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Williams K, French A, Jackson N, McMickens CL, White D, Vinson SY. Mental Health Crisis Responses and (In)Justice: Intrasystem and Intersystem Implications. Psychiatr Clin North Am 2024; 47:445-456. [PMID: 39122339 DOI: 10.1016/j.psc.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
Mental health crises among people who are marginalized merit special consideration. These groups are both overserved and underserved by mental health crisis systems: over-represented in acute treatment settings by number while facing inequities in outcomes. The predisposing, precipitating, and perpetuating factors that contribute to crises, however, neither begin nor end with the mental health system. Rather, these factors are multisystemic. As an illustration of this concept, this article highlights select marginalized groups, those that have faced inequities in mental health diagnosis and treatment due to race, medical complexity, age, and criminal justice system involvement.
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Affiliation(s)
- Kamille Williams
- Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, 720 Westview Drive Southwest, Atlanta, GA 30310, USA.
| | - Alexis French
- Department of Psychiatry and Behavioral Sciences, Duke University, 2608 Erwin Road, Durham, NC 27705, USA
| | - Nicole Jackson
- Lorio Forensics, 675 Seminole Avenue Northeast, Atlanta, GA 30307, USA
| | - Courtney L McMickens
- Department of Psychiatry and Behavioral Sciences, Duke University, 2608 Erwin Road, Durham, NC 27705, USA; Lorio Forensics, 675 Seminole Avenue Northeast, Atlanta, GA 30307, USA
| | - DeJuan White
- Department of Psychiatry and Behavioral Sciences, Emory University, 12 Executive Park Drive Northeast, Atlanta, GA 30329, USA
| | - Sarah Y Vinson
- Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, 720 Westview Drive Southwest, Atlanta, GA 30310, USA; Lorio Forensics, 675 Seminole Avenue Northeast, Atlanta, GA 30307, USA; Department of Psychiatry and Behavioral Sciences, Emory University, 12 Executive Park Drive Northeast, Atlanta, GA 30329, USA
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2
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Sangal RB, Khidir H, Agarwal AK. Interrogating and Uprooting Systemic Racism in the Emergency Department. JAMA HEALTH FORUM 2024; 5:e242347. [PMID: 39177981 DOI: 10.1001/jamahealthforum.2024.2347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024] Open
Abstract
This Viewpoint discusses how recognizing systemic racism in emergency departments will allow for the mitigation of racial and ethnic disparities and promote equitable treatment for all patients.
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Affiliation(s)
- Rohit B Sangal
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Hazar Khidir
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale University, New Haven, Connecticut
| | - Anish K Agarwal
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Transformation and Innovation, Philadelphia, Pennsylvania
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3
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Haslam N. Dehumanization and mental health. World Psychiatry 2024; 23:173-174. [PMID: 38727065 PMCID: PMC11083880 DOI: 10.1002/wps.21186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2024] Open
Affiliation(s)
- Nick Haslam
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
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Southerland LT, Pasadyn CL, Alnemer O, Foy C, Vaswani S, Chughtai S, Young HW, Brownlowe KB. Involuntary sedation of patients in the emergency department for mental health: A retrospective cohort study. Am J Emerg Med 2024; 77:53-59. [PMID: 38101227 DOI: 10.1016/j.ajem.2023.11.059] [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: 09/08/2023] [Revised: 11/14/2023] [Accepted: 11/28/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Involuntary sedation of agitated mental health patients in the Emergency Department (ED) is standard practice to obtain accurate medical assessments and maintain safety. However, the rate of this practice and what factors are associated with the use of involuntary sedation is unknown. The purpose of this study was to obtain baseline data on involuntary sedation in our EDs. METHODS Retrospective chart review of patients with ED visits for mental health care in 2020-2021. Patients >12 years old who received both a psychiatry consultation and involuntary sedation were included. Data variables included demographics, medical and mental health diagnoses, sedatives given, substance use, ED length of stay, and disposition. The primary outcome was repeated involuntary sedation. RESULTS Involuntary sedation was used in 18.8% of the mental health patients screened for study inclusion. 334 patients were included in the study cohort and 31.6% (n = 106) required repeated involuntary sedation. Their average age was 35.5 ± 13.5 years with 58.4% men, 40.1% women, and 1.2% transgender persons. Most (90.0%, n = 299) had prior mental health diagnoses with the most common being substance use disorder (38.9%, n = 130), bipolar disorder (34.1%, n = 114), depressive disorder (29.0%, n = 97), and schizophrenia (24.3%, n = 81). Two-thirds (65.9%, n = 220) had current substance use and 41.9% (n = 142) reported current use with a chemical associated with aggression. Hospital security was called for 73.1% (n = 244). Current cocaine, methamphetamines, or alcohol use was associated with decreased odds of repeated sedation (0.52 OR, 95% CI 0.32-0.85). Prior mental health diagnosis and non-white race were associated with increased odds of repeated sedation. In the multivariable regression, the effect of race was more significant. CONCLUSIONS Involuntary sedation was used in 18.8% of ED patients for mental health care and almost a third were repeatedly sedated, with race being a potential risk factor for repeated sedation. ED care could benefit from evidence-based interventions to reduce the need for involuntary sedation.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | | | - Omar Alnemer
