Voice Translator to Improve Door-to-needle Times
According to the Center for Disease Control (CDC), cerebrovascular strokes are the fifth leading cause of death in the United States of America being responsible for 140,000 deaths each year (2017) Out of the estimated 795,000 people yearly diagnosed with a stroke, 87% are caused by a blockage of blood flow to the brain (Betts, et al., 2017). The risk for stroke increases with age, it is not limited to the geriatric population. In 2009, it is reported that 34% of stroke patients were under the age of 65 (CDC, 2017). Black and white populations are associated with higher association of death with AIS than the Hispanic population (CDC, 2017). Stroke cost the United States approximately 34 billion dollars each year and are the third leading cause for long-term disability, affecting 15-30% of patients (Baker et al., 2011).
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Patients suffering from an acute ischemic stroke (AIS) can present with mental confusion, slurred speech, facial droop, and extremity weakness. Currently, standard treatment is the intravenous administration of tissue plasminogen activator (tPA) within one hour of arrival to the emergency department and 3 hours of onset of symptoms, 4.5 hours in rare eligibility cases (Mowla, et al., 2017). Nationwide, emergency departments honor the “Golden Hour” rule initiating tPA treatment within one hour of arrival. Failure to identify symptoms and obtaining consent can result in potentially fatal or permanent damage.
Reducing language barriers can lead to faster identification of onset of symptoms, cognitive changes, a more accurate neurological examination, and better understanding of treatment benefits and risks. This purpose of this DNP project is to improve clinical outcomes by reducing communication delays in stroke identification and tPA administration in non-English speaking patients by using an interactive voice translator at time of arrival.
Background and Significance
Ischemic strokes are the result of a sudden onset from either a thromboembolic occlusion of a cerebral artery or from a vascular occlusion depriving the brain of oxygen (Baker et al., 2011). When the brain cannot adequately profuse oxygen, it triggers an inflammatory process that cascades and ultimately leads to irreversible tissue damage if not corrected. Tissue plasminogen activator (tPA), breaks down the clot and restores the blood flow to the brain preventing cell death and reducing long term damage (Baker et al., 2011). When administered within 3 hours of onset, patients are 10% more likely to have no significant disabilities after 3-6 months (Betts, et al., 2017).
Due to its mechanism of action, patients receiving tPA are at risk for bleeding and intracranial hemorrhage, most commonly within the first 7 to 10 days (Betts, et al, 2017). Exclusion criteria includes current use of anticoagulant or antiplatelet therapy with an international normalization ration (INR) >1.7 or thromboplastin (PT) > 15 seconds (Fugata & Rabistein, 2015). The National Institutes of Health Stroke Sore (NIHHS) was developed to identify cognitive and physical symptoms associated with a cerebrovascular occlusion. Patients scoring a 10 or higher are at an increased for long-term disability and overall poorer outcomes (Baker et al., 2011).
Determining which patients are candidates for drug therapy is heavily dependent on exclusion criteria, presentation, and time of onset. Ineffective communication between patients and medical providers can lead to failure to recognize symptoms, inaccurate stroke scores, and potentially fatal errors. A delay in treatment can lead to permanent neurological deficits, increased risk of death, decreased quality of life, and emotional and financial stress on patients and caregivers (Meuter, Gallois, Segalowitz, Ryder, & Hocking, 2015).
Health care symptoms are faced with the challenges of multicultural populations across the globe due to diverse cultural traits and different languages commonly leading to miscommunications and errors (Meuter, et al, 2015). Language barriers are considered one of the biggest challenges in providing proper care leading to major delays in initiating treatment due to the uncertainty of symptoms. Family members are often burdened with interpreting for their loved ones, but many still struggle to speak the national language leading to further delays and misdiagnoses (Nkulu, Hurtig, Ahlm, & Ahlberg, 2012) The inability to successfully communicate presents as an even more complex challenge for patients with AIS as their treatment is time sensitive with a small therapeutic window.
In the United States, >25 million English speaking people consider themselves to have a limited proficiency. With more than 350 known languages other than English fluently spoken in the United States, language barriers largely contribute to the 24.9% of delays in symptom recognition, obtaining consent, and determining onset of symptoms (Mowla, et al., 2017). Of the 87% of patients suffering from AIS, only 5% are administered tPA resulting in the immediate need for change (Kleinschnitz, Fluri, & Schuhmann, 2015).
