Minimizing Variability in Interpretation Modality Among Spanish-Speaking Patients With Limited English Proficiency Hispanic Health Care International 2020, Vol. 18(1) 32-39 ª The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1540415319856329 journals.sagepub.com/home/hci Seiichi Villalona, MA1,2 , Christian Jeannot, MD, MPH3, Mery Yanez Yuncosa, BS, BA2, W. Alex Webb, MSc2, Carol Boxtha, BS4, and Jason W. Wilson, MD, MA2,3 Abstract Introduction: Provider–patient language discrepancies can lead to misunderstandings about follow-up care instructions and decreased adherence to treatment that may contribute to disparities in health outcomes among patients with limited English proficiency (LEP). This observational study aimed to understand how emergency department (ED) staff went about treating patients with LEP and examine the impact of consistent interpretation modality on overall patient satisfaction and comprehension. Method: A cross-sectional study was conducted among Spanish-speaking patients with LEP presenting to the ED. A survey was administered at two different time points: after patients provided their history of present illness and after the patient received information regarding follow-up treatment. Results: Analysis of average visual analog scale (VAS) scores by consistency of interpretation suggested higher overall scores among participants that received care via the same communication modalities during both the history of present illness and at disposition, when compared with patients that did not. At both time points, videobased interpretation was associated with higher VAS scores in comparison to other modalities, whereas phone-based interpretation was associated with lower VAS scores. Conclusion: Providing consistent modes of interpretation to patient’s with LEP throughout their ED visits improved their overall satisfaction of care provided and understandings of discharge instructions. Keywords Hispanic Americans, limited English, Spanish, acute care, emergency department Emergency departments (EDs) can be safety nets for many patients who otherwise have limited access to care (Allen & Cummings, 2016). Across patient populations, individuals with limited English proficiency (LEP) are at an increased risk of experiencing medical errors due to communication barriers and are more likely to report less satisfactory interactions with medical providers (Flores & Ngui, 2006). Effective patient– provider communication is particularly important in explaining the potential causes of a patient’s present condition, details of a diagnosis, treatment options, and potential risk factors of all possible courses of action (Flores, Abreu, Barone, Bachur, & Lin, 2012; Juckett & Unger, 2014; Meuter, Gallois, Segalowitz, Ryder, & Hocking, 2015; Neill, Irwin, Owings, & CathcartRake, 2017). Broadly speaking, language barriers in health care have been identified as an important determinant of overall poorer health outcomes among patients who speak a different first language than their medical providers (Meuter et al., 2015). Language discrepancies between patients and providers present communication barriers that can lead to misunderstandings of follow-up care instructions and adherence to treatments, which contribute to disparities in health outcomes among linguistic minority patients (Flores, 2005; Silva et al., 2014). These barriers can lead to communication errors, with significant medical consequences (Flores et al., 2012; Green & Nze, 2017; Wasserman et al., 2014) as well as increased psychological stress for patients who are already anxious about a health condition or set of symptoms. The Pew Research Center estimates the Spanish-speaking population in the United States totals 37,000,000, of which 73% speak Spanish as their primary language at home (Krogstad, Stepler, & Lopez, 2015). These findings make Spanish the most spoken, non-English language in the United States and the primary language used to communicate among immigrants (60%) as well as individuals older than 30 years of age (Gonzalez-Barrera & Lopez, 2013). Demographic studies additionally suggest that one third of the total Hispanic/Latino 1 Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA University of South Florida, Tampa, FL, USA 3 Tampa General Hospital, Tampa, FL, USA 4 Moffitt Cancer Center, Tampa, FL, USA 2 Corresponding Author: Seiichi Villalona, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane West Piscataway, NJ 08854, USA. Email: svillalona@mail.usf.edu 33 Villalona et al. population is not functionally proficient in English, with women, adults 65 years or older, and individuals with less than secondary education as the major subgroups among this population (Krogstad et al., 2015). Spanish-speaking individuals constitute the most common patient population with LEP in the United States and comprise a significant proportion of the patient populations that are seen in EDs (Flores & Ngui, 2006; Sandoval et al., 2010). An area of academic interest pertaining to patients with LEP has been to employ controlled trial studies in determining best practices for provider–patient communication (Crossman, Wiener, Roosevelt, Bajaj, & Hampers, 2010; Lee et al., 2018; Lion et al., 2015; Locatis et al., 2010). These studies have been aimed at comparing the effectiveness of interpretation modalities (ranging from audio/phone-based and visual/ video-based services to professional translators and ad hoc interpretation by either ED staff or patient family members) on overall patient satisfaction, health literacy, and comprehension. Despite literature consensus in recognizing the importance of language throughout the clinical encounter, no distinct modality has consistently stood out as the best evidenced-based practice in terms of communicating with Spanish-speaking patients (Joseph, Garruba, & Melder, 2018). A possible explanation for this could be due to what Chan et al. (2010) discuss in their review of the utilization of interpreter services in ED settings, where the authors point out that bridging language barriers when treating individuals with LEP ultimately depends on the local patient population and the accessible communication resources in individual hospitals (Chan et al., 2010). Even among EDs with multiple communication modalities, the use in clinical practice highly varies, is infrequent, and inconsistent (Crossman et al., 2010; Diamond, Schenker, Curry, Bradley, & Fernandez, 2009; López, Rodriguez, Huerta, Soukup, & Hicks, 2015; Mayo et al., 2016). Part of this variability in use relates directly to the daily unpredictability and continually shifting nature of ED clinical care, as well as preferences of individual health care providers. Purpose The predominant use of controlled trial approaches to study patients with LEP in these clinical settings often contrasts the continually fluctuating day-to-day operations of EDs. This inherent variability of ED clinical care elucidates how approaches to communication between health care staff and patients with LEP are more often inconsistent throughout the length of an ED visit. To the best of our knowledge, few studies have specifically explored the impact of variability and consistency in communication modality on the satisfaction and comprehension of patients with LEP. This observational study sought to address this gap in knowledge by examining how ED staff went about clinically evaluating and treating patients with LEP throughout nonurgent care visits. A cross-sectional approach was employed through surveying consented patients at two different time points throughout their ED care: (1) after initial encounter in triage areas and providing ED staff with the history of present illness and (2) at disposition after the patient received information regarding follow-up treatment or continued care from the provider overseeing their care. Method Study Site Florida has the seventh highest share of residents with LEP, which is proportionally higher than the overall distribution of this population across the country (U.S. Census Bureau, 2016). The Tampa–St. Petersburg–Clearwater metropolitan area is composed of about 368,000 Hispanic/Latino residents with an estimate that 272,300 identify Spanish as their primary language at home (Krogstad et al., 2015). County-level assessments suggest that in terms of access to care, this patient population was proportionally less likely to have a primary care physician, have higher uninsured rates (14%), and a significantly higher proportion of individuals reporting an inability to seek medical evaluation within the past year due to health care costs (Florida Department of Health, 2017). Health assessments comparing similar counties (Broward, Miami-Dade, Orange, and Palm Beach) in terms of size, demographics, public health resources, and funding per capita indicate Hillsborough County to have proportionally higher age-adjusted mortality rates due to chronic health problems such as cardiovascular (214.7 per 100,000) and hypertensive (21.4 per 100,000) diseases (Florida Department of Health, 2016). Taking into consideration this demographic backdrop, this observational study was conducted in an urban ED at a Level-1 trauma center in west central Florida. Study Procedures Eligible participants were at least 18 years of age, identified Spanish as their preferred language of communication, and were triaged with a low emergency severity index. A low emergency severity index was used to identify patients presenting to the ED for evaluation of a nonurgent condition, defined as clinical encounters that did not require immediate medical attention and could have been safely delayed up to 24 hours for evaluation of symptoms or could have been treated in outpatient settings (Allen & Cummings, 2016). Patients were excluded if they had any past medical history of psychiatric/ mental health conditions that would interfere with the informed consent process. Patients who were either under the custody of law enforcement officials, pregnant, or presenting to the ED for evaluation of potential substance or alcohol use were additionally excluded from participating. Patients were screened for eligibility by one of the study team members and ED staff. Verbal informed consent was obtained from patients willing to participate in the observational study