What Language do you Prefer: Care of Patients with Limited English Proficiency (Jordan, 11/2020)

Limited English Proficiency (LEP) refers to anyone above the age of 5 who reported speaking English less than “very well,” as classified by the U.S. Census Bureau. Though most LEP individuals are immigrants, nearly 19 percent (4.7 million) were born in the United States, most to immigrant parents

            The US Department of HHS  defines LEP as “individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English.”

• Overall, the LEP population represents about 8% of the total US population ages 5 and older.

• Between 1990 and 2013, the LEP population grew 80% from 14 million to 25.1 million.

• California has a high proportion of people with LEP, almost 20%

• Sonoma County is higher than the national average, at 10.5-11.5%. The overwhelming majority of people with LEP in SoCo speak Spanish.

Medical interpreters are trained to interpret the spoken word, whereas translators work with written words. Although the two professions are often confused, they require different skill sets, with interpreters working in live situations.

Professional Medical Interpreter: An individual who has been assessed for professional skills, demonstrates a high level of proficiency in at least two languages and has the appropriate training and experience to interpret with skill and accuracy (certification varies).

A bilingual individual is a person who has some degree of proficiency in two languages. A high level of bilingualism is the most basic of the qualifications of a competent interpreter, but by itself does not ensure the ability to interpret. A bilingual employee may provide direct services in both languages but, without additional training, is not qualified to serve as an interpreter.

LEP impacts health.

• Lower likelihood of having a regular source of care
• Lower rates of preventive services (mammogram, colonoscopy, paps)
• Less likely to receive standard care for chronic medical illnesses
• Increased rates of medication complications
• Higher acuity of illness at presentation to the hospital
• Longer length of hospital stay

Medical Interpretation impacts health. 

• Access to medical interpretation improves patient experience
• Patients who need but do not get interpreters have a poor self-reported understanding of their diagnosis and treatment plan and frequently wish their provider had explained things better
• Ad hoc interpreters
•     misinterpret or omit up to half of all physicians’ questions
•     are more likely to commit errors with potential clinical consequences
•     have a higher risk of not mentioning medication side effects
•     ignore embarrassing issues (esp when children are interpreting)

Who are our patients at SSRRH?

• 13.8% of ALL patients prefer a language other than English
• 12.6% of ALL patients prefer Spanish
• In addition to Spanish, languages include Vietnamese, Khmer (Cambodian), Tigrinya, Laotian and Mandarin

How are we doing on interpreter use?

• In 2020, 88% of minutes used were Spanish
• 5.7% American Sign Language (ASL), 2% Cambodian, 2% Lao
• Some departments in the hospital use interpreters more than others. Specifically L&D has increased their use of interpreters over the last year due to intensive interdepartmental work and the placement of an interpreter device in every room.
• ED and Women's Services also have high number of minutes
• 

That being said, our documented of use of interpreters is pretty depressing.

See graphic below which shows which percentage of patients with LEP have documented use of interpreter at least ONE time on their chart.

Some questions to ponder with regards to interpreters:

• Identification of language preference: How should we ask? How do we document that we asked? How do we not miss this? 

• Ad hoc Interpreter: When is it appropriate to use a family member as interpreter? Who decides? How can we best use family?

• Medical error and/or adverse outcome: Who is responsible for communicating medical error or bad outcomes? How should that be done for LEP patients?

• Family Meetings, Family with mixed language status: How should complex conversations with interdisciplinary teams  and multiple family members be conducted? When should bilingual staff be used vs. VRI vs. both?

We need to cultivate the expectation that we use the interpreter just like we use hand sanitizer. Every. Single. Time.

Hospital Care of the Patient with Super Obesity (Kirchner, 11/11/2020)

Thanks to Dr. Julia Kirchner for a great Grand Rounds presentation this week on Super Obesity. Dr. Kirchner walked us through the myriad of ways in morbid and super obesity add physiological complexities to patient care and can seriously affect patient outcomes. The list of acute and chronic health implications of obesity is long, and the physiology is dense but also very interesting! In addition, don't forget the role that our explicit and implicit biases play into our care of obese patients.

For clarity, definitions of obesity:

Overweight: BMI >25-29.0

Obesity: BMI >30

Morbid or Extreme Obesity:  BMI >40

Super Obesity: BMI >50

• 9.2% of US population is severely obese
• Super obese is the fastest growing subgroup (maybe up to 1% of the population)
• Morbidly obese patients have increased ICU length of stay, with particularly well documented increased morbidity and mortality in obese trauma patients 
• In obese trauma patients: OR 1.4 mortality OR 1.8 in hospital complications (pneumonia, ARDS, UTI)
• Having a pulmonary diagnosis on admission increases with increasing BMI, and there is an increased need for non-invasive mechanical ventilation (NIMV)

Transport and transfer issues:

• stretchers with higher weight limits
• bariatric wheelchairs
• lift team
• adequate O2 for transport
• staff capability and training

Hospital Capacity issues:

• bariatric beds
• room layouts (doorways, hallways)
• bedside commodes, walkers
• lift equipment
• larger BP cuff (see Table 3), gowns, larger NIMV masks, longer needles
• imaging capabilities
• staff training

Physical Exam of obese patients, can be challenging: including heart and lung auscultation, abdominal exam and skin survey

Labs: 

• Obese patient tend to have higher baseline CO2
• We should use a higher BNP cutoff >54 (for BMI >40)
• Be aware of possibly inaccurate SCr (consider using a GFR calculator)

Imaging capabilities are often limited: 500lb weight max on CT scanner (30 inch maximum circumference), also higher rates of uninterpretable CXR (see image), challenges with ultrasound (difficult FAST exam, may need TEE)

Medications may need dosing modifications based on several factors, including weight, type of medication distribution, and renal and hepatic metabolism. Here is a link to a calculator for body weight calculations: idea/actual body weight and this is a really great resource for medication dosing in obesity called ClinCalc.

