World J Emerg Med, Vol 4, No 1, 2013 5

Original Article

Language affects length of stay in emergency

departments in Queensland public hospitals
Ibrahim Mahmoud1, Xiang-yu Hou1,2, Kevin Chu1,2, Michele Clark1
1
School of Public Health, Queensland University of Technology, Brisbane, Australia
2
Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
Corresponding Author: Xiang-yu (Janet) Hou, Email: [email protected]

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<0.001).
Compared with English speakers, the Beta coefficient for the LOS in the EDs measured in minutes was
among Vietnamese, 26.3 (95%CI: 22.1–30.5); Arabic, 10.3 (95%CI: 7.3–13.2); Spanish, 9.4 (95%CI:
7.1–11.7); Chinese, 8.6 (95%CI: 2.6–14.6); Hindi, 4.0 (95%CI: 2.2–5.7); Italian, 3.5 (95%CI: 1.6–5.4); and
German, 2.7 (95%CI: 1.0–4.4). The final regression model explained 17% of the variability in LOS.
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.issn.1920–8642.2013.01.001

INTRODUCTION found in differences in language between health care

Overcrowding in emergency departments (EDs) providers and patients.[6,7] In Australia, approximately
is a serious and growing crisis confronting Australia's 15.6% of the population speaks a language other than
public hospitals and may affect the quality of and English at home, with approximately 3% having limited
access to care.[1] Length of stay (LOS) is a marker of English proficiency.[8] Some studies have suggested that
ED overcrowding and a key component of ED quality patients from non-English speaking backgrounds tend to
assurance monitoring.[2,3] ED LOS is usually defined as use ED care as their primary source of care.[9–11] Critical
the time from a patient's registration until that patient's time can be lost in the ED due to a lack of ability to
departure from the ED.[4,5] LOS can be associated with communicate effectively in English, which contributes
ED overcrowding, decreased patient satisfaction with ED significantly to increased LOS. However, these studies
care, ambulance diversion and poor clinical outcomes.[3,4] have been conducted in countries where the health
An association with a long LOS in the ED has also been system and patients' characteristics differ from those in

© 2013 World Journal of Emergency Medicine www.wjem.org

 6 Mahmoud et al World J Emerg Med, Vol 4, No 1, 2013

Australia. Currently, a limited body of literature exists patients who had completed their ED service and were
describing the effect of language on LOS in Australian discharged were included in the analysis. The study
EDs. was limited to the languages most commonly spoken at
The aim of this study is to determine if patients who home as specified by EDIS: English (1 984 087), Arabic
speak a language other than English at home have a (1 593), Chinese (3 356), Vietnamese (1 478), Spanish
longer LOS than those who speak only English at home (1 285), Italian (976), Hindi (957), and German (762).
in public hospital EDs in Queensland (QLD).
Data analysis
Descriptive analysis was performed to test for
METHODS the proportions of ED departure status (admission to
Study design and setting hospital, transferred, discharge, did not wait, or died) and
An analysis of the QLD public hospitals' ED dataset interpreter requirements. Two multiple linear regression
for the period from January 1, 2008 to December 31, models were used. The first model controlled for age,
2010 was undertaken. QLD, located in Australia's gender, and triage categories, and interpreter requirement
northeast, is the second-largest in land mass and third- was included to form the second model. The triage
most populated state in the country. priority was measured using the Australian Triage Scale
(ATS), where resuscitation patients need to be seen
Data collection immediately, emergency patients within 10 minutes,
The data were sourced from the Emergency urgent patients within 30 minutes, semi-urgent patients
Department Information System (EDIS). EDIS is an within 60 minutes, and non-urgent patients within 120
electronic information system for public hospital EDs minutes.[12]
in QLD. It provides data such as arrival time, departure The results were calculated using Statistical Package
time, triage category, gender, age, language spoken at for the Social Sciences (SPSS) version 19 (IBM SPSS
home, and ED departure status (admission to hospitals, Statistics 19).
did not wait, died or discharged).
Ethical approval to use unidentified data was
obtained from QLD Health Central Ethics Unit RESULTS
(HREC/11/QHC/29). Among the total of 2 953 731 patients attending
all public hospital EDs in QLD from January 1, 2008
Study population to December 31, 2010, 2 905 204 (98.4%) spoke only
Patients were divided into groups according to English at home and 48 527 (1.6%) spoke another
the language spoken at home. Those who had been language at home. Table 1 describes the proportions
admitted to hospital, transferred to another hospital, of the patients' departure status, including those whose
left without being seen, left after the commencement ED service was completed and were discharged.
of treatment, or died in ED were excluded. Only Table 2 shows the interpreter requirements among

Table 1. The Chi-square test for departure statuses from ED by language spoken at home, QLD 2008–2010
Departure status
Languages
Admitted/Referred (%) Discharged (%) Did not wait (%) Died (%) Total
English 697 169 (24) 1 984 087 (68.3) 221 551 (7.6) 2 397 (0.1) 2 905 204 (100)
Chinese* 1 341 (26.4) 3 356 (66.0) 381 (7.5) 4 (0.1) 5 082 (100)
Vietnamese 893 (35.1) 1 478 (58.0) 173 (6.8) 3 (0.1) 2 547 (100)
Arabic 421 (18.8) 1 593 (71.1) 225 (10.0) 2 (0.1) 2 241 (100)
Spanish 629 (30.7) 1 285 (62.8) 129 (6.3) 4 (0.2) 2 047 (100)
Italian 981 (48.7) 976 (48.5) 55 (2.7) 1 (0.0) 2 013 (100)
Hindi 444 (29.0) 957 (62.5) 128 (8.4) 1 (0.1) 1 530 (100)
German 471 (36.8) 762 (59.5) 47 (3.7) 1 (0.1) 1 281 (100)
Other 10 649 (33.5) 18 962 (59.7) 2 062 (6.5) 113 (0.4) 31 786 (100)
Total 712 998 (24.1) 2 013 456 (68.2) 224 751 (7.6) 2 526 (0.1) 2 953 731 (100)
*
: Including Cantonese & Mandarin.

