Race and Ethnicity and the Utilization of Security Responses in a Hospital Setting

Disparities Associated With Electronic Behavioral Alerts for Safety and Violence Concerns in the Emergency Department

STUDY OBJECTIVE

Although electronic behavioral alerts are placed as an alert flag in the electronic health record to notify staff of previous behavioral and/or violent incidents in emergency departments (EDs), they have the potential to reinforce negative perceptions of patients and contribute to bias. We provide characterization of ED electronic behavioral alerts using electronic health record data across a large, regional health care system.

METHODS

We conducted a retrospective cross-sectional study of adult patients presenting to 10 adult EDs within a Northeastern United States health care system from 2013 to 2022. Electronic behavioral alerts were manually screened for safety concerns and then categorized by the type of concern. In our patient-level analyses, we included patient data at the time of the first ED visit where an electronic behavioral alert was triggered or, if a patient had no electronic behavioral alerts, the earliest visit in the study period. We performed a mixed-effects regression analysis to identify patient-level risk factors associated with safety-related electronic behavioral alert deployment.

RESULTS

Of the 2,932,870 ED visits, 6,775 (0.2%) had associated electronic behavioral alerts across 789 unique patients and 1,364 unique electronic behavioral alerts. Of the encounters with electronic behavioral alerts, 5,945 (88%) were adjudicated as having a safety concern involving 653 patients. In our patient-level analysis, the median age for patients with safety-related electronic behavioral alerts was 44 years (interquartile range 33 to 55 years), 66% were men, and 37% were Black. Visits with safety-related electronic behavioral alerts had higher rates of discontinuance of care (7.8% vs 1.5% with no alert; P<.001) as defined by the patient-directed discharge, left-without-being-seen, or elopement-type dispositions. The most common topics in the electronic behavioral alerts were physical (41%) or verbal (36%) incidents with staff or other patients. In the mixed-effects logistic analysis, Black non-Hispanic patients (vs White non-Hispanic patients: adjusted odds ratio 2.60; 95% confidence interval [CI] 2.13 to 3.17), aged younger than 45 (vs aged 45-64 years: adjusted odds ratio 1.41; 95% CI 1.17 to 1.70), male (vs female: adjusted odds ratio 2.09; 95% CI 1.76 to 2.49), and publicly insured patients (Medicaid: adjusted odds ratio 6.18; 95% CI 4.58 to 8.36; Medicare: adjusted odds ratio 5.63; 95% CI 3.96 to 8.00 vs commercial) were associated with a higher risk of a patient having at least 1 safety-related electronic behavioral alert deployment during the study period.

CONCLUSION

In our analysis, younger, Black non-Hispanic, publicly insured, and male patients were at a higher risk of having an ED electronic behavioral alert. Although our study is not designed to reflect causality, electronic behavioral alerts may disproportionately affect care delivery and medical decisions for historically marginalized populations presenting to the ED, contribute to structural racism, and perpetuate systemic inequities.

Frequency of Perceived Conflict between Families and Clinicians at Time of Clinical Ethics Consultation in Hospitalized Children

BACKGROUND

Little is known about the frequency of conflict between clinicians and families at the time of pediatric clinical ethics consultation (CEC) and what factors are associated with the presence of conflict.

METHODS

We conducted a retrospective cohort study at a single, tertiary urban US pediatric hospital that included all hospitalized patients between January 2008 and December 2019 who received CEC. Utilizing the hospital's CEC database that requires documentation of the presence of conflict by the consultant at the time of CEC, we determined the frequency and types of perceived conflict between families and clinicians. We also assessed the bivariable association between conflict and patient age, patient- or family-reported race/ethnicity, language for care, insurance status, clinical setting, and consultant involvement.

RESULTS

Perceived conflict between clinicians and families was present in 44% (91/209) of CEC. We observed a higher occurrence of clinician-family conflict within certain consult topics than others, in particular, informed consent/parental permission (69%), cultural considerations (67%), benefit/harm assessment (58%), and limitation of life-sustaining treatment (58%). We found no other significant associations between the presence of perceived conflict and patient sociodemographic factors or CEC factors.

CONCLUSIONS

Conflict between healthcare teams and families appears common in CEC, particularly with certain consult topics. Further study is needed to better understand conflict types, causes of conflicts, management and mediation strategies, and outcomes.

Limited English Proficiency and Sepsis Mortality by Race and Ethnicity

Importance

Patients with limited English proficiency (LEP) face multiple barriers and are at risk for worse health outcomes compared with patients with English proficiency (EP). In sepsis, a major cause of mortality in the US, the association of LEP with health outcomes is not widely explored.

