Lost in translation? Information quality in pediatric pre-hospital medical emergencies with a language barrier in Germany.

BACKGROUND: In pediatric medical emergencies, paramedics and emergency physicians must often rely on the information of third parties, often caregivers, to gather information. Failing to obtain relevant information may lead to misinterpretation of symptoms and subsequent errors in decision making and clinical treatment. Thus, children and/or caregivers with limited proficiency of the locally spoken language may be at risk for medical errors. This study analyzes logs of rescue missions to determine whether paramedics could obtain essential information from German-speaking and foreign-language children and their caregivers. METHODS: We conducted a secondary data analysis based on retrospective data on pediatric patients of four emergency medical services (EMS) stations in Northern Germany. We defined language discordance with communication difficulties as main exposure. We used documentation quality as outcome defined as existing information on (a) pre-existing conditions, (b) current medication, and (c) events prior to the medical emergency. Statistical analyses include descriptive statistics, simple regression and multivariable regression. As multivariable regression model, a logistic regression was applied with documentation quality as dependent variable and language discordance with communication difficulties as independent variable adjusted for age, sex and Glasgow Coma Scale (GCS). RESULTS: Data from 1,430 pediatric rescue missions were analyzed with 3.1% (n = 45) having a language discordance with communication difficulties. Patients in the pediatric foreign-language group were younger compared to German-speaking patients. Thorough documentation was more frequent in German-speaking patients than in patients in the foreign-language group. Pre-existing conditions and events prior to the medical emergency were considerably more often documented in German-speaking than for foreign-language patients. Documentation of medication did not differ between these groups. The adjustment of sex, age and GCS in the multivariable analysis did not change the results. CONCLUSION: Language barriers are hindering paramedics to obtain relevant information in pediatric pre-hospital emergencies. This jeopardizes the safe provision of paramedic care to children who themselves or their caregivers are not fluent in German language. Further research should focus on feasible ways to overcome language barriers in pre-hospital emergencies. TRIAL REGISTRATION: This is a retrospective secondary data analysis of a study that was registered at the German Clinical Trials Register (No. DRKS00016719), 08/02/2019.

[Immunosuppressed people's beliefs, expectations, and experiences with COVID-19 vaccinations : Results of a longitudinal study]. / Impfeinstellung, Erwartungen und Impferfahrung von Immunsupprimierten bei COVID-19-Impfungen : Ergebnisse einer Längsschnittstudie.

BACKGROUND: Immunocompromised people are less likely to be vaccinated, despite an increased benefit of many vaccinations in terms of benefit-risk assessment, including the vaccines against SARS CoV-2 (COVID-19). Attitudes, expectations, and experiences with previous vaccinations influence the decision to get vaccinated. OBJECTIVE: To explore the attitudes of immunocompromised people towards vaccinations in general and COVID-19 vaccination in particular and their experiences with COVID-19 vaccinations. MATERIAL AND METHODS: As part of the CoCo Immune study, immunocompromised participants were surveyed in the spring and summer of 2021 (1 November 2021-7 September 2021) using questionnaires. Initially, they were asked about their expectations concerning a COVID-19 vaccination and followed up about their experience after COVID-19 vaccination. In addition, sociodemographic data, general attitudes toward vaccinations and experiences with previous vaccinations were collected. Analysis was performed using descriptive and bivariate statistics. RESULTS: The 243 participants mostly approved vaccinations and expected the COVID-19 vaccination to be effective and well-tolerated. Women were more concerned about the safety of vaccinations and were more often worried about side effects. Older persons felt better informed than younger persons. Participants who reported subjective side effects of previous vaccinations were more skeptical about vaccinations as well as the government institutions that recommend vaccinations. They less often agreed with the statement "in retrospect, the COVID-19 vaccination has been harmless for me so far". DISCUSSION: The participants mostly expressed a positive attitude and anticipation towards COVID-19 vaccinations; however, the age and sex differences found suggest that there are different information needs which should be addressed when educating individuals about vaccinations or designing vaccination campaigns.