in order to minimize interference with the workflow of the medical team overseeing the patient’s care and facilitate rapport building. A Spanish consent form was reviewed with eligible patients and a copy was provided to each patient that outlined the purposes of the 34 project. This study was approved by the Institutional Review Board (Pro00029308) at the University of South Florida. A cross-sectional approach was utilized to survey consented patients (n ¼ 100) at two time points throughout their ED visit: (1) after the ED staff obtained a patient’s history of present illness and (2) at disposition after follow-up treatment or continued care information was provided to patients by the overseeing provider. The survey tool used was a modified version of multiple patient satisfaction surveys used for quality improvement reporting such as the Press Ganey patient satisfaction surveys and the Hospital Consumer Assessment of Health Care Providers and Systems. These survey tools are widely used in assessing patient experience and satisfaction in different health care settings. The survey questions were modified to include ordinal responses and a visual analog scale (VAS) as a way of operationalizing patient satisfaction in distinct ways. VASs allow patients to specify their level of satisfaction along a continuous line with two endpoints, each endpoint representing very low satisfaction and very high satisfaction. The use of VASs allows for quantification and facilitates more types of analyses. VASs have previously been employed in quality improvement research in health care settings (Stiffler & Wilber, 2015). Higher VAS scores represented positive perceptions and lower VAS scores represented negative perceptions. Trained bilingual team members administered the Spanish survey to all consented patients in either patient rooms or hallway treatment areas. Patients were categorically considered to have received interpretation by ED staff if medical, nursing, ancillary, or other administrative staff facilitated communication with some proficiency in Spanish. The Statistical Package for the Social Sciences version 24 (SPSS24) was used to analyze patient responses. Multiple Kruskal–Wallis tests were used to determine differences in average patient ratings of their experiences while being evaluated in the ED by modality of interpretation. Multinomial regression and correspondence analysis were additionally used to explore the relationships between patient experiences by interpretation modality. Subsequent Student’s t tests of independence were conducted on the VAS scores as a way to further compare differences by modality and consistency of interpretation at both time points during the ED visit. Results The average age of the surveyed patients was 51 years. Fiftyfour percent of the patients consented into the study were female and 65% of the total participants were surveyed in ED rooms. Kruskal–Wallis tests comparing the overall mean of individual questions and mean rank by modality of interpretation suggested significant differences, where video-based interpretation appeared to positively affect patient satisfaction, perceptions of ED staff concern, as well as overall awareness and understanding of their medical care in relation to other modalities (Table 1). This finding was further supported through multinomial regression analysis where patients who reported a highly satisfactory overall ED experience were Hispanic Health Care International 18(1) 1.5 times more likely to have received video-based interpretation (odds ratio ¼ 1.54, 95% confidence interval [1.17, 2], p < .01, model compared with the intercept, w2 ¼ 50.03, degrees of freedom [df] ¼ 4, p < .01, and a modest pseudo R2, Naglekerke ¼ 0.42; Table 2). Secondary to video-based interpretation were the average VAS scores when ED staff and family provided interpretation, where either modality appeared to influence different aspects of patient satisfaction, awareness, and comprehension. Correspondence analysis of overall patient satisfaction by interpretation modality revealed low inertia (degree of variability that can be accounted for) of 32%. Despite the low inertia, both dimensions (overall satisfaction and interpretation modality) in the correspondence analysis were significant (w2 ¼ 26.63, p < .01). The least amount of variability of overall satisfaction was observed among patients who received videobased interpretation. This video modality was generally associated with higher overall patient satisfaction. At the first time point following the initial assessment and history of present illness, the use of ED staff as a modality of interpretation was found to be associated with higher VAS scores when compared with the use of phone-based interpretation. This was observed in responses to perceptions on how seriously nurses (t ¼ 2.43, df ¼ 57, p ¼ .02) and health care providers took patient concerns (t ¼ 2.25, df ¼ 57, p ¼ .03), as well as the perceived amount of attention demonstrated by doctors for patient concerns (t ¼ 2.32, df ¼ 54, p ¼ .02). A similar observation was made at this time point where the use of family members as a means of communication