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World J Emerg Med, Vol 4, No 1, 2013 7

the different language groups. Patients who spoke DISCUSSION

Chinese, Vietnamese, Arabic, Spanish, Italian, Hindi, This is the first study in Queensland to compare
and German at home had a significantly (P<0.05) longer the length of stay (LOS) in public hospital Emergency
LOS compared to patients who spoke only English, Departments (EDs) among patients whose primary
controlling for gender, age, and triage category (Table language is not English to those who speak only English
3). Table 4 shows the differences in LOS after adding at home. Our study showed that patients who speak
interpreter requirement to the model. Vietnamese had a higher rate of interpreter use and a
The r2 for the first regression model was 0.12 and longer LOS than the other language groups. The patients
0.17 for the final model, suggesting that 12% and 17% who speak a language other than English at home had
of the variance, respectively, could be explained by these significantly longer LOS in the EDs. More specifically,
two models. 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
Table 2. Interpreter requirement in ED, QLD 2008–2010
Chinese speakers (8.6 minutes), compared to those who
Main languages Total no. Interpreter required (%) spoke only English at home. These findings agree with
English only* 1 984 087 386 (0.0) previous studies in other countries.[3,13,14]
Chinese** 3 356 666 (19.8) Public hospital EDs in Queensland see patients who
Vietnamese 1 478 342 (23.1) have little or no understanding of English due to a high
Arabic 1 593 298 (18.7)
proportion of immigrants living in the state. Additional
Spanish 1 285 208 (16.2)
Italian 976 114 (11.7) time is needed to obtain an interpreter, and even when an
Hindi 957 132 (13.8) interpreter is readily available, the emergency physician
German 762 44 (5.8) requires additional time for this interaction.[15] Thus, if
*
: Auslan language; **: Including Cantonese & Mandarin. 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
Table 3. Multiple linear regression (ORs and 95%CI) for LOS in EDs in LOS, controlling for language, triage category, gender,
among main languages spoken at home, adjusted for sex, age, and
triage categories, QLD 2008–2010 and age. That was improved significantly to 17% when
Main languages OR (95%CI) P
the interpreter requirement was added to the final model,
Reference group: English only which suggests the importance of this factor. This also
Chinese* 14.5 (9.3–19.6) 0.000 indicates that there are other influential factors affecting
Vietnamese 28.4 (24.5–32.3) 0.000 LOS in EDs which were not captured by our study.
Arabic 14.4 (11.9–16.8) 0.000
The first possible reason is that sometimes ED
Spanish 11.4 (9.3–13.5) 0.000
Italian 3.4 (1.5–5.3) 0.001 care providers use whoever bilingual and available at
Hindi 4.1 (2.5–5.7) 0.000 the ED such as a family member or hospital staff to
German 2.0 (0.5–3.5) 0.01 communicate with patients, rather than use a professional
*
: Including Cantonese & Mandarin. interpreter.[13,16] It was reported that using nonprofessional
interpreter might result in serious consequences including
breach of patient confidentiality, less understanding of
Table 4. Multiple linear regression (ORs and 95%CI) for LOS in EDs the patient's problems, un-necessary diagnostic tests,
among main languages spoken at home, adjusted for sex, age, triage
categories, and interpreter requirement, QLD 2008–2010 wrong diagnosis, wrong treatment, frequent ED visits,
Main languages OR (95%CI) P and reduced quality of care. [16–18] This would lead to
Reference group: English only higher health care costs, add greater burden to already
Chinese* 8.6 (2.6–14.6) 0.005 overcrowded EDs, and delay treatment.[18]
Vietnamese 26.3 (22.1–30.5) 0.000 The second possible reason is that some disadvantaged
Arabic 10.3 (7.3–13.2) 0.000
immigrants, such as refugees, might attend EDs with
Spanish 9.4 (7.1–11.7) 0.000
Italian 3.5 (1.6–5.4) 0.001 more advanced illnesses or complex conditions which
Hindi 4.0 (2.2–5.7) 0.000 require longer assessment, additional diagnostic tests,
German 2.7 (1.0–4.4) 0.001 and treatment times.[19] Unfortunately, patients' refugee
*
: Including Cantonese & Mandarin. status is not available for this study, and warrants future

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 8 Mahmoud et al World J Emerg Med, Vol 4, No 1, 2013

research in this area. the EDIS data, and particularly Jean Sloan, who extracted and
The third possible reason is the clinical situation provided the data.
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] Funding: None.
The fourth possible reason could be the cultural Ethical approval: Ethical approval to use unidentified data
was obtained from QLD Health Central Ethics Unit (HREC/11/
barriers. For example, women from Islamic or Middle
QHC/29).
Eastern cultures prefer to be seen by a female doctor, Conflicts of interest: The authors have no financial or other conflicts
which can prolong their LOS or cause them to leave the of interest regarding this article.
ED without seeing the doctor.[20,21] Contributors: Mahmoud I proposed and wrote the study. All
This specific culture could potentially explain the authors read and approved the final manuscript. Hou XY is the
guarantor.
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
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