Obtaining patients' medical history using a digital device prior to consultation in primary care: study protocol for a usability and validity study.

BACKGROUND: With the help of digital tools patients' medical histories can be collected quickly and transferred into their electronic medical records. This information can facilitate treatment planning, reduce documentation work, and improve care. However, it is still unclear whether the information collected from patients in this way is reliable. In this study, we assess the accuracy of the information collected by patients using an app for medical history taking by comparing it with the information collected in a face-to-face medical interview. We also study the app's usability from the patients' point of view and analysing usage data. METHODS: We developed a software application (app) for symptom-oriented medical history taking specialized for general practice. Medical history taking will take place involving patients with acute somatic or psychological complaints (1) using the app and (2) verbally with trained study staff. To assess the perceived usability, patients will complete a questionnaire for the System Usability Scale. We will collect sociodemographic data, information about media use and health literacy, and app usage data. DISCUSSION: Digital tools offer the opportunity to improve patient care. However, it is not self-evident that the medical history taken by digital tools corresponds to the medical history that would be taken in an interview. If simply due to a design flaw patients answer questions about signs and symptoms that indicate possible serious underlying conditions 'wrong', this could have severe consequences. By additionally assessing the app's usability as perceived by a diverse group of patients, potential weaknesses in content, design and navigation can be identified and subsequently improved. This is essential in order to ensure that the app meets the need of different groups of patients. Trial registration German Clinical Trials Register DRKS00026659 , registered Nov 03 2021. World Health Organization Trial Registration Data Set, https://trialsearch.who.int/Trial2.aspx? TrialID = DRKS00026659.

[Impact of the COVID-19 lockdown on emergency medical service operations]. / Auswirkung des COVID-19-Lockdowns auf Rettungseinsätze.

Background: As a response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, extensive contact restrictions were imposed by law in Germany as in other European countries. The present study intends to clarify the effect of these restrictions on emergency medical service (EMS) operations. Materials and methods: Retrospective chart review of EMS operation protocols over the first 6 months of 2020 (n = 6668 rescue missions) in four rescue stations in eastern Lower Saxony (Germany). Description and statistical comparison of operations 6 weeks before the restrictions with an equally long period after the order of the restrictions ("lockdown"). Results: During the 6 weeks after the lockdown the frequency of rescue operations decreased by 17.7%. In particular, there was a 40.6% (n = 91) decrease of emergency cases with respiratory diseases, mainly due to a decline of pneumonia and exacerbated chronic-obstructive pulmonary disease (COPD). At the same time, patients' mean age increased with fewer patients under 65 years. There were no changes in the frequency of psychiatric disorders, deceased or injured patients, or refusal of treatment and transport. A total of 67 patients with suspected or confirmed SARS-CoV­2 infection (1.0%) were observed during this period. Discussion: EMS experienced a reduction of operations as a result of contact restrictions, although not as pronounced as was recently described for emergency rooms. This supports the hypothesis that the reduction is particularly evident in less severe cases and in younger patients. The reduction in pneumonia and COPD cases is striking. On the one hand, this could indicate that contact restrictions reduce the incidence of other respiratory infections and their impact on chronic respiratory disorders, but it could also mean that patients try to avoid hospital treatment.

[Usability of an app to overcome language barriers in paramedic care]. / Nutz- und Bedienbarkeit einer App zur Überwindung von Sprachbarrieren im Rettungsdienst.