Okay, now for some serious physiology and pathophysiology

Respiratory issues are a BIG deal in the care of morbidly obese patients. Predisposing factors that make obese patients at risk for respiratory distress include: underlying chronic respiratory failure (that is why that elevated baseline CO2), difficulty with airway maintenance, higher baseline oxygen consumption, impaired central response to hypercapnia and hypoxia, and disordered gas exchange. 

• 42% of morbidly obese patients will require NIMV regardless of reason for admission
• AVOID SUPINE position (exacerbates everything), consider HOB elevated vs. reverse trendelenberg
• high PEEP may be indicated (starting 10, up to 20-25)
• care with fluids

Obesity hypoventilation is super common and important in our care of morbidly obese patients!

• BMI>30
• daytime hypercapnea (pCO2>45)
• disordered breathing during sleep
• all other dx excluded

Cardiac complications and Renal complications are common. Often these are acute on chronic. Take home points:

• Care with IV Fluids
• Consider ADJUSTED weight based dosing of IV fluids
• Have high suspicion for underlying renal and cardiac disease that may be undiagnosed but is very likely present. 
• care with nephrotoxic drugs
• low threshold for telemetry monitoring

lCVD=cardiovascular disease, IAP=intra-abdominal pressure, RV=right ventricle, LV=Left ventricle,

AKI=acute kidney injury, CO=carbon dioxide, AKI=acute kidney injury

And finally, how we treat patients matters!

Bias and Obesity:

"Weight appears to be the last acceptable bias", Rita Rubin writes in JAMA, article available here. The general population AND physicians show very high anti-fat bias and there is clear evidence of bias and discrimination against obese patients. There is an intersectionality with race and racism in this country that we need to be aware of, as there are higher rates of obesity in Hispanic and Black populations.  

T"Weightake home

Aftermath of the 2017 Wildfires: WHAT-now-CA* Study Results on Needs, Respiratory Health, and Mental Health (Hertz-Picciotto, 11/3/2020)

Great thanks to Dr. Irva Hertz-Picciotto and graduate student in public health, Diego Rivera, from UC Davis' Environmental Health Sciences Core Center for their update this week on the WHAT-now-CA* Study, Aftermath of the 2017 Wildfires. 

Their research team is following a cohort of people who lived through the Northern California fires of 2017 (including Tubbs, Nuns, Atlas, and Redwood Valley fires). They are studying both the short and long-term health impacts of these fires. The study features data from several counties, but the bulk of participants in their cohort are from Sonoma County.

Diego Rivera presented data on physical and mental health needs in 2018 and 2019, and Dr. Hertz-Picciotto presented health impact data, including respiratory and mental health, from year 1 (2018). 

(By Phoenix7777 - Own workData source: VIIRS-AF Active Fire Detections for CONUS - 10/07/2017 through 10/14/2017 0200 MDT)

For many of us who lived through the 2017 fires and the ensuing years of smoke, fire and more evacuations, the study findings are not terribly surprising: greatest reported needs in year 1 (2018) included: clean air, clean up, insurance help, finding housing, and help with refurnishing homes

• greatest reported needs in year 2 (2019) included: mental health, improved health, clean air
• people with underlying pulmonary issues experienced increased respiratory symptoms after fire and smoke exposure; some with no underlying lung disease also had respiratory symptoms
• mental health needs increased after the first year's needs (e.g. housing, clean up, insurance issues) were addressed.

Mental Health Impacts of Fire 

There is a paucity of literature on the impact of wildfires on mental health, but a few studies that have been reported recently from fires in Canada and Australia have found high rates of PTSD in the early months following a fire event, as well as high rates of generalized anxiety and depression.

In the WHAT-now-CA study, adults and children are asked to report rates of agitated behavior, anxiety and stress, depressed moods, difficulty concentrating, loss of appetite, trouble sleeping/nightmares, as well as substance use (including alcohol, smoking, vaping). 

Dr. Hertz-Picciotto's team found high rates of all of the above symptoms in fire survivors, extra high rates of anxiety and stress and trouble sleeping/nightmares in children. They also have found a very strong correspondence between an adult in the home having mental health symptoms and children having these symptoms. Mental health symptoms were more frequent in children ages 12-17 than younger children, also more frequent for those who have experienced multiple evacuations, and those whose home was destroyed. 

I look forward to seeing ongoing data collection from Dr. Hertz-Picciotto--  perhaps if we can have concrete data demonstrating the long-term physical and mental health impacts of these fires on our community, we can actually help to do something about them. . . and eventually heal.

Be safe all, the rains are close.

(*Wildfires and Health-Assessing the Toll in Northern California)