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Chase Foy
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sheela Vaswani
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Sana Chughtai
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Henry W Young
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Katherine B Brownlowe
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Connell J, McCann B, Feng X, Shotwell MS, Hughes CG, Boncyk CS. The Association of Nonmodifiable Patient Factors on Antipsychotic Medication use in the Intensive Care Unit. J Intensive Care Med 2024; 39:176-182. [PMID: 37644873 PMCID: PMC10771026 DOI: 10.1177/08850666231198030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE We investigated the association of age, sex, race, and insurance status on antipsychotic medication use among intensive care unit (ICU) patients. MATERIALS AND METHODS Retrospective study of adults admitted to ICUs at a tertiary academic center. Patient characteristics, hospital course, and medication (olanzapine, quetiapine, and haloperidol) data were collected. Logistic regression models evaluated the independent association of age, sex, race, and insurance status on the use of each antipsychotic, adjusting for prespecified covariates. RESULTS Of 27,137 encounters identified, 6191 (22.8%) received antipsychotics. Age was significantly associated with the odds of receiving olanzapine (P < .001), quetiapine (P = .001), and haloperidol (P = .0046). Male sex and public insurance status were associated with increased odds of receiving antipsychotics olanzapine, quetiapine, and haloperidol (Male vs Female: OR 1.13, 95% CI [1.04, 1.24], P = .0005; OR 1.22, 95% CI [1.10, 1.34], P = .0001; OR 1.28, 95% CI [1.17, 1.40], P < .0001, respectively; public insurance vs private insurance: OR 1.32, 95% CI [1.20, 1.46], P < .0001; OR 1.21, 95% CI [1.09, 1.34], P = .0004; OR 1.15, 95% CI [1.04, 1.27], P = .0058, respectively). Black race was also associated with a decreased odds of receiving all antipsychotics (olanzapine (P = .0177), quetiapine (P = .004), haloperidol (P = .0041)). CONCLUSIONS Age, sex, race, and insurance status were associated with the use of all antipsychotic medications investigated, highlighting the importance of investigating the potential impact of these prescribing decisions on patient outcomes across diverse populations. Recognizing how nonmodifiable patient factors have the potential to influence prescribing practices may be considered an important factor toward optimizing medication regimens.
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Affiliation(s)
| | - Brittany McCann
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G. Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S. Boncyk
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA
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6
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Zambrano J, Celano CM, Onyeaka H, Rodriguez AM, Shea T, Ahn-Horst R, Grossman M, Mullersman K, Ordoñez AS, Smith FA, Beach S. Ethnoracial disparities in care on a consultation-liaison service at an academic hospital. Gen Hosp Psychiatry 2024; 86:50-55. [PMID: 38070241 PMCID: PMC10843593 DOI: 10.1016/j.genhosppsych.2023.11.010] [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: 08/03/2023] [Revised: 10/13/2023] [Accepted: 11/25/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND There is currently an increasing recognition of and focus on structural and institutional racism and its impacts on health disparities. In psychiatry and mental health, research has focused on racial and ethnic disparities in the availability and utilization of mental health services, care in emergency departments, and inpatient psychiatric services. Little is known about disparities in care on general hospital psychiatry consultation-liaison (CL) services. METHODS In this exploratory study, we conducted a retrospective chart review using electronic health record (EHR) data of all adults (≥ 18 years of age) admitted to inpatient medical or surgical floors at an urban academic medical center for whom a psychiatric consultation was requested during the study period. We examined differences by race and ethnicity in: rates of consultation requests; use of legal holds, constant observation, restraints; follow-up by the CL service; and ultimate disposition. RESULTS The service received 310 unique consults during the study period. Compared to hospital-wide numbers, Black-identifying patients were over-represented in our sample (11.9% vs 6.6%), while Latinx patients were underrepresented (6.1% vs 9.8%). Of the clinical and outcome variables collected, there were higher odds of being placed on a legal hold both prior to (OR 2.6) and after the consult question (OR 2.98) and in the odds of having a one-to-one observer prior to (OR 2.47) and after (OR 2.9) the initial consult visit for Black-identifying patients, when adjusting for confounders. There were no other measurable differences in care or outcomes by racial or ethnic categories. CONCLUSION Black-identifying patients may be more likely to receive psychiatric consultation and be placed on legal holds because of a combination of chronic adverse social determinants of health and race-based bias. Conversely, Latinx patients may be less likely to receive psychiatric consultation because of language barriers among other factors. The lack of disparities identified in other domains may be encouraging, but larger studies are needed. Further research is also needed to identify causality and interventions that could help close the gap in care and outcomes for racial and ethnic minorities.