Background: Communication with foreign-speaking patients in emergency medical situations can be challenging. In contrast to the inpatient setting, adequate interpreters are often not readily available in emergency services. At the same time, however, emergency situations require rapid assessment as the basis for any treatment. Materials and methods: A smartphone app that enables basic communication in 18 languages using 600 different phrases was piloted over a period of 6 months in four emergency medical service stations. Finally, the usability of the app was evaluated by the whole rescue service staff in a questionnaire study using the System Usability Score and the AttrakDiff questionnaire. Results: The response rate was 48.5% and n = 48 questionnaires were evaluated. The average age of the respondents was 36 years and almost two-thirds were male. The System Usability Score showed a median of 67.5 points, indicating borderline good usability. The AttrakDiff questionnaire showed pragmatic quality with an average of 0.69 (SD 0.86), hedonic quality with 0.59 (SD 0.58), and attractiveness (ATT) with 0.64 points (SD 0.83). The average values show satisfying results above the neutral limit of 0. It was observed that those rescue workers who stated that they had already actively used the app with patients rated the app significantly better. Discussion: Given that the app studied is a complex work tool, its usability and attractiveness were rated as overall good, and paramedics who had already used the app rated it even more positively. This could indicate a hesitancy by some paramedics to use a complex digital tool in complex situations that are already characterized by language and cultural barriers.

Overcoming language barriers in paramedic care: a study protocol of the interventional trial 'DICTUM rescue' evaluating an app designed to improve communication between paramedics and foreign-language patients.

BACKGROUND: It is essential for medical treatment that patients and medical staff can communicate about acute complaints, pre-existing conditions, and the treatment procedure. Misunderstandings can have far-reaching consequences, particularly in time-critical emergencies, which require rapid assessments and decision-making and in which interpreters are rarely available. In this study, we aim to develop a digital communication tool that is to help paramedics communicate with patients who speak hardly any or no German, to monitor its implementation, and to investigate its effect on communication between foreign-language patients and staff. Furthermore, a large amount of data on patients that are cared for in emergency medical services in Germany are collected for the first time. METHODS: To consider the complex situations of paramedic care and to meet paramedics' demands, we use an action-oriented research approach to develop the tool. We include the staff of the participating emergency medical service stations and software designers in our approach. The tool is then used and evaluated within an open interventional, non-randomised study with two control groups. Control group 1 (German-speaking patients) and control group 2 (non-German-speaking patients treated without the tool) are recruited starting from the first study phase. In the second study phase, an intervention group is additionally recruited, i.e. non-German-speaking patients with whom the tool is used. The primary outcome of the clinical trial is improved communication with non-German-speaking patients in emergencies by means of the communication tool. The secondary outcome is an improved quality and quantity of the collected information. We exploratively observe on-scene times, demands for emergency physicians, and the usage of the intervention. By recording patients' clinical parameters, we consider the severity of the health restrictions. DISCUSSION: Our study is an innovative research project in paramedic healthcare comprising the development of a digital communication tool to overcome language barriers in emergency medical services and investigating its usability, acceptance, and effect on communication, in short, its usefulness and value for paramedic care. Additonally, we expect to gain comprehensive information on rescue operations. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00016719, registered 08 February 2019, World Health Organization Trial Registration Data Set, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00016719.

Usability of an App for Medical History Taking in General Practice From the Patients' Perspective: Cross-Sectional Study.

BACKGROUND: A future shortage of physicians, especially in general practice, will result in an increasing workload for health care providers as a whole. Therefore, it is important to optimize patient-encounter processes to increase time efficiency related to visits. Utilizing digital tools to record patients' medical histories prior to a consultation offers great potential to achieve this goal. The collected information can be stored into the practice's electronic medical record, allowing for the general practitioner to review structured information of the patients' complaints and related medical history beforehand, thereby saving time during the encounter. However, the low usability of new digital developments in this setting often hinders implementation. OBJECTIVE: The aim of this study was to evaluate the usability of an app designed for medical history taking in general practice to capture the patients' perspective. METHODS: Between November 2021 and January 2022, we recruited 406 patients with acute complaints in one out-of-hour urgent care and seven general practice clinics. These study participants used the app during their waiting time and subsequently assessed its usability by completing the System Usability Scale (SUS), a robust and well-established 10-question survey measuring the perceived usability of products and technologies. Additionally, we collected general participant information, including age, sex, media usage, health literacy, and native language. Descriptive and inferential statistics were applied to identify patient characteristics associated with low or high SUS scores. RESULTS: We analyzed data from 397 patients (56.7% female, 43.3% male). The mean total SUS score was 77.8 points; 54.4% (216/397) of participants had SUS scores of 80 points or higher, indicating high usability of the app. In a multiple linear regression predicting SUS score, male sex and higher age (65 years or older) were significantly negatively associated with the SUS score. Conversely, a higher health literacy score and German as the native language were significantly positively associated with the SUS score. CONCLUSIONS: Usability testing based on the SUS anticipates successful implementation of the app. However, not all patients will easily adapt to utilizing the app, as exemplified by the participants of older age in this study who reported lower perceived usability. Further research should examine these groups of people, identify the exact problems in operating such an app, and provide targeted solutions. TRIAL REGISTRATION: German Clinical Trials Register World Health Organization Trial Registration Data Set DRKS00026659; https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00026659.