was associated with higher VAS scores than phone-based interpretation. This was the case for the responses to the perceived amount of attention demonstrated by doctors for patient concerns (t ¼ 2.07, df ¼ 54, p ¼ .04). At disposition, the use of family members as a modality of interpretation was associated with higher VAS scores when compared with ED staff. This relationship was observed in response to the perceived amount of care demonstrated by the ED staff during a patient’s visit (t ¼ 2.28, df ¼ 17, p ¼ .04). An opposite association between these two modalities was observed in responses to how informed nurses (t ¼ 2.06, df ¼ 17, p ¼ .05) and doctors (t ¼ 2.55, df ¼ 17, p ¼ .02) kept patients about their care during the ED visit. The use of phone-based interpretation at disposition appeared to be associated with lower VAS scores when compared with the use of ED staff as a means of communicating with patients. This relationship was observed in responses to how informed nurses (t ¼ 2.28, df ¼ 40, p ¼ .03) and doctors (t ¼ 2.86, df ¼ 39, p ¼ .01) kept patients about their care during the ED visit, as well as the perceived amount of care demonstrated by ED staff (t ¼ 2.59, df ¼ 40, p ¼ .01). The use of phone-based interpretation was associated with higher VAS scores than instances where ED staff were used as a means of communication among responses to the clarity in understanding the information provided by doctors (t ¼ 3.13, df ¼ 42, p < .01). 35 Villalona et al. Table 1. Average Visual Analog Scale Scores by Modality of Interpretation. Video Phone Staff Family Overall mean n Modality Mean Modality Mean Modality Mean Modality Mean mean rank n mean rank n mean rank n mean rank 68.55 14 87.14 67.82 40 64.99 42.76 19 69.10 47.13 21 65.50 43.31 64.71 12 93.50 76.67 40 57.80 38.59 19 66.20 47.39 21 63.60 43.52 19.29 <.01 62.92 12 89.92 73.71 39 62.24 43.59 19 57.40 39.82 21 57.80 40.24 15.70 <.01 63.73 14 75.82 52.04 40 59.36 33.65 18 62.50 39.28 5 69.40 44.30 70.30 14 94.30 71.39 22 62.50 44.30 38 73.50 32.01 12 73.00 45.88 25.93 <.01 66.19 14 87.10 66.43 22 58.80 44.55 38 69.30 33.91 12 68.40 45.21 17.73 <.01 69.36 14 85.00 60.36 22 61.00 43.05 38 77.90 36.11 12 71.10 48.08 10.29 .02 64.11 14 83.20 62.07 22 58.30 46.95 38 64.00 34.61 12 65.60 43.67 13.03 .01 75.56 14 98.50 74.86 22 67.20 44.55 38 78.60 30.33 12 77.80 46.71 33.27 <.01 74.83 14 94.40 69.79 22 67.90 46.32 38 79.30 33.16 12 75.00 40.42 22.85 <.01 78.50 14 95.80 71.75 22 71.70 42.61 38 84.50 36.75 12 76.50 33.54 23.38 <.01 54.48 14 83.60 63.18 22 39.30 46.86 38 66.50 33.33 12 54.60 46.58 15.75 <.01 55.32 14 95.90 74.00 22 38.20 45.75 38 58.50 30.33 12 56.30 45.50 31.04 <.01 63.84 14 99.80 76.50 22 55.80 48.45 38 54.10 31.61 12 60.30 33.58 36.20 <.01 74.00 14 92.10 57.57 17 70.10 38.94 28 63.80 24.18 12 74.50 34.25 25.33 <.01 57.04 13 84.40 56.04 17 43.60 38.50 31 56.60 25.94 12 61.30 42.83 20.12 <.01 71.60 14 92.10 69.29 22 65.00 46.34 38 67.70 31.30 12 74.40 46.83 24.81 <.01 69.76 12 96.50 54.42 16 66.50 24.94 26 57.80 29.12 10 65.60 27.10 21.14 <.01 52.82 12 94.40 64.96 17 39.20 33.71 37 54.50 31.53 9 54.80 36.78 22.49 <.01 63.36 14 80.60 52.14 22 56.30 34.30 32 62.60 32.70 5 64.70 34.00 74.34 14 99.10 75.68 22 67.70 44.27 38 69.10 32.16 12 75.60 40.46 31.57 <.01 71.58 14 99.50 75.00 22 63.80 41.00 38 75.20 35.08 12 67.60 38.00 27.88 <.01 w2 p 9.59 .02 After history of present illness (HPI) How helpful was staff that first asked you about your condition? How was the waiting time in the waiting room? How was your waiting time before seeing a doctor? How helpful was the translation service? (at HPI) How much attention did the nurses show for your concerns? How concerned were the nurses for your privacy? How seriously did the nurses take your problem? How easy or difficult was it to understand the nurse? How much attention did the doctor show for your concerns? How concerned were doctors in treating you? How seriously did the doctor take your problem? 7.93 .05 After disposition How informed did the nurses keep you during your stay? How informed did the doctor keep you during your stay? How clear was it to understand the doctor? How was your family or friend treated? How informed did the staff keep your family/friend during your stay? How much did the staff care about you? How well was your pain controlled? How clear was the information given to you about caring for yourself at home? How helpful was the translation service? (at disposition) What is your overall rating of ED experience? How likely would you recommend our ED? Note. ED ¼ emergency department. 