Date: November 26th, 2022

Reference: James et al. Emergency Department Condition Acuity, Length of Stay, and Revisits Among Deaf and Hard-of-Hearing Patients: A Retrospective Chart Review. AEM November 2022

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine.

Click on the LINK for a transcript of the podcast

Case: One night you grab the next patient on the board, and upon entering the room introduce yourself as you normally would. The patient waves at you and gestures to a friend in the room, who explains that the patient is deaf and needs a sign language interpreter. You know from your brief look at the triage report that the patient’s vitals are stable and their chief complaint isn’t likely to be immediately life threatening, so you politely explain you’ll be back, and go find the charge nurse to obtain interpreter services.

Background: The emergency department sees anyone at anytime for anything. This includes some patients who have difficulty accessing the healthcare system due to social determinants of health, race, gender, mental health, substance use disorder, and physical difficulties.

Deaf and hard-of-hearing (DHH) experience disparities in social outcomes as well as health inequities (1), likely due to audism, which creates privilege for non-DHH people in our society (2).

DHH patients are more likely to use the ED than non-DHH patients, but little research has been done to compare ED-focused outcomes for these groups of patients (1, 3-4). DHH patients are heterogenous, with adult-onset DHH patients being less likely to use American Sign Language (ASL) with proficiency (5).

DHH ASL users may have delays due to interpreter availability, potentially resulting in care discrepancies (1, 6).

Clinical Question: How do deaf and hard-of-hearing (DHH) American Sign Language speakers and DHH English speakers utilize the ED, specifically regarding acuity of complaints and pain, what is their ED length of stay and what is the prevalence of acute revisits?

Reference: James et al. Emergency Department Condition Acuity, Length of Stay, and Revisits Among Deaf and Hard-of-Hearing Patients: A Retrospective Chart Review, AEM November 2022

  • Population: All DHH-American Sign Language, DHH-English speakers, non-DHH English speakers users who had used a single academic center for care
    • Excluded: Patients who had not had an ED visit during the time period
  • Intervention: None
  • Comparison: Non-DHH English speakers were compared to DHH ASL-users and DHH English speakers
  • Outcomes:
    • Primary Outcome: Emergency Severity Index (ESI), triage pain score, ED length of stay (LOS), and acute ED revisit (defined as within 9 days)
  • Type of Study: Retrospective chart review of a single health care system

Dr. Tyler James

This is an SGEMHOP episode which means we have the lead author on the show Dr. Tyler James. Dr. James is a Postdoctoral Research Fellow in the Department of Family Medicine at the University of Michigan Medical School. His research focuses on healthcare access, utilization, and delivery for people with disabilities, with specific interest in working with people with sensory disabilities. He is also a mixed methods research methodologist, and serves as Associate Editor for Media Reviews of the Journal of Mixed Methods Research.

Authors’ Conclusions: Our study identified that DHH ASL-users have longer ED LOS than non-DHH English-speakers. Additional research is needed to further explain the association between DHH status and ED care outcomes (including ED LOS, and acute revisit), which may be used to identify intervention targets to improve health equity.

Quality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Yes
  5. Was the outcome accurately measured to minimize bias? Yes
  6. Have the authors identified all important confounding factors? Yes
  7. Was the follow up of subjects complete enough? Yes
  8. How precise are the results? Fairly precise
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Unsure
  11. Do the results of this study fit with other available evidence? Yes
  12. Funding of the Study: Agency for Healthcare Research and Quality, and the National Center for Advancing Translational Sciences of the National Institutes of Health under University of Florida Clinical and Translational Science

Results: The sample included 100% of DHH-ASL people (n=277). This was compared to 1,000 randomly sampled DHH English speakers, and 1,000 randomly sampled non-DHH English speakers. Of this total sample, 39%, 36% and 30% had an ED visit during the study time frame and were analyzed. The Mean age was mid to late 40’s, ~55% were women and about two-thirds identified as white.

Key Result: There were no statistical differences in ESI, triage pain score, or acute ED visits but DHH ASL patients had longer ED LOS.