[Rescue Missions with Patients with Psychiatric and Psychosocial Symptoms: An Analysis from Eastern Lower Saxony]. / Notfallrettungseinsätze mit Patient*innen mit psychiatrischer oder psychosozialer Symptomatik: eine Analyse aus Ostniedersachsen.

OBJECTIVE: Characterization of medical emergencies of patients with psychiatric symptoms or in psychosocial crisis. METHODS: Analysis of emergency medical services (EMS) mission logs from four German EMS stations of patients aged 12-65 from 2019 to 2020. RESULTS: 23.4% of missions involved patients with psychiatric or psychosocial symptoms (1.6% psychotic, 3.0% suicidal, 7.1% psychosocial crisis, 15.7% intoxicated). On average, these patients were younger than those with other symptoms. 48.9% exhibited additional somatic complaints. The COVID-19 pandemic showed only little impact on the frequency of such emergencies. CONCLUSION: Psychiatric and psychosocial symptoms account for a significant proportion of rescue missions in our sample. Managing psychiatric and psychosocial emergencies should be an integral part of the training of medical and paramedical staff.

Overcoming Language Barriers in Paramedic Care With an App Designed to Improve Communication With Foreign-Language Patients: Nonrandomized Controlled Pilot Study.

BACKGROUND: Communication across language barriers is a particular challenge for health care providers. In emergency medical services, interpreters are mostly not available on rescue scenes, which jeopardizes safe and high-quality medical care. In a cocreative process together with paramedics and software designers, we developed a fixed-phrase translation app with 600 phrases and 18 supported languages that supports paramedics when providing care to foreign-language patients. This paper reports on the results of a pilot study to evaluate the app's effect on paramedic-patient communication. OBJECTIVE: This study aims to gain insights into the efficacy and feasibility of a multilingual app that helps paramedics to communicate with patients who are not proficient in the local language. METHODS: A 3-armed nonrandomized interventional pilot study was conducted in 4 rescue stations in the German Federal State of Lower Saxony: 3 rural areas and 1 in urban environment. The intervention group comprised rescue missions with patients with limited German language proficiency (LGP) with whom the app was used; control group 1 comprised LGP patients without app usage; and control group 2 consisted of rescue missions with German-speaking patients. For each rescue operation with LGP patients, paramedics filled out questionnaires about the communications with patients. From standardized Rescue Service Case Protocols, we extracted information on patient demographics (age and sex), clinical aspects (preliminary diagnosis and Glasgow Coma Scale), and rescue operation characteristics (time spent on emergency scene and additional dispatch of emergency physicians). The primary outcome was the paramedics' perceived quality of communication with LGP patients. The secondary outcome was the ability to obtain necessary information from patients and the ability to provide important information to patients. A linear regression model was applied to assess the impact of the app on perceived communication, controlling demographic factors, and severity of illness. RESULTS: A total of 22 LGP patients were recruited into the intervention group and 122 into control group 1. The control group 2 included 27,212 German-speaking patients. LGP patients were more than 2 decades younger than German-speaking patients. App usage among LGP patients was associated with higher perceived overall quality of communication (0.7 points on a 5-point Likert scale, P=.03). Applying a linear regression model controlling for age, sex, and Glasgow Coma Scale, the quality of communication was associated with an increase of 0.9 points (95% CI 0.2-1.6, P=.01). Compared to either German-speaking patients or LGP patients, paramedics spent 6-7 minutes longer on an emergency scene when the app was used (P=.24). CONCLUSIONS: The use of the app suggests a relevant improvement in communication with patients with limited proficiency in the locally spoken language in paramedic care. The small sample size and the lack of randomization reduce the generalizability of the findings. TRIAL REGISTRATION: German Clinical Trials Register DRKS00016719; https://drks.de/search/de/trial/DRKS00016719.

