5 minute read
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 Case 1. One of the clinicians, concerned Medicine Residency began a longitudinal A Black man in his 20s presented that the presence of security was health equity curriculum in 2019 to to the emergency department (ED) aggravating the situation, had a address racism and social identityvoluntarily for suicidal ideation without closer conversation with the patient based discrimination in emergency a plan. He was accompanied by family and learned that he had a history of medicine. Part of the curriculum involved members. Shortly after his arrival, four childhood trauma. He worked two a review of cases in which a patient’s security guards were posted outside jobs, had private health insurance, social identity influenced their care. of his room. They informed him that he and stated he was doing all he could Residents and social workers submitted could not leave until he was evaluated. to get his life on track. The clinician a series of cases specifically regarding Despite having no history of self-harm, requested to defer the belonging the management of agitated patients. the patient’s care team — almost all of search and re-contacted psychiatry In each case, we observed how the whom were white — determined that for an expedited evaluation. Psychiatry patient’s race influenced staff members’ the patient met criteria for an involuntary deemed the patient safe for discharge perceptions of threat, their threshold hold, would have to have his belongings with outpatient support. 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. 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. 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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He disclosed to his care team — all of whom were white — that he had a criminal history. Security was not called. The care team allowed the patient to remain in his street clothes. His belongings were searched after evaluation by psychiatry outside the room within his view and were subsequently returned to him. His bag contained his belt, a laptop, a power cord, two cell phones, a bag of shaving razors, and all of his psychiatric medications. His belongings remained with him in his room for two days until transfer to an inpatient psychiatric facility.
Case 3.
A Black man in his 20s was wheeled into the ED with a stab wound to his chest. Per protocol, a “Code Trauma” page summoned a large multidisciplinary team to his bedside. The patient was transferred to a stretcher and hooked up to a monitor, which revealed normal oxygen saturation and hemodynamics. A senior clinician who arrived shortly thereafter loudly reprimanded the team for not removing the patient’s pants to facilitate full exposure. As multiple staff members attempted to do so, the patient became upset, asking the crowd why they needed to examine his lower body since he had not reported any injuries there. With the exception of two junior residents, the entire care team was white. As staff members continued to try to undress the patient, he became increasingly agitated and attempted to get off of the stretcher.
“If you don’t want our help, you should just leave,” the senior clinician told the patient. “Why did you even bother coming here anyway?” A senior emergency medicine resident intervened, requesting everyone except the patient’s nurse step outside of the room. The resident privately communicated the importance of the exam to the patient, who subsequently agreed to be examined underneath a sheet.
Case 4.
A middle-aged white man presented to the ED with knee pain. A female resident of color evaluated the patient and noticed that he had tattoos of swastikas and spiked rings. During the evaluation, the patient made hateful comments about non-white people, which grew louder after the resident left the room. While the resident felt personally threatened, the rest of the care team, including the attending, was white; the resident felt unsure about requesting security assistance and ultimately did not involve them.
Why was security called for the first patient, but not the second? Whose sense of safety was security protecting, the patient’s or staff members’? How do the care team members’ own social identities and clinical positions affect their ability to de-escalate conflict, raise concern about bias, or involve security?
Our working group discussed these questions and developed the following algorithm for situations in which there is not an immediate threat to patient or provider safety. We recommend brief internal assessments of one’s own perceived threat to safety, recognition of how social identities may be driving perceptions of threat, and consideration of whether a clinician feels supported in raising concerns about bias to the rest of the care team. Additionally, the algorithm features strategies to facilitate verbal de-escalation adapted from a consensus statement from the American
Association for Emergency Psychiatry De-escalation Workgroup (2012).
We recognize that clinicians in our specialty face an unacceptably high rate of physical and verbal assault from patients, and that care team members who spend more time at the bedside, such as nurses, bear a disproportionate burden of safety risks. We hope this algorithm helps ED clinicians provide more equitable care while maintaining a safe environment for all patients and providers.
ABOUT THE AUTHORS
Dr. Chary is a resident physician (PGY-4) at the Harvard Affiliated Emergency Medicine Residency.
Dr. Dadabhoy is a resident physician (PGY-4) at the Harvard Affiliated Emergency Medicine Residency.
Dr. Molina is a resident physician (PGY-4) at the Harvard Affiliated Emergency Medicine Residency.
Dr. Cleveland is faculty in the department of emergency medicine at Boston Medical Center.
