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Morra C, Nguyen K, Sieracki R, Pavlic A, Barry C. Trauma-informed Care Training in Trauma and Emergency Medicine: A Review of the Existing Curricula. West J Emerg Med 2024; 25:423-430. [PMID: 38801050 PMCID: PMC11112657 DOI: 10.5811/westjem.18394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 12/29/2023] [Accepted: 01/04/2023] [Indexed: 05/29/2024] Open
Abstract
Background and Objectives Greater lifetime exposure to psychological trauma correlates with a higher number of health comorbidities and negative health outcomes. However, physicians often are not specifically trained in how to care for patients with trauma, especially in acute care settings. Our objective was to identify implemented trauma-informed care (TIC) training protocols for emergency and/or trauma service physicians that have both sufficient detail that they can be adapted and outcome data indicating positive impact. Methods We conducted a comprehensive literature search in MEDLINE (Ovid), Scopus, PsycInfo, Web of Science, Cochrane Library, Ebsco's Academic Search Premier, and MedEdPORTAL. Inclusion criteria were EM and trauma service clinicians (medical doctors, physician assistants and nurse practitioners, residents), adult and/or pediatric patients, and training evaluation. Evaluation was based on the Kirkpatrick Model. Results We screened 2,280 unique articles and identified two different training protocols. Results demonstrated the training included patient-centered communication and interprofessional collaboration. One curriculum demonstrated that targeted outcomes were due to the training (Level 4). Both curricula received overall positive reactions (Level 1) and illustrated behavioral change (Level 3). Neither were found to specifically illustrate learning due to the training (Level 2). Conclusion Study findings from our review show a paucity of published TIC training protocols that demonstrate positive impact and are described sufficiently to be adopted broadly. Current training protocols demonstrated an increasing comfort level with the TIC approach, integration into current practices, and referrals to trauma intervention specialists.
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Affiliation(s)
| | - Kevin Nguyen
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Ashley Pavlic
- Medical College of Wisconsin, Department of Emergency Medicine, Milwaukee, Wisconsin
| | - Courtney Barry
- Medical College of Wisconsin, Department of Psychiatry and Behavioral Medicine, Milwaukee, Wisconsin
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Wong AH, Nath B, Shah D, Kumar A, Brinker M, Faustino IV, Boyce M, Dziura JD, Heckmann R, Yonkers KA, Bernstein SL, Adapa K, Taylor RA, Ovchinnikova P, McCall T, Melnick ER. Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol. BMJ Open 2024; 14:e082834. [PMID: 38373857 PMCID: PMC10882402 DOI: 10.1136/bmjopen-2023-082834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
INTRODUCTION The burden of mental health-related visits to emergency departments (EDs) is growing, and agitation episodes are prevalent with such visits. Best practice guidance from experts recommends early assessment of at-risk populations and pre-emptive intervention using de-escalation techniques to prevent agitation. Time pressure, fluctuating work demands, and other systems-related factors pose challenges to efficient decision-making and adoption of best practice recommendations during an unfolding behavioural crisis. As such, we propose to design, develop and evaluate a computerised clinical decision support (CDS) system, Early Detection and Treatment to Reduce Events with Agitation Tool (ED-TREAT). We aim to identify patients at risk of agitation and guide ED clinicians through appropriate risk assessment and timely interventions to prevent agitation with a goal of minimising restraint use and improving patient experience and outcomes. METHODS AND ANALYSIS This study describes the formative evaluation of the health record embedded CDS tool. Under aim 1, the study will collect qualitative data to design and develop ED-TREAT using a contextual design approach and an iterative user-centred design process. Participants will include potential CDS users, that is, ED physicians, nurses, technicians, as well as patients with lived experience of restraint use for behavioural crisis management during an ED visit. We will use purposive sampling to ensure the full spectrum of perspectives until we reach thematic saturation. Next, under aim 2, the study will conduct a pilot, randomised controlled trial of ED-TREAT at two adult ED sites in a regional health system in the Northeast USA to evaluate the feasibility, fidelity and bedside acceptability of ED-TREAT. We aim to recruit a total of at least 26 eligible subjects under the pilot trial. ETHICS AND DISSEMINATION Ethical approval by the Yale University Human Investigation Committee was obtained in 2021 (HIC# 2000030893 and 2000030906). All participants will provide informed verbal consent prior to being enrolled in the study. Results will be disseminated through publications in open-access, peer-reviewed journals, via scientific presentations or through direct email notifications. TRIAL REGISTRATION NUMBER NCT04959279; Pre-results.
