The Safety and Quality Challenges for Families Facing Language Barriers in Paediatric Emergency Departments – A Scoping Review to inform tailored interventions

Aim: To understand the patient safety challenges associated with language barriers experienced by families in paediatric emergency departments. Objective 1 – To explore how and where language barriers influence safety and quality along the care journey for paediatric patients and families in emergency care settings. Objective 2 – To understand the range of existing interventions aimed at addressing language barriers in paediatric emergency care. Objective 3 - To identify knowledge gaps in the literature related to how language barriers influence safety and quality of care and in the development of interventions designed to address these barriers. Background Studies in a paediatric emergency department (PED) setting have identified disparities in care, such as longer lengths of stay and delayed treatments for children from families facing language barriers, compared to families proficient in the primary language of care (1). These findings are reinforced by research indicating that families experiencing language barriers often experience limited understanding of medical diagnoses and follow-up plans, a critical safety concern in emergency settings (2). Existing literature on language barriers in healthcare primarily focus on their impact on communication, patient satisfaction, and health outcomes, with majority of studies investigating hospital and emergency department settings without a focus on a paediatric population. The World Health Organization defines patient safety as the “prevention of errors and adverse effects to patients associated with health care” (3). Some evidence has demonstrated that language barriers negatively affect patient safety, with associations observed between limited proficiency in the primary language of care and increased rates of diagnostic errors, prolonged emergency department stays, and lower quality of care outcomes (3,4).However, some studies do not consistently demonstrate these associations or suggest that the relationship may vary depending on the context. For instance, Goldman et al. (3) found that while language barriers were associated with slightly increased lengths of stay in a Canadian PED, the differences were not always statistically significant. Similarly, studies examining resource utilisation and safety outcomes suggest that the impact of language barriers may depend on factors such as the availability and use of interpreters, provider training, and system-level interventions (5). This variability may indicate that while language barriers often correlate with safety risks, the strength of these associations can be influenced by factors both contextual and systemic. The literature also reflects gaps in understanding the specific mechanisms through which language barriers impact safety in PEDs. Interventions, such as professional interpreters and technological solutions, are frequently proposed but are often inconsistently implemented and rarely evaluated in terms of their direct impact on patient safety outcomes (5). While many studies highlight challenges faced by patients and families with limited language proficiency, few examine the lived experience of children and their families, which limits the depth of understanding needed to develop effective, family-centered interventions (6). Despite the recognition of challenges in this field, there remains a lack of consensus on how to effectively address language and communication barriers across these settings. This scoping review will begin to address this by systematically mapping the state of research on the impact of language barriers on patient safety outcomes for paediatric patients and families in emergency care settings. Methods This protocol will be prospectively registered with the Open Science Framework (OSF) to ensure transparency and prevent duplication. PCC Framework Population – Paediatric patients (ages 0-18) and their families who are identified as having limited proficiency in the primary language of care. Healthcare professionals in paediatric emergency settings may also be included if the studies focus on their experiences managing language barriers. Concept – Research literature concerning safety and quality. This may include studies examining patient safety outcomes, adverse events, quality of care, or implemented interventions aimed at mitigating these. Context: Emergency care settings in diverse healthcare environments, without restriction to a specific geographic region or healthcare system. Sources The review will consider a variety of evidence sources, including: Primary research studies Quantitative, qualitative, and mixed methods Systematic reviews and meta-analyses Systematic reviews and meta-analyses will be screened primarily to identify relevant individual studies that meet the inclusion criteria. Individual studies within these reviews that directly address language barriers and patient safety outcomes, or interventions in paediatric emergency care, will be included and assessed independently. Policy reports and guidelines Grey literature Reports from healthcare organisations, theses, conference proceedings Search Strategy Initial search: A preliminary search will be conducted in MEDLINE and Embase to identify relevant keywords and index terms. This will involve reviewing the titles, abstracts, and index terms of studies retrieved. Comprehensive search: Using the identified keywords and index terms, a comprehensive search will be performed across multiple databases, including Medline, CINAHL, Embase, Cochrane Library, Scopus, and Web of Science. Consideration given to synonyms, variation in spellings, abbreviations Handsearching: Further relevant studies will be identified through manual searching of Google Scholar. The reference list of key identified studies and relevant review articles will be examined for additional sources. Grey literature will be searched using resources such as OpenGrey, Overton across the first 15 pages of results. Source of Evidence Selection The selection process will involve two stages: Title and Abstract Screening: Two independent reviewers will screen the titles and abstracts of identified articles against the eligibility criteria. Full-Text Review: Full-text articles will be retrieved and reviewed for eligibility by two independent reviewers. Reasons for exclusion will be documented. Data Extraction (Charting) The following details will be extracted: Author(s) Year of publication Country of origin Aims/Purpose of study Population characteristics (age, LEP status) Study design and methodology Interventions and comparators (if applicable) Outcomes and measures related to patient safety Key findings relevant to language barriers and safety outcomes References: 1. Lowe J, Grubenhoff J, Mendenhall M, Leonard J, Widmer K. Contribution of Limited English Proficiency to Diagnostic Errors in Pediatric ED Patients. Diagnosis. 2023 May;10(2):A29–30. 2. Nissen V, Meuter RFI. Language and culture in health communication in an emergency context: do health practitioners and patients talk differently about uncertainty and risk? Front Commun. 2023;8. 3. Patient safety EURO [Internet]. [cited 2024 Dec 11]. Available from: https://www.who.int/europe/health-topics/patient-safety#tab=tab_1 4. Goldman RD, Amin P, Macpherson A. Language and length of stay in the pediatric emergency department. Pediatr Emerg Care. 2006;22(9):640–3. 5. Bell SK, Dong J, Ngo L, McGaffigan P, Thomas EJ, Bourgeois F. Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey. BMJ Qual Saf. 2023 Nov;32(11):644–54. 6. Taira BR, Kim K, Mody N. Hospital and health system–level interventions to improve care for limited English proficiency patients: a systematic review. Jt Comm J Qual Patient Saf. 2019;45(6):446–58. 7. Flores G, Rabke-Verani J, Pine W, Sabharwal A. The importance of cultural and linguistic issues in the emergency care of children. Pediatr Emerg Care. 2002 Aug;18(4):271–84.