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Affiliation(s)
- Juliana Zambrano
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA.
| | - Christopher M Celano
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Henry Onyeaka
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | | | - Timothy Shea
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Rosa Ahn-Horst
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Mila Grossman
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Katherine Mullersman
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Andrea Soto Ordoñez
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Felicia A Smith
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
| | - Scott Beach
- Massachusetts General Hospital, Department of Psychiatry, USA; Harvard Medical School, USA
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Wolf RM, Hall M, Williams DJ, Antoon JW, Carroll AR, Gastineau KAB, Ngo ML, Herndon A, Hart S, Bell DS, Johnson DP. Disparities in Pharmacologic Restraint for Children Hospitalized in Mental Health Crisis. Pediatrics 2024; 153:e2023061353. [PMID: 38073320 PMCID: PMC10764008 DOI: 10.1542/peds.2023-061353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children hospitalized with a mental health crisis often receive pharmacologic restraint for management of acute agitation. We examined associations between pharmacologic restraint use and race and ethnicity among children admitted for mental health conditions to acute care nonpsychiatric children's hospitals. METHODS We performed a retrospective cohort study of children (aged 5-≤18 years) admitted for a primary mental health condition from 2018 to 2022 at 41 US children's hospitals. Pharmacologic restraint use was defined as parenteral administration of medications for acute agitation. The association of race and ethnicity and pharmacologic restraint was assessed using generalized linear multivariable mixed models adjusted for clinical and demographic factors. Stratified analyses were performed based on significant interaction analyses between covariates and race and ethnicity. RESULTS The cohort included 61 503 hospitalizations. Compared with non-Hispanic Black children, children of non-Hispanic White (adjusted odds ratio [aOR], 0.81; 95% confidence interval [CI], 0.72-0.92), Asian (aOR, 0.82; 95% CI, 0.68-0.99), or other race and ethnicity (aOR, 0.68; 95% CI, 0.57-0.82) were less likely to receive pharmacologic restraint. There was no significant difference with Hispanic children. When stratified by sex, racial/ethnic differences were magnified in males (aORs, 0.49-0.68), except for Hispanic males, and not found in females (aORs, 0.83-0.93). Sensitivity analysis revealed amplified disparities for all racial/ethnic groups, including Hispanic youth (aOR, 0.65; 95% CI, 0.47-0.91). CONCLUSIONS Non-Hispanic Black children were significantly more likely to receive pharmacologic restraint. More research is needed to understand reasons for these disparities, which may be secondary to implicit bias and systemic and interpersonal racism.