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Affiliation(s)
- Ambrose H Wong
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Dhruvil Shah
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anusha Kumar
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Morgan Brinker
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Isaac V Faustino
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael Boyce
- Yale New Haven Health System, New Haven, Connecticut, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Rebekah Heckmann
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kimberly A Yonkers
- Department of Psychiatry, University of Massachusetts System, Worchester, Massachusetts, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Karthik Adapa
- Carolina Health Informatics Program, University of North Carolina System, Chapel Hill, North Carolina, USA
| | - Richard Andrew Taylor
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Polina Ovchinnikova
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Terika McCall
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut, USA
| | - Edward R Melnick
- Yale New Haven Health System, New Haven, Connecticut, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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3
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Haimovich AD, Taylor RA, Chang-Sing E, Brashear T, Cramer LD, Lopez K, Wong AH. Disparities Associated With Electronic Behavioral Alerts for Safety and Violence Concerns in the Emergency Department. Ann Emerg Med 2024; 83:100-107. [PMID: 37269262 PMCID: PMC10689576 DOI: 10.1016/j.annemergmed.2023.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/12/2023] [Accepted: 04/05/2023] [Indexed: 06/05/2023]
Abstract
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.
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Affiliation(s)
- Adrian D Haimovich
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - R Andrew Taylor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - Erika Chang-Sing
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Taylor Brashear
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Laura D Cramer
- National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT
| | - Kevin Lopez
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Yau BN, Aggarwal R, Coverdale J, Guerrero APS, Beresin EV, Brenner AM. Beyond Psychopharmacology: the Interpersonal Dynamics of Agitation Management. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2024; 48:1-4. [PMID: 38062338 DOI: 10.1007/s40596-023-01919-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Affiliation(s)
- Bernice N Yau
- Columbia University Irving Medical Center, New York, NY, USA.
| | | | | | | | | | - Adam M Brenner
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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5
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Agboola IK, Rosenberg A, Robinson L, Brashear TK, Eixenberger C, Shah D, Pavlo AJ, Im DD, Ray JM, Coupet E, Wong AH. A Qualitative Study of Racial, Ethnic, and Cultural Experiences of Minority Clinicians During Agitation Care in the Emergency Department. Ann Emerg Med 2024; 83:108-119. [PMID: 37855791 PMCID: PMC10843036 DOI: 10.1016/j.annemergmed.2023.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Abstract
STUDY OBJECTIVE Racial and ethnic bias in health care has been documented at structural, organizational, and clinical levels, impacting emergency care, including agitation management in the emergency department (ED). Little is known about the experiences of racial and ethnic minority ED clinicians caring for racial and ethnic minority groups, especially during their agitated state. The objective of this study was to explore the lived experiences of racial and ethnic minority ED clinicians who have treated patients with agitation in the ED. METHODS We performed semistructured individual interviews of Black, Latino, and multiracial clinicians who worked at 1 of 3 EDs from an urban quaternary care medical center in the Northeast United States between August 2020 and June 2022. We performed thematic analysis through open coding of initial transcripts and identifying additional codes through sequential iterative rounds of group discussion. Once the codebook was finalized and applied to all transcripts, the team identified key themes and subthemes. RESULTS Of the 27 participants interviewed, 14 (52%) identified as Black, 9 (33%) identified as Hispanic/Latino, and 4 (15%) identified as multiracial and/or other race and ethnicity. Three primary themes emerged from racial and ethnic minority clinician experiences of managing agitation: witness of perceived bias during clinical interactions with patients of color who bear racialized presumptions of agitation, moral injury and added workload to address perceived biased agitation management practices while facing discrimination in the workplace, and natural advocacy and allyship for agitated patients of color based on a shared identity and life experience. CONCLUSIONS Our study found that through their shared minority status, racial and ethnic minority clinicians had a unique vantage point to observe perceived bias in the management of agitation in minority patients. Although they faced added challenges as racial and ethnic minority clinicians, their allyship offered potential mitigation strategies for addressing disparities in caring for an underserved and historically marginalized patient population.
