Patient perceptions of behavioral flags in the emergency department: A qualitative analysis.

BACKGROUND: To combat increasing levels of violence in the emergency department (ED), hospitals have implemented several safety measures, including behavioral flags. These electronic health record (EHR)-based notifications alert future clinicians of past incidents of potentially threatening patient behavior, but observed racial disparities in their placement may unintentionally introduce bias in patient care. Little is known about how patients perceive these flags and the disparities that have been found in their placement. OBJECTIVE: This study aims to investigate patient perceptions and perceived benefits and harms associated with the use of behavioral flags. METHODS: Twenty-five semistructured qualitative interviews were conducted with a convenience sample of patients in the ED of a large, urban, academic medical center who did not have a behavioral flag in their EHR. Interviews lasted 10-20 min and were recorded then transcribed. Thematic analysis of deidentified transcripts took place in NVivo 20 software (QSR International) using a general inductive approach. RESULTS: Participant perceptions of behavioral flags varied, with both positive and negative opinions being shared. Five key themes, each with subthemes, were identified: (1) benefits of behavioral flags, (2) concerns and potential harms of flags, (3) transparency with patients, (4) equity, and (5) ideas for improvement. CONCLUSIONS: Patient perspectives on the use of behavioral flags in the ED vary. While many saw flags as a helpful tool to mitigate violence, concerns around negative impacts on care, transparency, and equity were also shared. Insights from this stakeholder perspective may allow for health systems to make flags more effective without compromising equity or patient ideals.

Mapping Buprenorphine Access at Philadelphia Pharmacies.

OBJECTIVES: Buprenorphine is not reliably stocked in many pharmacies, and pharmacy-level barriers may deter patients from opioid use disorder care. We surveyed all outpatient pharmacies in Philadelphia to describe variation in buprenorphine access and developed a map application to aid in identifying pharmacies that stock the medication. METHODS: Using a dataset from the Bureau of Professional and Occupational Affairs, we conducted a telephone survey of operating outpatient pharmacies (N = 422) about their buprenorphine stocking and dispensing practices. We used ArcGIS Pro 3.0.3 to join US Census Bureau ZIP code-level race and ethnicity data, conduct descriptive analyses, and create a map application. RESULTS: We collected data from 351 pharmacies (83% response rate). Two hundred thirty-eight pharmacies (68%) indicated that they regularly stock buprenorphine; 6 (2%) would order it when a prescription is sent. Ninety-one (26%) said that they do not stock or order buprenorphine, and 16 (5%) were unsure. We identified 137 "easier access" pharmacies (39%), meaning they regularly stock buprenorphine, dispense to new patients, and have no dosage maximums. Zip codes with predominantly White residents had a median (interquartile range) of 3 (2-4) "easier access" pharmacies, and those with predominantly Black residents a median (interquartile range) of 2 (1-4.5). Nine zip codes had no "easier access" pharmacies, and 3 had only one; these 3 zip codes are areas with predominantly Black residents. CONCLUSIONS: Buprenorphine access is not equitable across Philadelphia and a quarter of pharmacies choose not to carry the medication. Our map application may be used to identify pharmacies in Philadelphia that stock buprenorphine.

Qualitative Perspectives of Emergency Nurses on Electronic Health Record Behavioral Flags to Promote Workplace Safety.

Importance: Emergency nurses experience high levels of workplace violence during patient interactions. Little is known about the efficacy of behavioral flags, which are notifications embedded within electronic health records (EHRs) as a tool to promote clinician safety. Objective: To explore the perspectives of emergency nurses on EHR behavioral flags, workplace safety, and patient care. Design, Setting, and Participants: In this qualitative study, semistructured interviews were conducted with emergency nurses at an academic, urban emergency department (ED) between February 8 and March 25, 2022. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. Data analysis was performed from April 2 to 13, 2022. Main Outcomes and Measures: Themes and subthemes of nursing perspectives on EHR behavioral flags were identified. Results: This study included 25 registered emergency nurses at a large academic health system, with a mean (SD) tenure of 5 (6) years in the ED. Their mean (SD) age was 33 (7) years; 19 were women (76%) and 6 were men (24%). Participants self-reported their race as Asian (3 [12%]), Black (3 [12%]), White (15 [60%]), or multiple races (2 [8%]); 3 participants (12%) self-reported their ethnicity as Hispanic or Latinx. Five themes (with subthemes) were identified: (1) benefits of flags (useful advisory; prevents violence; engenders compassion), (2) issues with flags (administrative and process issues; unhelpful; unenforceable; bias; outdated), (3) patient transparency (patient accountability; damages patient-clinician relationship), (4) system improvements (process; built environment; human resources; zero-tolerance policies), and (5) difficulties of working in the ED (harassment and abuse; unmet mental health needs of patients; COVID-19-related strain and burnout). Conclusions and Relevance: In this qualitative study, nursing perspectives on the utility and importance of EHR behavioral flags varied. For many, flags served as an important forewarning to approach patient interactions with more caution or use safety skills. However, nurses were skeptical of the ability of flags to prevent violence from occurring and noted concern for the unintended consequences of introducing bias into patient care. These findings suggest that changes to the deployment and utilization of flags, in concert with other safety interventions, are needed to create a safer work environment and mitigate bias.

