Language affects length of stay in emergency departments in Queensland public ho
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BACKGROUND： A long length of stay （LOS） in the emergency department （ED） associated with overcrowding has been found to adversely affect the quality of ED care. The objective of this study is to determine whether patients who speak a language other than English at home have a longer LOS in EDs compared to those whose speak only English at home.
METHODS： A secondary data analysis of a Queensland state-wide hospital EDs dataset （Emergency Department Information System） was conducted for the period， 1 January 2008 to 31 December 2010.
RESULTS： The interpreter requirement was the highest among Vietnamese speakers （23.1%） followed by Chinese （19.8%） and Arabic speakers （18.7%）. There were significant differences in the distributions of the departure statuses among the language groups （Chi-squared=3236.88， P
CONCLUSION： There is a close relationship between the language spoken at home and the LOS at EDs， indicating that language could be an important predictor of prolonged LOS in EDs and improving language services might reduce LOS and ease overcrowding in EDs in Queensland's public hospitals.
KEY WORDS： Emergency department； Language； Length of stay
World J Emerg Med 2013；4（1）：5–9
DOI： 10.5847/ wjem.j.1920–8642.2013.01.001
INTRODUCTION
Overcrowding in emergency departments （EDs） is a serious and growing crisis confronting Australia's public hospitals and may affect the quality of and access to care.[1] Length of stay （LOS） is a marker of ED overcrowding and a key component of ED quality assurance monitoring.[2，3] ED LOS is usually defined as the time from a patient's registration until that patient's departure from the ED.[4，5] LOS can be associated with ED overcrowding， decreased patient satisfaction with ED care， ambulance diversion and poor clinical outcomes.[3，4] An association with a long LOS in the ED has also been found in differences in language between health care providers and patients.[6，7] In Australia， approximately 15.6% of the population speaks a language other than English at home， with approximately 3% having limited English proficiency.[8] Some studies have suggested that patients from non-English speaking backgrounds tend to use ED care as their primary source of care.[9–11] Critical time can be lost in the ED due to a lack of ability to communicate effectively in English， which contributes significantly to increased LOS. However， these studies have been conducted in countries where the health system and patients' characteristics differ from those in Australia. Currently， a limited body of literature exists describing the effect of language on LOS in Australian EDs.
The aim of this study is to determine if patients who speak a language other than English at home have a longer LOS than those who speak only English at home in public hospital EDs in queensland （QLD）.
METHODS
Study design and setting
An analysis of the QLD public hospitals' ED dataset for the period from January 1， 2008 to December 31， 2010 was undertaken. QLD， located in Australia's northeast， is the second-largest in land mass and third-most populated state in the country.
Data collection
The data were sourced from the Emergency Department Information System （EDIS）. EDIS is an electronic information system for public hospital EDs in QLD. It provides data such as arrival time， departure time， triage category， gender， age， language spoken at home， and ED departure status （admission to hospitals， did not wait， died or discharged）.
Ethical approval to use unidentified data was obtained from QLD Health Central Ethics Unit （HREC/11/QHC/29）.
Study population
Patients were divided into groups according to the language spoken at home. Those who had been admitted to hospital， transferred to another hospital， left without being seen， left after the commencement of treatment， or died in ED were excluded. Only patients who had completed their ED service and were discharged were included in the analysis. The study was limited to the languages most commonly spoken at home as specified by EDIS： English （1 984 087）， Arabic （1 593）， Chinese （3 356）， Vietnamese （1 478）， Spanish （1 285）， Italian （976）， Hindi （957）， and German （762）.
Data analysis
Descriptive analysis was performed to test for the proportions of ED departure status （admission to hospital， transferred， discharge， did not wait， or died） and interpreter requirements. Two multiple linear regression models were used. The first model controlled for age， gender， and triage categories， and interpreter requirement was included to form the second model. The triage priority was measured using the Australian Triage Scale （ATS）， where resuscitation patients need to be seen immediately， emergency patients within 10 minutes， urgent patients within 30 minutes， semi-urgent patients within 60 minutes， and non-urgent patients within 120 minutes.[12]
The results were calculated using Statistical Package for the Social Sciences （SPSS） version 19 （IBM SPSS Statistics 19）.
RESULTS
Among the total of 2 953 731 patients attending all public hospital EDs in QLD from January 1， 2008 to December 31， 2010， 2 905 204 （98.4%） spoke only English at home and 48 527 （1.6%） spoke another language at home. Table 1 describes the proportions of the patients' departure status， including those whose ED service was completed and were discharged. Table 2 shows the interpreter requirements among the different language groups. Patients who spoke Chinese， Vietnamese， Arabic， Spanish， Italian， Hindi， and German at home had a significantly （P
The r2 for the first regression model was 0.12 and 0.17 for the final model， suggesting that 12% and 17% of the variance， respectively， could be explained by these two models.