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Affiliation(s)
- Isaac K Agboola
- Department of Emergency Medicine, NorthShore University Health System, Evanston, Illinois; Department of Emergency Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alana Rosenberg
- SEICHE Center for Health and Justice, Yale School of Medicine, New Haven, Connecticut
| | - Leah Robinson
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Taylor K Brashear
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Dhruvil Shah
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Anthony J Pavlo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Dana D Im
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica M Ray
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
| | - Edouard Coupet
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.
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Im DD, Bukhman AK, Joseph JW, Dziobek JC, Grant J, Clifford KC, Kim I, Chen PC, Schmelzer NA, Powell R, Waters B, Dundin A, Askman N, Lassiter T, Baymon DE, Shankar K, Sanchez LD. Code De-Escalation: Decreasing restraint use during agitation management in a community hospital emergency department. Am J Emerg Med 2024; 76:193-198. [PMID: 38091903 DOI: 10.1016/j.ajem.2023.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 01/22/2024] Open
Abstract
INTRODUCTION Restraint use in the emergency department (ED) can pose significant risks to patients and health care workers. We evaluate the effectiveness of Code De-escalation- a standardized, team-based approach for management and assessment of threatening behaviors- in reducing physical restraint use and workplace violence in a community ED. METHODS A retrospective observational study of a pathway on physical restraint use among patients placed on an involuntary psychiatric hold in a community ED. This pathway includes a built-in step for the team members to systematically assess perceptions of threats from the patient behavior and threats perceived by the patient. Our primary outcome was the change in the rate of physical restraint use among patients on an involuntary psychiatric hold. Our secondary outcome was the change in the rate of workplace violence events involving all ED encounters. We evaluated our outcomes by comparing all encounters in a ten-month period before and after implementation, and compared our results to rates at neighboring community hospitals within the same hospital network. RESULTS Pre intervention there were 434 ED encounters involving a psychiatric hold, post-intervention there were 535. We observed a significant decrease in physical restraint use, from 7.4% to 3.7% (ARR 0.028 [95% CI 0.002-0.055], p < 0.05). This was not seen at the control sites. CONCLUSIONS A standardized de-escalation algorithm can be effective in helping ED's decrease their use of physical restraints in management of psychiatric patients experiencing agitation.
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Affiliation(s)
- Dana D Im
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA.
