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In March 2020, just weeks before the covid-19 pandemic, the incident command center at Boston’s Brigham and Women’s Hospital was struggling to understand this new deadly disease. He seemed to kill more black and brown than white patients. For the Latins, there was an additional warning sign: the language.
Patients who did not speak much, or any other type of English, were 35% more likely to die.
Doctors who could not clearly communicate with patients in the covide units of the hospital noticed that it affected the results.
“We had the idea that language would be an issue at first,” said Dr. Karthik Sivashanker, then Brigham’s medical director for quality, safety and equity. “We received security reports that said language is an issue.”
Sivashanker immersed himself in the records, isolating and highlighting the unique characteristics of each of the patients who died: their race, age, and sex and whether they spoke English.
“It was here that we started to really discover some deeper and invisible inequalities,” he said.
Inequalities that did not consist of race alone.
Hospitals across the country have reported more hospitalizations and deaths of black and Latin patients than of white ones. Black and brown patients may be more susceptible because they are more likely to have a chronic illness that increases the risk of severe covidity. But when Brigham’s team compared black and brown patients with white patients who had similar chronic diseases, they found no difference in the risk of death from covid.
But a difference arose for non-English speaking Latin patients. This disturbing finding helped them learn about a specific health disparity, think of some possible solutions, and begin a commitment to change.
“This is the future,” Sivashanker said.
But first, Brigham had to reveal this latest example of life-threatening health disparity. It started outside the hospital, in lower-income communities, and on the outskirts of Boston, where the coronavirus quickly spread among many native Spanish-speakers living in nearby areas with jobs they can’t do from home.
Some avoided coming to the hospital until they were very ill, because they did not trust the care of large hospitals or feared being detected by immigration authorities. However, within weeks of the pandemic, covid patients who spoke little English began to enter Boston hospitals, including Brigham and Women.
“Frankly, we weren’t fully prepared for this wave,” Sivashanker said. “We have really amazing performer services, but they were starting to overflow.”
“At first we didn’t know how to act. We panicked,” said Ana Maria Rios-Velez, Brigham’s Spanish-language interpreter.
Rios-Velez recalled looking for words to translate this new disease and experience for patients. When they were called to a covetous patient’s room, the performers were confused about whether they could enter and how close they had to get to the patient. Some performers said so it felt disposable the first days of the pandemic, when they were not provided with adequate personal protective equipment.
When he had PPE, Rios-Velez said, he was still struggling to earn a patient’s trust behind a mask, a face shield, and a dressing gown. For safety, many performers were urged to work from home. But talking to patients over the phone created new problems.
“It was extremely difficult, extremely difficult,” he said. “Patients had respiratory problems. They were coughing. They had their voices muted.”
And Rios-Velez couldn’t look his patients in the eyes to put them at ease and establish a connection.
“It’s not just the voice. Sometimes I have to see the lips, if they smile,” he said. “I want them to see compassion in me.”
Add performers and technique
Brigham responded by adding more interpreters and buying more iPads so remote workers could see patients. The hospital bought amplifiers to raise the volume of patients ’voices above the sounds and machines that cornered in an ICU. He Brigadier General Brigham network is piloting the use of interpreters available via video in primary care offices. A to study it was found that Spanish-speaking patients used less telemedicine than white patients during the pandemic.
Brigham’s goal is for every patient who needs an interpreter to receive one. Sivashanker said this is happening now for most patients who make the request. The biggest challenge, he said, is to include an interpreter in the care of patients who may need help but don’t ask for it.
During the first wave, interpreters also became translators for the hospital’s website, information kiosks, covides security signs, and brochures.
“It was very hard. I got sick and had to take a week off,” said Yilu Ma, director of interpreter services at Brigham. Mass General Brigham is now expanding a centralized translation service for the entire hospital network.
Inequalities within the hospital staff
Brigham and Women’s analysis team discovered other disparities. Lower paid employees were paid more often than nurses and doctors. Sivashanker said there were dozens of small group meetings with medical assistants, transportation workers, security and environmental services staff in which he shared the highest positive test rates and encouraged everyone to take the test. .
“We let them know they wouldn’t lose their jobs” if they had to lose their jobs, Sivashanker said. And he, along with executives, told these employees “that we realize you’re risking your life just like any other nurse, every day you come to work.”
Some employees complained of favoritism in the distribution of PPE, which the hospital investigated. To ensure that all employees received timely updates as the pandemic guidelines changed, Brigham began translating all coronavirus messages into Spanish and other languages and sending them via text messages, which are more likely to read. people who move all day. The General Brigham Mass system offered hardship grants of up to $ 1,000 for employees with additional financial pressures, such as additional childcare costs.
Angelina German, a hospital cleaner with limited English, said she enjoys receiving updates via Spanish text as well as in-person coveted information from her bosses.
“Now they’re more aware of all of us,” German said through an interpreter, “making sure people take care of themselves.”
Beyond the walls of the hospital
The hospital also established test sites in some Boston neighborhoods with high rates of coronavirus infection, including neighborhoods where many employees live and became infected. At least one of these sites now offers covid vaccines.
“No one should be scheduled. You don’t need insurance. You just have to go up and we can test you,” Dr. Christin Price explained during a visit last fall to a test site in the Jamaican Plains neighborhood.
Nancy Santiago left the test site carrying a free bag of 10 kilos of fruits and vegetables, which she will share with her mother. Santiago said he is grateful for the help.
“I had to quit my job because of [lack of] Nursery, and it’s been pretty tough, “he said.” But, you know, we have to stay strong and hopefully this will end sooner rather than later. “
Brigham recently opened a similar indoor operation at the Strand Theater in the Dorchester neighborhood. Everyone who comes for a coronavirus test is asked if they have enough food, if they can afford their medications, if they need help with housing, and if they are registered to vote.
Mass General Brigham’s leaders said they will take what they have learned by dissecting disparities during the pandemic and expand remedies across the hospital network.
“Many of the issues that were identified during the covid equity response are unfortunately fairly universal issues that we need to address, if we are to be an anti-racist organization,” said Tom Sequist, Mass Patient Experience and Equity Chief General Brigham.
Brigham’s work on health disparities comes, in part, from one collaboration with the Institute for Health Improvement.
“There are many defensive routines in which we position ourselves as physicians whose data can help resolve and reveal that there are some biases in your own practice,” explained IHI President and CEO Dr. Kedar Mate.
“If we don’t name it and start talking about racism and how we intend to dismantle or undo it,” Mate added, “we will continue to put tapes against the problem and not address the underlying causes.”
“Poverty and the social determinants of health needs will not go away soon, so if there is a way to continue to serve communities, I think it would be tremendous,” said Price, who helped organize the testing program. of Brigham.
But has Brigham’s work reduced the risk of death by covidi for Spanish-speaking patients? The hospital has not yet updated the analysis, and even when it does, determining whether (or how) the interventions will work will be tough, Sivashanker said.
“It will never be as simple as‘ We just didn’t give them enough iPads or translators and that was the only problem, ’” Sivashanker said.
But Sivashanker said more interpreters and iPads and better messaging for non-English-speaking employees, in addition to the rest of the measures Brigham has taken during the pandemic, have improved the patient and employee experience. He said this is a success, while continuing to work on the next layer of discrimination.