DISCUSSION
This is the first study in Queensland to compare the length of stay （LOS） in public hospital Emergency Departments （EDs） among patients whose primary language is not English to those who speak only English at home. Our study showed that patients who speak Vietnamese had a higher rate of interpreter use and a longer LOS than the other language groups. The patients who speak a language other than English at home had significantly longer LOS in the EDs. More specifically， patients who spoke Vietnamese at home stayed the longest in the EDs （26.3 minutes）， followed by Arabic （10.3 minutes）， Spanish speakers （9.4 minutes） and Chinese speakers （8.6 minutes）， compared to those who spoke only English at home. These findings agree with previous studies in other countries.[3，13，14]
Public hospital EDs in Queensland see patients who have little or no understanding of English due to a high proportion of immigrants living in the state. Additional time is needed to obtain an interpreter， and even when an interpreter is readily available， the emergency physician requires additional time for this interaction.[15] Thus， if a patient with limited English proficiency requires an interpreter， this can prolong the LOS. However， our first regression model explained only 12% of the variability in LOS， controlling for language， triage category， gender， and age. That was improved significantly to 17% when the interpreter requirement was added to the final model， which suggests the importance of this factor. This also indicates that there are other influential factors affecting LOS in EDs which were not captured by our study.
The first possible reason is that sometimes ED care providers use whoever bilingual and available at the ED such as a family member or hospital staff to communicate with patients， rather than use a professional interpreter.[13，16] It was reported that using nonprofessional interpreter might result in serious consequences including breach of patient confidentiality， less understanding of the patient's problems， un-necessary diagnostic tests， wrong diagnosis， wrong treatment， frequent ED visits， and reduced quality of care.[16–18] This would lead to higher health care costs， add greater burden to already overcrowded EDs， and delay treatment.[18]
The second possible reason is that some disadvantaged immigrants， such as refugees， might attend EDs with more advanced illnesses or complex conditions which require longer assessment， additional diagnostic tests， and treatment times.[19] Unfortunately， patients' refugee status is not available for this study， and warrants future research in this area.
The third possible reason is the clinical situation of these patients such as the number of patients in the ED at that time， the laboratory tests ordered， the use of diagnostic imaging， and specialty consultation.[2，6]
The fourth possible reason could be the cultural barriers. For example， women from Islamic or Middle Eastern cultures prefer to be seen by a female doctor， which can prolong their LOS or cause them to leave the ED without seeing the doctor.[20，21]
This specific culture could potentially explain the reason， at least partly， that Arabic speakers had 10% higher than any other group who did not wait for their treatment to be completed at EDs and left the EDs against the doctor's wish. Further research is needed to confirm this assumption. This is important as the immigration data indicate that there are increasing numbers of immigrants， refugees， and foreign students from Arabic speaking countries coming to Australia.[22]
Several studies have shown that language barriers not only increased the LOS in EDs， but also decreased patients' satisfaction.[3，13，14] Carrasquillo et al[13] reported that compared to English speakers， non-English speakers were less satisfied with the care they received in the ED as， were less willing to return to same ED if they had a problem which they felt required emergency care， and reported more problems with emergency care. Therefore， understanding why these patients are staying longer in the ED is an important factor in enhancing the acute care delivered to these patients in the EDs.
The limitations of this study are mainly the limitations of large secondary data analysis such as adequacy， accuracy， completeness， and other measures of the quality of the data.[23] However， every humanly possible effort has been made to make sure the process of retrieving the data is accurate and consistent.
In conclusion， patients who speak a language other than English at home had a longer length of stay in Queensland public hospital emergency departments which largely cannot be explained by the language itself. Further research is needed to identify reasons behind the longer stay and provide scientific evidence for effective future interventions so that everyone can access acute care in time despite their language spoken at home.
ACKNOWLEDGEMENT
The authors are grateful to the Hospital Access Analysis Team （HAAT） of Queensland Health， the data custodians of the EDIS data， and particularly Jean Sloan， who extracted and provided the data.
Funding： None.
Ethical approval： Ethical approval to use unidentified data was obtained from QLD Health Central Ethics Unit （HREC/11/QHC/29）.
Conflicts of interest： The authors have no financial or other conflicts of interest regarding this article.
Contributors： Mahmoud I proposed and wrote the study. All authors read and approved the final manuscript. Hou XY is the guarantor.
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