| | - Alice K Bukhman
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Josh W Joseph
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Jim C Dziobek
- Mass General Brigham, Office of the Chief Medical Officer, 399 Revolution Drive, Somerville, MA 02145, USA
| | - Jill Grant
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA
| | - Kathleen C Clifford
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Inkyu Kim
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Naomi A Schmelzer
- Department of Psychiatry, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, 2(nd) floor, Boston, MA 02130, USA
| | - Robin Powell
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA
| | - Beth Waters
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA
| | - Andrew Dundin
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Noah Askman
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Terrance Lassiter
- Department of Police, Security, Safety, and Parking, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA
| | - Da'Marcus E Baymon
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Kalpana Shankar
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
| | - Leon D Sanchez
- Department of Emergency Medicine, Brigham and Women's Faulkner Hospital, Boston, MA, 1153 Centre Street, Boston, MA 02130, USA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, 75 Francis Street, NH-2, Boston, MA 02115, USA
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Pino EC, Gonzalez F, Nelson KP, Jaiprasert S, Lopez GM. Disparities in use of physical restraints at an urban, minority-serving hospital emergency department. Acad Emerg Med 2024; 31:6-17. [PMID: 37597262 DOI: 10.1111/acem.14792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Recent reports have identified associations between patient race and ethnicity and use of physical restraint while receiving care in the emergency department (ED). However, no study has assessed this relationship in hospitals primarily treating patients of color and underserved populations. The primary objective of this study was to evaluate the association between race/ethnicity and the use of restraints in an ED population at a minority-serving, safety-net institution. METHODS For this cross-sectional study, chart review identified all adult patients presenting to the Boston Medical Center ED between January 2018 and April 2021. Generalized estimating equation logistic regression modeling was conducted to evaluate associations between race and use of restraints. RESULTS Of 348,384 ED visits (22.9% White, 46.7% Black, 23.1% Hispanic), 1852 (0.5%) had an associated physical restraint order. Multivariable models showed significant interactions (p = 0.02) between race/ethnicity, behavioral health diagnosis, and sex on the primary outcome of physical restraint. Stratified analysis revealed that among patients with no behavioral health diagnoses, Black (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.34-0.72, p = 0.0003) and Hispanic (OR 0.35, 95% CI 0.20-0.63, p = 0.0004) patients had lower odds of restraint than White patients. Among female patients with a mental health and/or substance use disorder diagnosis, Black (OR 1.95, 95% CI 1.49-2.54, p < 0.0001) and Hispanic (OR 2.13, 95% CI 1.49-3.03, p < 0.0001) patients had higher odds of restraint than White patients. Similar trends were observed for Black male patients (OR 1.60, 95% CI 1.34-1.91, p < 0.0001) but not for Hispanic male patients (OR 0.96, 95% CI 0.73-1.26, p = 0.77) with behavioral health diagnoses who had similar odds of restraint to White patients. Additional factors associated with physical restraint include younger age, public or lack of insurance, and ED visits during the pandemic. CONCLUSIONS Racial disparities exist in restraint utilization at this minority-serving safety-net hospital; however, these disparities are modified by sex and by behavioral health diagnoses. The reasons for these disparities may be multifactorial and warrant further investigation.
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Affiliation(s)
- Elizabeth C Pino
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Felisha Gonzalez
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kerrie P Nelson
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sorraya Jaiprasert
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Gina M Lopez
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
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Macias-Konstantopoulos WL, Collins KA, Diaz R, Duber HC, Edwards CD, Hsu AP, Ranney ML, Riviello RJ, Wettstein ZS, Sachs CJ. Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity. West J Emerg Med 2023; 24:906-918. [PMID: 37788031 PMCID: PMC10527840 DOI: 10.5811/westjem.58408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 04/17/2023] [Accepted: 05/24/2023] [Indexed: 10/04/2023] Open
Abstract
An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.