Emergency Physician Observations and Attitudes on Law Enforcement Activities in the Emergency Department.

INTRODUCTION: Law enforcement officers (LEO) interact with patients and clinicians in the emergency department (ED) for many reasons. There is no current consensus on what should comprise, or how to best enact, guidelines that ideally balance LEO activities in the service of public safety with patient health, autonomy, and privacy. The purpose of this study was to explore how a national sample of emergency physicians (EP) perceives activities of LEOs during the delivery of emergency medical care. METHODS: Members of the Emergency Medicine Practice Research Network (EMPRN) were recruited via an email-delivered, anonymous survey that elicited experiences, perceptions, and knowledge of policies that guide interactions with LEOs in the ED. The survey included multiple-choice items, which we analyzed descriptively, and open-ended questions, which we analyzed using qualitative content analysis. RESULTS: Of 765 EPs in the EMPRN, 141 (18.4%) completed the survey. Respondents represented diverse locations and years in practice. A total of 113 (82%) respondents were White, and 114 (81%) were male. Over a third reported LEO presence in the ED on a daily basis. A majority (62%) perceived LEO presence as helpful for clinicians and clinical practice. When asked about the factors deemed highly important in allowing LEOs to access patients during care, 75% reported patients' potential as a threat to public safety. A small minority of respondents (12%) considered the patients' consent or preference to interact with LEOs. While 86% of EPs felt that information-gathering by LEO was appropriate in the ED setting, only 13% were aware of policy to guide these decisions. Perceived barriers to implementation of policy in this area included: issues of enforcement; leadership; education; operational challenges; and potential negative consequences. CONCLUSION: Future research is warranted to explore how policies and practices that guide intersections between emergency medical care and law enforcement impact patients, clinicians, and the communities that health systems serve.

Prevalence of Behavioral Flags in the Electronic Health Record Among Black and White Patients Visiting the Emergency Department.

Importance: Behavioral flags in the electronic health record (EHR) are designed to alert clinicians of potentially unsafe or aggressive patients. These flags may introduce bias, and understanding how they are used is important to ensure equitable care. Objective: To investigate the incidence of behavioral flags and assess whether there were differences between Black and White patients and whether the flags were associated with differences in emergency department (ED) clinical care. Design, Setting, and Participants: This was a retrospective cohort study of EHR data of adult patients (aged ≥18 years) from 3 Philadelphia, Pennsylvania, EDs within a single health system between January 1, 2017, and December 31, 2019. Secondary analyses excluded patients with sickle cell disease and high ED care utilization. Data were analyzed from February 1 to April 4, 2022. Main Outcomes and Measures: The primary outcome of interest was the presence of an EHR behavioral flag. Secondary measures included variation of flags across sex, race, age, insurance status, triage status, ED clinical care metrics (eg, laboratory, medication, and radiology orders), ED disposition (discharge, admission, or observation), and length of key intervals during ED care. Results: Participating EDs had 195 601 eligible patients (110 890 [56.7%] female patients; 113 638 Black patients [58.1%]; 81 963 White patients [41.9%]; median [IQR] age, 42 [28-60] years), with 426 858 ED visits. Among these, 683 patients (0.3%) had a behavioral flag notification in the EHR (3.5 flags per 1000 patients), and it was present for 6851 ED visits (16 flagged visits per 1000 visits). Patient differences between those with a flag and those without included male sex (56.1% vs 43.3%), Black race (71.2% vs 56.7%), and insurance status, particularly Medicaid insurance (74.5% vs 36.3%). Flag use varied across sites. Black patients received flags at a rate of 4.0 per 1000 patients, and White patients received flags at a rate of 2.4 per 1000 patients (P < .001). Among patients with a flag, Black patients, compared with White patients, had longer waiting times to be placed in a room (median [IQR] time, 28.0 [10.5-89.4] minutes vs 18.2 [7.2-75.1] minutes; P < .001), longer waiting times to see a clinician (median [IQR] time, 42.1 [18.8-105.5] minutes vs 33.3 [15.3-84.5] minutes; P < .001), and shorter lengths of stay (median [IQR] time, 274 [135-471] minutes vs 305 [154-491] minutes; P = .01). Black patients with a flag underwent fewer laboratory (eg, 2449 Black patients with 0 orders [43.4%] vs 441 White patients with 0 orders [36.7%]; P < .001) and imaging (eg, 3541 Black patients with no imaging [62.7%] vs 675 White patients with no imaging [56.2%]; P < .001) tests compared with White patients with a flag. Conclusions and Relevance: This cohort study found significant differences in ED clinical care metrics, including that flagged patients had longer wait times and were less likely to undergo laboratory testing and imaging, which was amplified in Black patients.