Evaluating an app for digital medical history taking in urgent care practices: study protocol of the cluster-randomized interventional trial 'DASI'.

BACKGROUND: In out-of-hours urgent care practices in Germany, physicians of different specialties care for a large number of patients, most of all unknown to them, resulting in a high workload and challenging diagnostic decision-making. As there is no common patient file, physicians have no information about patients' previous conditions or received treatments. In this setting, a digital tool for medical history taking could improve the quality of medical care. This study aims to implement and evaluate a software application (app) that takes a structured symptom-oriented medical history from patients in urgent care settings. METHODS: We conduct a time-cluster-randomized trial in two out-of-hours urgent care practices in Germany for 12 consecutive months. Each week during the study defines a cluster. We will compare participants with (intervention group) and without app use (control group) prior to consultation and provision of the self-reported information for the physician. We expect the app to improve diagnostic accuracy (primary outcome), reduce physicians' perceived diagnostic uncertainty, and increase patients' satisfaction and the satisfaction with communication of both physician and patient (secondary outcomes). DISCUSSION: While similar tools have only been subject to small-scale pilot studies surveying feasibility and usability, the present study uses a rigorous study design to measure outcomes that are directly associated with the quality of delivered care. TRIAL REGISTRATION: The study was registered at the German Clinical Trials Register (No. DRKS00026659 registered Nov 03 2021. World Health Organization Trial Registration Data Set, https://trialsearch.who.int/Trial2.aspx? TrialID = DRKS00026659.

A Multilingual App for Providing Information to SARS-CoV-2 Vaccination Candidates with Limited Language Proficiency: Development and Pilot.

Language barriers are obstacles in receiving vaccinations against COVID-19. They jeopardize informed consent, vaccination safety, and a positive immunization experience. We have developed a multilingual app to overcome language barriers when dealing with vaccination candidates with a limited proficiency in the locally spoken language. We applied the Spiral Technology Action Research (STAR) model to create the app within a discursive process involving healthcare professionals (HCPs) from vaccination sites, literature searches and guidelines, and field trials at vaccination centers. In a real-world pilot test, we assessed the usability and feedback for further improvement. Our efforts resulted in an app that facilitates communication with vaccination candidates in 40 languages, each with over 500 phrases that can be played back or displayed as text. In the pilot test, the app demonstrated its usability, and was well accepted by the vaccination candidates (n = 20). The app was mainly used to inform about the risks and benefits of the SARS-CoV-2 vaccination. Some HCPs struggled to navigate the comprehensive content and the pilot test exposed the need for additional phrases. The STAR model proved to be flexible in adapting to dynamic pandemic conditions and changing recommendations. This multilingual app overcomes language barriers in healthcare settings, promoting vaccines to migrants with limited language proficiency.

Multilingual competencies among ambulatory care providers in three German Federal States.