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Affiliation(s)
- Wendy L Macias-Konstantopoulos
- Center for Social Justice and Health Equity, Department of Emergency Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | | | - Rosemarie Diaz
- University of California-Los Angeles, Department of Emergency Medicine, Los Angeles, California
| | - Herbert C Duber
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
- Washington State Department of Health, Tumwater, Washington
| | - Courtney D Edwards
- Samford University, Moffett & Sanders School of Nursing, Birmingham, Alabama
| | - Antony P Hsu
- Trinity Health Ann Arbor Hospital, Department of Emergency Medicine, Ypsilanti, Michigan
| | - Megan L Ranney
- Yale University, Yale School of Public Health, New Haven, Connecticut
| | - Ralph J Riviello
- University of Texas Health San Antonio, Department of Emergency Medicine, San Antonio, Texas
| | - Zachary S Wettstein
- University of Washington School of Medicine, Department of Emergency Medicine, Seattle, Washington
| | - Carolyn J Sachs
- Ronald Reagan-UCLA Medical Center and David Geffen School of Medicine at University of California-Los Angeles, Department of Emergency Medicine, Los Angeles, California
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Lewis‐O'Connor A, Olson R, Grossman S, Nelson D, Levy‐Carrick N, Stoklosa H, Banning S, Rittenberg E. Factors that influence interprofessional implementation of trauma-informed care in the emergency department. J Am Coll Emerg Physicians Open 2023; 4:e13001. [PMID: 37469488 PMCID: PMC10352596 DOI: 10.1002/emp2.13001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/30/2023] [Accepted: 06/09/2023] [Indexed: 07/21/2023] Open
Abstract
Background To describe factors that influence interprofessional staff decisions and ability to implement trauma-informed care (TIC) in a level-one emergency department (ED) trauma center. Methods This qualitative research study consisted of semi-structured interviews and quantitative surveys that were conducted between March and December 2020 at an urban trauma center. Eligible participants were staff working in the ED. Interview questions were developed using the Theoretical Domains Framework (TDF), which is designed to identify influences on health professional behavior related to implementation of evidence-based recommendations. Interview responses were transcribed, coded using Atlas software, and analyzed using thematic analysis. Results Key themes identified included awareness of TIC principles, impact of TIC on staff and patients, and experiences of bias. Participants identified opportunities to improve care for patients with a trauma history, including staff training, more time with patients, and efforts to decrease bias toward patients. Most participants (85.7%) felt that a TIC plan, tiered trauma inquiry, and warm handovers would be easy or very easy to implement. Conclusion We identified key interprofessional staff beliefs and attitudes that influence implementation of TIC in the ED. These factors represent potential individual, team-based, and organizational targets for behavior change interventions to improve staff response to patient trauma and to address secondary trauma experienced by ED staff.
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Affiliation(s)
- Annie Lewis‐O'Connor
- Division of Women's Health, Department of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Rose Olson
- Department of Medicine, Brigham and Women's HospitalBostonMassachusettsUSA
| | - Samara Grossman
- Department of PsychiatryBrigham and Women's HospitalBostonMassachusettsUSA
| | - Derek Nelson
- Division of Women's Health, Department of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Nomi Levy‐Carrick
- Department of PsychiatryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of PsychiatryHarvard Medical SchoolBostonMassachusettsUSA
| | - Hanni Stoklosa
- Department of International Emergency Medicine and Humanitarian ProgramsBrigham and Women's HospitalBostonMassachusettsUSA
- Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Stephanie Banning
- Department of Medicine, Brigham and Women's HospitalBostonMassachusettsUSA
| | - Eve Rittenberg
- Division of Women's Health, Department of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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10
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Lee CH, Santos CD, Brown T, Ashworth H, Lewis JJ. Trauma-Informed Care for Acute Care Settings: A Novel Simulation Training for Medical Students. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2023; 19:11327. [PMID: 37520013 PMCID: PMC10376910 DOI: 10.15766/mep_2374-8265.11327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 04/11/2023] [Indexed: 08/01/2023]
Abstract
Introduction Physicians often care for patients who have experienced traumatic events including abuse, discrimination, and violence. Trauma-informed care (TIC) is a framework that recognizes the prevalence of trauma, promotes patient empowerment, and minimizes retraumatization. There are limited education curricula on how to apply TIC to acute care settings, with simulation-based training presenting a novel educational tool for this aim. Methods Students participated in a didactic on TIC principles and its applications in acute care settings. Learners participated in three simulation cases where they performed physical exams and gathered history on patients with urgent medical needs related to intimate partner violence, transgender health, and health care discrimination. Debriefing followed each simulation. Results Seventeen medical students participated across four sessions. The sessions were evaluated with pre- and postparticipation surveys, including Likert scales and free-response questions. After participation, individuals' self-assessed confidence improved across multiple domains, including identifying situations for trauma screenings, inquiring about trauma, and responding as a bystander. Learners also felt more familiar with TIC-specific history taking and physical exam skills. Finally, simulation was perceived as a beneficial educational tool. All findings were statistically significant (p ≤ .01). Discussion Our simulation-based training enabled students to practice conversations and interventions related to trauma. This novel training represents a feasible and effective means for teaching TIC for acute care settings, including in the emergency department and in-patient settings. Development and evaluation were supported by the Society for Academic Emergency Medicine.
