Reducing Bias with Agitated Patients in the Emergency Department By Anita Chary MD, PhD, Farah Dadabhoy MD, MSc, Melanie Molina MD, Emily Cleveland, MD, MPH The Harvard Affiliated Emergency Medicine Residency began a longitudinal health equity curriculum in 2019 to address racism and social identitybased discrimination in emergency medicine. Part of the curriculum involved a review of cases in which a patient’s social identity influenced their care. Residents and social workers submitted a series of cases specifically regarding the management of agitated patients. In each case, we observed how the patient’s race influenced staff members’ perceptions of threat, their threshold for involving security officers, and their willingness to engage in verbal deescalation. We present the selected cases below and then offer an algorithm we developed to promote assessment for bias when de-escalating agitated patients.
Case 1.
A Black man in his 20s presented to the emergency department (ED) voluntarily for suicidal ideation without a plan. He was accompanied by family members. Shortly after his arrival, four security guards were posted outside of his room. They informed him that he could not leave until he was evaluated. Despite having no history of self-harm, the patient’s care team — almost all of whom were white — determined that the patient met criteria for an involuntary hold, would have to have his belongings searched, and needed to change into scrubs per hospital policy. On hearing this news, the patient became upset and started to pace in his room, distraught about potentially being held against his will.
One of the clinicians, concerned that the presence of security was aggravating the situation, had a closer conversation with the patient and learned that he had a history of childhood trauma. He worked two jobs, had private health insurance, and stated he was doing all he could to get his life on track. The clinician requested to defer the belonging search and re-contacted psychiatry for an expedited evaluation. Psychiatry deemed the patient safe for discharge with outpatient support.
Case 2.
A middle-aged White man presented to the ED voluntarily with suicidal ideation with a plan. He arrived alone, pacing around his room, speaking loudly, and responding to internal stimuli.
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