BACKGROUND: Providing medical care to newly arrived migrants presents multiple challenges. A major challenge is a lack of a common language in the absence of language interpretation services. We examine the multilingualism of German physicians and clinical psychotherapists providing ambulatory care. METHODS: We retrieved publicly available data from the Associations of Statutory Health Insurance Physicians provider registry of three German federal states (Lower Saxony, Saarland, Bavaria). We selected and grouped relevant practice-based disciplines. We used descriptive statistics to analyze the provider's multilingualism among different disciplines. RESULTS: 69.6% of ambulatory providers offer consultations only in German. 15.5% of providers reported offering consultations in one additional non-German language, and 14.9% in two or more additional languages. Most common additional languages were English (28.6%) and French (9.9%). 1.4% of providers reported offering consultation in at least one language of the Middle Eastern region (Arabic, Dari, Hebrew, Kurdish, Pashtu, Farsi, and Turkish). There were differences in the offered languages between the medical disciplines with the highest mean rates found for gynecologists and obstetricians, urologists, and general surgeons. Psychotherapeutic disciplines offered consultation in other languages significantly less often. CONCLUSION: Our study suggests a significant numeric mismatch in the number of providers offering consultations in the languages of people seeking protection in Germany. The resulting language barriers are compromising equitable access and quality of care.

Designing an App to Overcome Language Barriers in the Delivery of Emergency Medical Services: Participatory Development Process.

BACKGROUND: In emergencies, language barriers may have dangerous consequences for the patients. There have been some technical approaches to overcome language barriers in medical care but not yet in the prehospital emergency care setting. The use of digital technologies in health care is expanding rapidly. Involving end users at all stages of the development process may help to ensure such technologies are usable and can be implemented. OBJECTIVE: We aimed to develop a digital communication tool that addresses paramedic needs in the specific circumstances of prehospital emergency care and helps paramedics to overcome language barriers when providing care to foreign-language patients. METHODS: We actively engaged paramedics and software designers in an action-oriented, participatory, iterative development process, which included field observations, workshops, background conversations, questionnaires on rescue missions, studying the literature, and preliminary testing in the field. RESULTS: With input from paramedics, we created an app with 600 fixed phrases supporting 18 languages. The app includes medical history-taking questions, phrases asking for consent, and phrases providing specific additional information. Children as patients, as well as their carers and other third parties, can be addressed with appropriate wording. All phrases can be played back audibly or displayed as text. The comprehensive content is grouped into categories and adapted to diverse scenarios, which makes the tool rapidly usable. The app includes a function to document patient responses and the conversation history. For evaluation in a clinical study, the app is run on a smartphone with extra speakers to be of use in noisy environments. The use of prototypes proved valuable to verify that the content, structure, and functions discussed in theory were of value and genuinely needed in practice and that the various device control elements were intuitive. CONCLUSIONS: The nature of the paramedic work environment places specific demands on the communication options used and need for such devices. The active involvement of paramedics in the development process allowed us to understand and subsequently consider their experience-based knowledge. Software designers could understand the paramedics' work environment and consider respective needs in the menu navigation and design principles of the app. We argue that the development of any medical software product should actively involve both end users and developers in all phases of the development process. Providing the users with the opportunity to influence technology development ensures that the result is closer to their needs, which can be seen as crucial for successful implementation and sustainable use. TRIAL REGISTRATION: German Clinical Trials Register DRKS00016719; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00016719. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12913-020-05098-5.

Medical Characteristics of Foreign Language Patients in Paramedic Care.

BACKGROUND: In this study, medical and socio-demographic characteristics of foreign language patients in prehospital emergency medical care are analyzed and compared with non-foreign language patients. METHODS: We performed retrospective chart review of rescue operations in four emergency medical service stations in Northern Germany over seven months as part of the DICTUM Rescue study (DRKS00016719). We performed descriptive analyses including test statistics and used partial correlation to adjust for patients' sex and age. RESULTS: Patients with limited German proficiency were served in 2.2% of all 7494 covered rescue operations. On average, these patients were two decades younger than their German speaking counterparts. There were significantly more patients with limited German proficiency with gynecological and obstetric problems, especially births, as well as psychiatric disorders, especially suicide attempts. CONCLUSIONS: Our findings suggest that the existing preventive programs for pregnant women and people at risk of suicide do not sufficiently reach patients with limited German proficiency. Additionally, giving birth and psychiatric breakdowns are exceptional and sensitive situations, both for patients and the paramedic staff, where the ability to communicate safely appears to be of enormous importance to enable safe treatment.