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Affiliation(s)
| | | | - Taylor Brown
- Second-Year Resident, Department of Emergency Medicine, Beth Israel Deaconess Medical Center
| | - Henry Ashworth
- First-Year Resident, Department of Emergency Medicine, Highland Hospital, Alameda Health System
| | - Jason J. Lewis
- Assistant Professor, Department of Emergency Medicine, Beth Israel Deaconess Medical Center
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11
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Ashworth H, Lewis-O'Connor A, Grossman S, Brown T, Elisseou S, Stoklosa H. Trauma-informed care (TIC) best practices for improving patient care in the emergency department. Int J Emerg Med 2023; 16:38. [PMID: 37208640 DOI: 10.1186/s12245-023-00509-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/03/2023] [Indexed: 05/21/2023] Open
Abstract
A patient's current or previous experience of trauma may have an impact on their health and affect their ability to engage in health care. Every year, millions of patients who have experienced physically or emotionally traumatic experiences present to emergency departments (ED) for care. Often, the experience of being in the ED itself can exacerbate patient distress and invoke physiological dysregulation. The physiological reactions that lead to fight, flight, or freeze responses can make providing care to these patients complex and can even lead to harmful encounters for providers. There is a need to improve the care provided to the vast number of patients in the ED and create a safer environment for patients and healthcare workers. One solution to this complex challenge is understanding and integrating trauma-informed care (TIC) into emergency services. The federal Substance Abuse and Mental Health Service Administration's (SAMHSA) six guiding principles of TIC offer a universal precaution framework that ensures quality care for all patients, providers, and staff in EDs. While there is growing evidence that TIC quantitatively and qualitatively improves ED care, there is a lack of practical, emergency medicine-specific guidance on how to best operationalize TIC. In this article, using a case example, we outline how emergency medicine providers can integrate TIC into their practice.
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Affiliation(s)
- Henry Ashworth
- Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, CA, USA.
| | | | - Samara Grossman
- Department of Psychiatry, Boston Public Health Commission, Boston, MA, USA
| | - Taylor Brown
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sadie Elisseou
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Hanni Stoklosa
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- HEAL Trafficking, Los Angeles, CA, USA
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12
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Hutton J, Gunatillake T, Barnes D, Phillips G, Maplesden J, Chan A, Shanahan P, Zordan R, Sundararajan V, Arabena K, Quigley A, Pynor-Greedy T, Mason T. Characteristics of First Nations patients who take their own leave from an inner-city emergency department, 2016-2020. Emerg Med Australas 2023; 35:74-81. [PMID: 36041727 PMCID: PMC10087393 DOI: 10.1111/1742-6723.14057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/29/2022] [Accepted: 07/26/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Using a strength-based framework, we aimed to describe and compare First Nations patients who completed care in an ED to those who took their own leave. METHODS Routinely collected adult patient data from a metropolitan ED collected over a 5-year period were analysed. RESULTS A total of 6446 presentations of First Nations patients occurred from 2016 to 2020, constituting 3% of ED presentations. Of these, 5589 (87%) patients waited to be seen and 857 (13%) took their own leave. Among patients who took their own leave, 624 (73%) left not seen and 233 (27%) left at own risk after starting treatment. Patients who were assigned a triage category of 4-5 were significantly more likely to take their own leave (adjusted odds ratio [OR] 3.17, 95% confidence interval [CI] 2.67-3.77, P < 0.001). Patients were significantly less likely to take their own leave if they were >60 years (adjusted OR 0.69, 95% CI 1.01-1.36, P = 0.014) and had private health insurance (adjusted OR 0.61, 95% CI 0.45-0.84, P < 0.001). Patients were more likely to leave if they were women (adjusted OR 1.17, 95% CI 1.01-1.36, P = 0.04), had an unknown housing status (adjusted OR 1.76, 95% CI 1.44-2.15, P < 0.001), were homeless (adjusted OR 1.50, 95% CI 1.22-1.93, P < 0.001) or had a safety alert (adjusted OR 1.60, 95% CI 1.35-1.90, P < 0.001). CONCLUSION A lower triage category is a strong predictor of First Nations patients taking their own leave. It has been documented that First Nations patients are under-triaged. One proposed intervention in the metropolitan setting is to introduce practices which expediate the care of First Nations patients. Further qualitative studies with First Nations patients should be undertaken to determine successful approaches to create equitable access to emergency healthcare for this population.