9.52 .02 36 Hispanic Health Care International 18(1) Table 2. Multinomial Regression of Overall Satisfaction Visual Analog Scale Scores by Interpretation Modality. Translation modality Video Phone Staff Family Overall satisfaction B p Exp. (B) 0.43 0.02 0.01 0.01 39.58 2.94 1.96 0.77 <.01 .52 .65 .79 1.54 0.98 0.98 1.01 95% CI for Exp. (B) [1.17, [0.94, [0.94, [0.96, 2.01] 1.03] 1.04] 1.06] Note. CI ¼ confidence interval. Figure 1. Modality of interpretation at different time points during emergency department visits. Sixty of the participants received consistent forms of interpretation at both time points, meaning the same modality was used during the history of present illness and at disposition. Technology-assisted interpretation appeared to be used more during the initial patient encounter at the history of present illness in comparison to communication at disposition where the use of ED staff was more frequent (Figure 1). Analysis of the average VAS scores by consistency of interpretation suggested higher overall scores among participants who received care via the same communication modalities during both the history of present illness and at disposition when compared with patients who did not (Table 3). This was observed in responses to how informed nurses and doctors kept patients during their stay, clarity in understanding follow-up care plans and information provided by doctors, how family members were treated and kept informed, perceived amount of caring demonstrated by ED staff, pain management, helpfulness of translation modality, and the overall rating of their ED experience. Discussion The results from this study support previous works that have identified video-based interpretation to be an effective modality in facilitating communication throughout the clinical encounter between health care providers and patients with LEP (Lion et al., 2015; Nápoles, Santoyo-Olsson, Karliner, Gregorich, & Pérez-Stable, 2015). Our analyses also revealed phone- based interpretation to be associated with lower VAS scores for most of the participant responses provided in comparison to the other communication modalities. Significant differences in mean VAS scores were observed when phone-based interpretation was used during the history of present illness and at disposition. At the first time point, participants reported lower VAS scores regarding how seriously the ED nursing and medical staff took their concerns when phone-based interpretation was used in comparison to when either staff or present family members were used in facilitating provider–patient communication. At the second time point, participants also reported lower VAS scores in terms of the perceived amount of care demonstrated by ED staff as well as how informed they felt the nursing and medical staff kept them throughout their stay. The differences between phone-based interpretation and the other communication modalities could be due to the less personalized feel of using remote telephonic technology throughout the clinical encounter (Estrada & Messias, 2018; Schenker, Lo, Ettinger, & Fernandez, 2008). Phone-based interpretation tends to be shorter in length of time (Locatis et al., 2010) and could impede providers from establishing rapport with this specific patient population because of the less fluid style of communication in comparison to having a videoconference interpreter or another person physically present (i.e., a bilingual staff or family member) (Price, Pérez-Stable, Nickleach, López, & Karliner, 2012). This same communication modality also limits the interpreter from conveying nonverbal language to the providers overseeing the patient’s care both while the patient is providing their history of present illness and providing feedback when a physical examination is being performed on them. Despite hindering the social aspects of provider–patient communication, the instances where phone-based interpretation appeared to be associated with higher VAS scores in comparison to when ED staff was used to interpret was in relation to understanding the information presented by health care providers at disposition. This difference could be due to what previous works have identified as common errors introduced during communication between health care providers and patients with LEP, where untrained ad hoc interpreters are more prone to introducing inaccuracies (Nápoles et al., 2015) because of omissions, additions, substitutions, editorialization, and false fluency that can result in the improper communication of what either party is attempting to convey (Flores et al., 2012). Our findings additionally demonstrated that the consistency in use of translation services could affect the care delivered to 37 Villalona et al. Table 3. Average Visual Analog Scale Scores by Consistency of Interpretation Modality. Survey questions How informed did the nurses keep you during your stay? How informed did the doctor keep you during your stay? How clear was it to understand the doctor? How was your family or friend treated? How informed did the staff keep your family/friend during your stay? How much did the staff care about you? How well was your pain controlled? How clear was the information given to you about caring for yourself at home? How helpful was the translation service? (At disposition) What is your overall rating of ED experience? How likely would you recommend our ED? Consistent Inconsistent interpretation mean interpretation mean t df p 92 92 85 74 79 85 69 79 <.01 <.01 <.01 .03 .01 .01 .06 <.01 w2 p 65.88 65.79 71.39 77.63 65.29 75.98 74.27 63.61 35.25 35.87 48.24 66.96 43.75 64.15 62.36 37.88 4.37 3.94 4.21 2.24 2.73 2.64 1.90 4.33 21.18 <.01 11.94 <.01 18.00 <.01 10.83 .03 7.04 .03 6.86 .08 3.41 .49 14.07 .01 65.25 80.01 78.25 58.80 64.52 61.79 1.17 73 .25 1.57 .46 3.90 87 <.01 22.53 <.01 3.18 92 <.01 10.16 .01 Note. ED ¼ emergency department. Spanish-speaking patients with LEP. Patients who received consistent means of interpretation at both time points (after history of present illness and at disposition) reported higher VAS scores when compared with those that received different modalities of communication throughout their ED visit. Significant differences were observed in responses to survey questions pertaining to interactions with ED staff, overall patient satisfaction, as well as comprehension of the status of their medical evaluation/ED treatment and follow-up care instructions (Table 3). Examining patterns by use of interpretation modality at both time points revealed differences in more frequent use of technology-assisted communication (i.e., video or telephone) at the history of present illness versus disposition, where there was more reliance of ED staff in facilitating communication (Figure 1). The disproportionate use of ad hoc interpretation from ED staff at the end of the patients’ visit could result in misunderstandings of diagnoses or follow-up care instructions in comparison to the use of technologyassisted communication. Certain limitations are worth noting about our observational study when considering new directions of future health research of Spanish-speaking patients with LEP. For starters, this study was conducted in one ED in a single urban metropolitan setting with a small sample size. This limits the generalizability of the findings across Spanish-speaking populations in different urban metropolitan counties or rural areas. Another limitation of this study was the inherent difficulty in categorizing ED staff as an ad hoc modality of interpretation. This is to say that not all members of the ED staff that interpreted for consented patients were functionally fluent in medical Spanish. Some of the staff that provided interpretation were either bilingual, partially proficient in conversational Spanish enough to “get by”(Diamond et al., 2009; Lion et al., 2015; Mayo et al., 2016), or fluent in Spanish but not a member of the clinical aspects of patient care with limited medical knowledge (such as registration personnel). ED staff was grouped together as a category of interpretation to compare this type of approach to other available modalities. To address these limitations, medical institutions could be given incentives to increase the proficient Spanish-speaking staff (Ortega, 2018). Conclusion In this observational study, video-based interpretation was associated with higher VAS scores that is consistent with previous findings. Phone-based interpretation was generally associated with lower VAS scores. The findings from this study contribute to a gap in current medical interpretation literature by specifically considering variability and consistency of communication modality as important factors that influence patient comprehension, awareness of treatment during their ED stay, and patient satisfaction. Providing this patient population with one consistent mode of interpretation throughout their ED visits significantly improved their overall satisfaction of care provided and understandings of discharge instructions. The findings from this observational study present important considerations for health care providers treating Spanishspeaking patients with LEP for nonurgent conditions in ED settings. First, video-based interpretation should be used by providers if this modality is available at their institution because of this approach’s facilitation of effective provider– patient communication. Second, the inherent unpredictability and continually shifting nature of this clinical setting can effectively act as a barrier for patient understandings of ED standard operations, their personal medical evaluation, and follow-up care. For these reasons, variability in communicating with the Spanish-speaking LEP patient population should be minimized and a consistent interpretation modality should be used. Improving these aspects throughout the clinical encounter could result in overall better health outcomes, connections to available outpatient follow-up care, and reduced repeat ED visits for similar nonurgent concerns (Chan et al., 2010; Flores, 2005; Lee et al., 2018). Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. 38 Hispanic Health Care International 18(1) Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was partially supported by the USF Health Division of Emergency Medicine Research TEAMHealth Scholars Program. ORCID iD Seiichi Villalona, MA https://orcid.org/0000-0003-2442-576X References Allen, L., & Cummings, J. (2016). Emergency department use among Hispanic adults: The role of acculturation. Medical Care, 54, 449–456. doi:10.1097/MLR.0000000000000511 Chan, Y.-F., Alagappan, K., Rella, J., Bentley, S., Soto-Greene, M., & Martin, M. (2010). Interpreter services in emergency medicine. Journal of Emergency Medicine, 38, 133–139. Crossman, K. L., Wiener, E., Roosevelt, G., Bajaj, L., & Hampers, L. C. (2010). 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