Objective

To assess the association between LEP and inpatient mortality among patients with sepsis and test the hypothesis that LEP would be associated with higher mortality rates.

Design, Setting, and Participants

This retrospective cohort study of hospitalized patients with sepsis included those who met the Centers for Disease Control and Prevention's sepsis criteria, received antibiotics within 24 hours, and were admitted through the emergency department. Data were collected from the electronic medical records of a large New England tertiary care center from January 1, 2016, to December 31, 2019. Data were analyzed from January 8, 2021, to March 2, 2023.

Exposures

Limited English proficiency, gathered via self-reported language preference in electronic medical records.

Main Outcomes and Measures

The primary outcome was inpatient mortality. The analysis used multivariable generalized estimating equation models with propensity score adjustment and analysis of covariance to analyze the association between LEP and inpatient mortality due to sepsis.

Results

A total of 2709 patients met the inclusion criteria, with a mean (SD) age of 65.0 (16.2) years; 1523 (56.2%) were men and 327 (12.1%) had LEP. Nine patients (0.3%) were American Indian or Alaska Native, 101 (3.7%) were Asian, 314 (11.6%) were Black, 226 (8.3%) were Hispanic, 38 (1.4%) were Native Hawaiian or Other Pacific Islander or of other race or ethnicity, 1968 (72.6%) were White, and 6 (0.2%) were multiracial. Unadjusted mortality included 466 of 2382 patients with EP (19.6%) and 69 of 327 with LEP (21.1%). No significant difference was found in mortality odds for the LEP compared with EP groups (odds ratio [OR], 1.12 [95% CI, 0.88-1.42]). When stratified by race and ethnicity, odds of inpatient mortality for patients with LEP were significantly higher among the non-Hispanic White subgroup (OR, 1.76 [95% CI, 1.41-2.21]). This significant difference was also present in adjusted analyses (adjusted OR, 1.56 [95% CI, 1.02-2.39]). No significant differences were found in inpatient mortality between LEP and EP in the racial and ethnic minority subgroup (OR, 0.99 [95% CI, 0.63-1.58]; adjusted OR, 0.91 [95% CI, 0.56-1.48]).

Conclusions and Relevance

In a large diverse academic medical center, LEP had no significant association overall with sepsis mortality. In a subgroup analysis, LEP was associated with increased mortality among individuals identifying as non-Hispanic White. This finding highlights a potential language-based inequity in sepsis care. Further studies are needed to understand drivers of this inequity, how it may manifest in other diverse health systems, and to inform equitable care models for patients with LEP.

Violence in the pain clinic: the hidden pandemic

Workplace violence is any physical assault, threatening behavior or other verbal abuse directed toward persons at work or in the workplace. The incidence of workplace violence in healthcare settings in general and more specifically the pain clinic is thought to be underestimated due to hesitancy to report, lack of support from management and healthcare systems, and lack of institutional policies as it relates to violence from patients against healthcare workers. In the following article, we explore risk factors that place clinicians at risk of workplace violence, the cost and impact of workplace violence, how to build a violence prevention program and lastly how to recover from violence in the practice setting.

Structural Racism in Behavioral Health Presentation and Management

Nia is a first-grade student with a history of trauma who was brought in by ambulance to the pediatric emergency department for "out of control behavior" at school. This is the first of multiple presentations to the emergency department for psychiatric evaluation, stabilization, and management throughout her elementary and middle school years. Several of the visits resulted in admission to the inpatient pediatric service, where she "boarded" while awaiting transfer to an inpatient psychiatric facility. At times, clinical teams used involuntary emergency medications and physical restraints, as well as hospital security presence at the bedside, to control Nia's behavior. Nia is Black and her story is a case study of how structural racism manifests for an individual child. Her story highlights the impact of adultification bias and the propensity to mislabel Black youth with diagnoses characterized by fixed patterns of negative behaviors, as opposed to recognizing normative reactions to trauma or other adverse childhood experiences-in Nia's case, poverty, domestic violence, and Child Protective Services involvement. In telling Nia's story, we (1) define racism and discuss the interplay of structural, institutional, and interpersonal racism in the health care, education, and judicial systems; (2) highlight the impact of adultification bias on Black youth; (3) delineate racial disparities in behavioral health diagnosis and management, school discipline and exclusion, and health care's contributions to the school-to-prison pipeline; and finally (4) propose action steps to mitigate the impact of racism on pediatric mental health and health care.