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Affiliation(s)
- Jennie Hutton
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Tilini Gunatillake
- Victorian Comprehensive Cancer Centre, The University of Melbourne, Melbourne, Victoria, Australia
| | - Deborah Barnes
- Aboriginal Health Unit, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Georgina Phillips
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jacqueline Maplesden
- Emergency Department, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Andrew Chan
- Complex Care Services, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Prudence Shanahan
- Department of Psychiatry, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Rachel Zordan
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Education and Learning, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Vijaya Sundararajan
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kerry Arabena
- Karabena Consulting, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alyssa Quigley
- St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - T'ia Pynor-Greedy
- Aboriginal Health Unit, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Toni Mason
- Aboriginal Health Unit, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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13
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Bliton JN, Zakrison TL, Vong G, Johnson DA, Rattan R, Hanos DS, Smith RN. Ethical Care of the Traumatized: Conceptual Introduction to Trauma-Informed Care for Surgeons and Surgical Residents. J Am Coll Surg 2022; 234:1238-1247. [PMID: 35703822 DOI: 10.1097/xcs.0000000000000183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Trauma-informed care (TIC) is a set of principles and practices designed to improve the ways professionals treat people who have been traumatized. This study reviews fundamental concepts of TIC and applies them to the work of surgeons. TIC is described in relation to fundamental medical ethical concepts, and evidence for TIC-based intervention is reviewed. Implementation of TIC in medical education is also described, and recommendations for practice changes are made.
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Affiliation(s)
- John N Bliton
- From the Wellstar Atlanta Medical Center, Atlanta, GA (Bliton)
| | - Tanya L Zakrison
- Trauma and Acute Care Surgery, University of Chicago Medicine, Chicago, IL (Zakrison, Johnson)
| | - Gerard Vong
- Emory University, Center for Ethics, Atlanta, GA (Vong)
| | - Dwane A Johnson
- Trauma and Acute Care Surgery, University of Chicago Medicine, Chicago, IL (Zakrison, Johnson)
| | - Rishi Rattan
- Division of Trauma and Surgical Critical Care, University of Miami Miller School of Medicine, Miami, FL (Rattan)
| | - Dustin S Hanos
- Emory University School of Medicine, Grady Hospital, Atlanta, GA (Hanos, Smith)
| | - Randi N Smith
- Emory University School of Medicine, Grady Hospital, Atlanta, GA (Hanos, Smith)
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14
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Wong AH, Ray JM, Eixenberger C, Crispino LJ, Parker JB, Rosenberg A, Robinson L, McVaney C, Iennaco JD, Bernstein SL, Yonkers KA, Pavlo AJ. Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice. BMJ Open 2022; 12:e059876. [PMID: 35545394 PMCID: PMC9096567 DOI: 10.1136/bmjopen-2021-059876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Agitation, defined as excessive psychomotor activity leading to aggressive or violent behaviour, is prevalent in the emergency department (ED) due to rising behavioural-related visits. Experts recommend use of verbal de-escalation and avoidance of physical restraint to manage agitation. However, bedside applications of these recommendations may be limited by system challenges in emergency care. This qualitative study aims to use a systems-based approach, which considers the larger context and system of healthcare delivery, to identify sociotechnical, structural, and process-related factors leading to agitation events and physical restraint use in the ED. DESIGN Qualitative study using a grounded theory approach to triangulate interviews of patients who have been physically restrained with direct observations of agitation events. SETTING Two EDs in the Northeast USA, one at a tertiary care academic centre and the other at a community-based teaching hospital. PARTICIPANTS We recruited 25 individuals who experienced physical restraint during an ED visit. In addition, we performed 95 observations of clinical encounters of agitation