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A study conducted by Erfe, Siddiqui, Schwamm, & Mejia (2016) found that patients who are not provided interpreter services are half as likely to receive appropriate treatment for AIS than English speaking patients resulting in poorer outcomes. The use of professional medical interpreters (PMI) lead to quicker identification of AIS and shorter door to needle times. Barriers affecting the success of PMI in improving included inconsistent use of translators due to perceived time constraints and department availability (Erfe, et al., 2016). The development and implementation of a voice interpreter would allow health care providers to speak into the phone or tablet with a direct translation for the patient reducing the time spent with a third-party translator.
Despite the use of professional medical interpreters and interactive phone translators to reduce language barriers, 30% individuals suffering from AIS aren’t meeting the American Stoke Association guidelines of door-to-needle time in under 60 minutes (Mowla, et al., 2017). Due to the highly sensitive therapeutic window, any delays in initiating treatment can result in permanent disability or death. AIS patients speaking a different language are at an increased risk for a delay in treatment and negative outcomes. Currently, there is a limited research to further investigate how voice translators can help improve door to needle time. The purpose of this quality improvement project it to reduce language barriers in recognition and initiation of treatment in AIS patients.
Does the use of implementing a voice translator at time of arrival to the emergency department improve door-to-needle time in non-English speaking adult acute ischemic stroke patients?
Aims and Objectives
The primary aim of this project is to successfully implement use of a voice translator to reduce language barriers at time of patient arrival and improve door-to-needle times. The objectives are as follows:
- Improve door-to-needle time for non-English speaking AIS patients
- To decrease language barriers delaying care
- Allow for a more accurate assessment of cognitive deficits and NIHS stroke score
- Decrease risks of long-term disabilities in AIS patients
- Improve quality of care provided to non-English speaking patients
- Bahnasy, W. S., Ragab, O. A., & Elhassanien, M. E. (2019). Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience. ENeurologicalSci,14, 68-71. doi:10.1016/j.ensci.2019.01.003
- Baker WL, Colby JA, Tongbram V, et al. Neurothrombectomy Devices for Treatment of Acute Ischemic Stroke [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; 2011 Jan. (Comparative Effectiveness Technical Briefs, No. 4.) Background and Objectives for the Systematic Review. Available from: https://www.ncbi.nlm.nih.gov/books/NBK52904/
- Betts, K. A., Hurley, D., Song, J., Sajeev, G., Guo, J., Du, E. X., . . . Wu, E. Q. (2017). Real-World Outcomes of Acute Ischemic Stroke Treatment with Intravenous Recombinant Tissue Plasminogen Activator. Journal of Stroke and Cerebrovascular Diseases,26(9), 1996-2003. doi:10.1016/j.jstrokecerebrovasdis.2017.06.010
- Erfe, B. L., Siddiqui, K. A., Schwamm, L. H., & Mejia, N. I. (2016). Relationship Between Language Preference and Intravenous Thrombolysis Among Acute Ischemic Stroke Patients. Journal of the American Heart Association,5(12). doi:10.1161/jaha.116.003782
- Fugate, J. E., & Rabinstein, A. A. (2015). Absolute and Relative Contraindications to IV rt-PA for Acute Ischemic Stroke. The Neurohospitalist, 5(3), 110-21.
- Kleinschnitz, C., Fluri, F., & Schuhmann, M. (2015). Animal models of ischemic stroke and their application in clinical research. Drug Design, Development and Therapy,3445. doi:10.2147/dddt.s56071
- Meuter, R. F., Gallois, C., Segalowitz, N. S., Ryder, A. G., & Hocking, J. (2015). Overcoming language barriers in healthcare: A protocol for investigating safe and effective communication when patients or clinicians use a second language. BMC Health Services Research,15(1). doi:10.1186/s12913-015-1024-8
- Mowla, A., Doyle, J., Lail, N. S., Rajabzadeh-Oghaz, H., Deline, C., Shirani, P., . . . Sawyer, R. N. (2017). Delays in door-to-needle time for acute ischemic stroke in the emergency department: A comprehensive stroke center experience. Journal of the Neurological Sciences,376, 102-105. doi:10.1016/j.jns.2017.03.003
- Nkulu Kalengayi, F. K., Hurtig, A. K., Ahlm, C., & Ahlberg, B. M. (2012). “It is a challenge to do it the right way”: an interpretive description of caregivers’ experiences in caring for migrant patients in Northern Sweden. BMC health services research, 12, 433. doi:10.1186/1472-6963-12-433
- Stroke Facts. (2017). Retrieved from https://www.cdc.gov/stroke/facts.htm
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