  • Primary Outcome:
    • Emergency Severity Index (ESI): When compared to non-DHH English speakers, neither DHH ASL users nor DHH English speakers had higher odds of being classified into lower-acuity ESI levels.
    • Triage Pain Score: On a scale of 0 to 10 the mean score was 5.8 and the median was 7. Neither of the DHH patient groups had pain scale ratings significantly different than non-DHH English speakers.
    • Acute ED Revisit: This was defined as a return within nine days. Ten percent of patients had acute revisits to the ED. There was no statistical difference between the groups for this metric.
    • Length of Stay: DHH ASL-using patients stayed in the ED 9% longer than non-DHH English-speaking patients (IRR 1.09, 95% CI 1.05 to 1.13, P = 0.016). On average, this equated to approximately 30 min longer ED LOS (95% CI 17 to 44 min). There were no significant differences between DHH English-speaking patients and non-DHH English speakers

For a transcript of this podcast and all of Tyler’s responses to our nerdy questions clinic on this LINK.

1. Selecting the Cohort: Can you explain the decision to start with the cohort of patients who utilized any of the medical center facilities and then select those who presented to the ED, as opposed to just isolating DHH patients from all ED visits?

2. Return Visit: Often in ED literature, we see 72-hour return visits or seven-day returns. In addition, two weeks is sometimes used or even one month. Why did you decide to use nine days for your acute ED revisit metric?

3. Patient Level Data: I understand how it’s important to look at patient-level and encounter-level data, as a small subset of patients may have many encounters. However, how is this used for revisits, as that measurement seems to me to be a patient-specific outcome?

4. Length of Stay: The only metric measured that was statistically different was the ED LOS. It was 30 minutes longer in DHH ASL-using patients or approximately 9% compared to non-DHH English-speaking patients. Do you think this is clinically significant and we should be cautious not to over-interpret a single-centre retrospective observational data?

5. Any Thing Else: Is there any other data or themes that you want to highlight from this publication?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ cautious conclusions.

SGEM Bottom Line: Deaf and hard-of-hearing (DHH) patients present to the ED with similar acuity levels, triage pain scores and had no significant difference in acute ED revisits compared to non-DHH English speaking patients. However, there was an association observed between DHH-ASL patients and longer ED LOS comparted to non-DHH English speaking patients.

Dr. Corey Heitz

Case Resolution: Fortunately, your ED has on-site interpreter ASL services that can be accessed quickly and efficiently. This service is preferred to an online, remote interpreter system due to technical difficulties, lack of staff training, which can lead to poor patient-provider communication (7).

Clinical Application: Deaf and hard of hearing patients should be triaged and treated with the same level of concern and care. Use of interpreter services is essential as with any non-English speaking patient.

What Do I Tell the Patient? Thank you for your patience while we obtained interpreter services. How may we help you today?

Keener Kontest: Last weeks’ winner was a repeat win for Dr. Cindy Bitter. She knew acute pancreatitis was first described in 1652 by Dutch anatomist Nicholas Tulp.

Listen to the podcast this week to hear the trivia question. Send your answer to with “Keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on DHH in the ED? What questions do you have for Tyler and this team? Tweet your comments using #SGEMHOP or post your feedback on the SGEM blog. The best social media feedback will be published in AEM.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.


  1. James TG, Varnes JR, Sullivan MK, et al. Conceptual model of emergency department utilization among deaf and hard-of-hearing patients: A critical review. Int J Environ Res Public Health [Internet] 2021 [cited 2021 Dec 9];18(24):12901. Available from:
  2. Bauman H-DL. Audism: Exploring the metaphysics of oppression. J Deaf Stud Deaf Educ 2004;9(2):239–46.
  3. McKee MM, Winters PC, Sen A, Zazove P, Fiscella K. Emergency department utilization among deaf American Sign Language users. Disabil Health J 2015;8(4):573–8.
  4. James TG, McKee MM, Miller MD, et al. Emergency department utilization among deaf and hard-of-hearing patients: A retrospective chart review. Disabil Health J 2022
  5. Zazove P, Meador HE, Reed BD, Gorenflo DW. Deaf persons’ english reading levels and associations with epidemiological, educational, and cultural factors. J Health Commun 2013;18(7):760–72.
  6. James TG, Coady KA, Stacciarini J-MR, et al. “They’re not willing to accommodate Deaf patients”: Communication experiences of Deaf American Sign Language users in the emergency department. Qual Health Res 2022;32(1):48–63.
  7. James et al., 2022, Qualitative Health Research; Kushalnagar et al., 2019, JMIR Rehab Assist Technology