events on unique patients. Patients represented both behavioural (psychiatric, alcohol/drug use) and non-behavioural (medical, trauma) chief complaints. RESULTS Three primary themes with implications for systems-based practice of agitation events in the ED emerged: (1) pathways within health and social systems; (2) interpersonal contexts as reflections of systemic stressors on behavioural emergency care and (3) systems-based and patient-oriented strategies and solutions. CONCLUSIONS Agitation events represented manifestations of patients' structural barriers to care from socioeconomic inequities and high burden of emotional and physical trauma as well as staff members' simultaneous exposure to external stressors from social and healthcare systems. Potential long-term solutions may include care approaches that recognise agitated patients' exposure to psychological trauma, improved coordination within the mental health emergency care network, and optimisation of physical environment conditions and organisational culture.
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Affiliation(s)
- Ambrose H Wong
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jessica M Ray
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Outcomes & Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | - Lauren J Crispino
- Department of Emergency Medicine, Virginia Tech Carilion Clinic, Roanoke, Virginia, USA
| | - John B Parker
- Department of Emergency Medicine, Coliseum Health System, Macon, Georgia, USA
| | | | - Leah Robinson
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Caitlin McVaney
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joanne DeSanto Iennaco
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Nursing, Orange, Connecticut, USA
| | - Steven L Bernstein
- Department of Emergency Medicine, Dartmouth-Hitchcock Health System, Lebanon, New Hampshire, USA
| | - Kimberly A Yonkers
- Department of Psychiatry, University of Massachusetts Medical School, Worchester, Massachusetts, USA
| | - Anthony J Pavlo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
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15
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Hamm B, Pozuelo L, Brendel R. General Hospital Agitation Management Under the Lens of Leadership Theory and Health Care Team Best Practices Using TeamSTEPPS. J Acad Consult Liaison Psychiatry 2021; 63:213-224. [PMID: 34793998 DOI: 10.1016/j.jaclp.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 10/17/2021] [Accepted: 10/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute agitation management is an emergency clinical intervention, often presenting acute danger to patients and medical staff. Unlike many other emergency clinical interventions, acute agitation management lacks a substantial evidence base regarding leadership and teamwork best practices. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) framework is a comprehensive strategy for improving health care outcomes in acute clinical situations. OBJECTIVE Practical application of TeamSTEPPS frameworks in team-based acute agitation management in the medical setting. METHODS A literature review was performed from January 1990 to March 2021 for verbal de-escalation in acute agitation management, leadership and teamwork in psychiatry and medicine, and TeamSTEPPS. RESULTS No literature was found that applied TeamSTEPPS for acute agitation management in the general medical unit context although limited application has been trialed in the inpatient psychiatric context. The verbal de-escalation literature describes applicable content including conflict management approaches, communication strategies, security presence management, modeling therapeutic behavior, and debriefing strategies. Several articles were found regarding a rapid response team model for acute agitation management and describing handoff tools in psychiatric care contexts. Translation of the TeamSTEPPS approach provided many additional approaches for operation of a rapid response team in acute agitation management. CONCLUSIONS The leadership and teamwork best practices in TeamSTEPPS provide a clear and actionable framework for team-based acute agitation management as an emergency clinical intervention.
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Affiliation(s)
- Brandon Hamm
- Department of Psychiatry & Behavioral Neuroscience, Northwestern University, Chicago, IL.
| | | | - Rebecca Brendel
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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