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Affiliation(s)
- Ryan M Wolf
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatrics, Section on Hospital Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Derek J Williams
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - James W Antoon
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison R Carroll
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelsey A B Gastineau
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - My-Linh Ngo
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison Herndon
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah Hart
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deanna S Bell
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
| | - David P Johnson
- Department of Pediatrics, Division of Hospital Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee
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Eswaran V, Molina MF, Hwong AR, Dillon DG, Alvarez L, Allen IE, Wang RC. Racial Disparities in Emergency Department Physical Restraint Use: A Systematic Review and Meta-Analysis. JAMA Intern Med 2023; 183:1229-1237. [PMID: 37747721 PMCID: PMC10520842 DOI: 10.1001/jamainternmed.2023.4832] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 07/28/2023] [Indexed: 09/26/2023]
Abstract
Importance Recent studies have demonstrated that people of color are more likely to be restrained in emergency department (ED) settings compared with other patients, but many of these studies are based at a single site or health care system, limiting their generalizability. Objective To synthesize existing literature on risk of physical restraint use in adult EDs, specifically in reference to patients of different racial and ethnic backgrounds. Data Sources A systematic search of PubMed, Embase, Web of Science, and CINAHL was performed from database inception to February 8, 2022. Study Selection Included peer-reviewed studies met 3 criteria: (1) published in English, (2) original human participants research performed in an adult ED, and (3) reported an outcome of physical restraint use by patient race or ethnicity. Studies were excluded if they were conducted outside of the US, or if full text was unavailable. Data Extraction and Synthesis Four independent reviewers (V.E., M.M., D.D., and A.H.) abstracted data from selected articles following Meta-Analysis of Observational Studies in Epidemiology guidelines. A modified Newcastle-Ottawa scale was used to assess quality. A meta-analysis of restraint outcomes among minoritized racial and ethnic groups was performed using a random-effects model in 2022. Main Outcome(s) and Measure(s) Risk of physical restraint use in adult ED patients by racial and ethnic background. Results The search yielded 1597 articles, of which 10 met inclusion criteria (0.63%). These studies represented 2 557 983 patient encounters and 24 030 events of physical restraint (0.94%). In the meta-analysis, Black patients were more likely to be restrained compared with White patients (RR, 1.31; 95% CI, 1.19-1.43) and to all non-Black patients (RR, 1.27; 95% CI, 1.23-1.31). With respect to ethnicity, Hispanic patients were less likely to be restrained compared with non-Hispanic patients (RR, 0.85; 95% CI, 0.81-0.89). Conclusions and Relevance Physical restraint was uncommon, occurring in less than 1% of encounters, but adult Black patients experienced a significantly higher risk of physical restraint in ED settings compared with other racial groups. Hispanic patients were less likely to be restrained compared with non-Hispanic patients, though this observation may have occurred if Black patients, with a higher risk of restraint, were included in the non-Hispanic group. Further work, including qualitative studies, to explore and address mechanisms of racism at the interpersonal, institutional, and structural levels are needed.
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Affiliation(s)
- Vidya Eswaran
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
- Section of Health Services Research, Department of Medicine, Center for Innovations in Quality, Effectiveness and Safety, DeBakey VA Medical Center; Houston, Texas
- Department of Emergency Medicine, University of California, San Francisco
| | - Melanie F. Molina
- Department of Emergency Medicine, University of California, San Francisco
- National Clinician Scholars Program, Philip R Lee Institute of Health Policy Studies, University of California, San Francisco
- Philip R Lee Institute of Health Policy Studies, University of California, San Francisco
| | - Alison R. Hwong
- National Clinician Scholars Program, Philip R Lee Institute of Health Policy Studies, University of California, San Francisco
- Department of Psychiatry and Behavioral Sciences, University of California; San Francisco
- San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - David G. Dillon
- Department of Emergency Medicine, University of California, Davis, Sacramento
| | - Lizbeth Alvarez
- School of Medicine, University of California, Davis, Sacramento
| | - Isabel E. Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Ralph C. Wang
- Department of Emergency Medicine, University of California, San Francisco
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Smith CM, Daley LA, Lea C, Daniel K, Tweedy DS, Thielman NM, Staplefoote-Boynton BL, Aimone E, Gagliardi JP. Experiences of Black Adults Evaluated in a Locked Psychiatric Emergency Unit: A Qualitative Study. Psychiatr Serv 2023; 74:1063-1071. [PMID: 37042104 PMCID: PMC10732806 DOI: 10.1176/appi.ps.20220533] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
OBJECTIVE Evidence shows that Black individuals have higher rates of coercive emergency psychiatric interventions than other racialized groups, yet no studies have elevated the voices of Black patients undergoing emergency psychiatric evaluation. This qualitative study sought to explore the experiences of Black individuals who had been evaluated in a locked psychiatric emergency unit (PEU). METHODS Electronic health records were used to identify and recruit adult patients (ages ≥18 years) who self-identified as Black and who had undergone evaluation in a locked PEU at a large academic medical center. In total, 11 semistructured, one-on-one interviews were conducted by telephone, exploring experiences during psychiatric evaluation. Transcripts were analyzed with thematic analysis. RESULTS Participants shared experiences of criminalization, stigma, and vulnerability before and during their evaluation. Although participants described insight into their desire and need for treatment and identified helpful aspects of the care they received, they noted a mismatch between their expectations of treatment and the treatment received. CONCLUSIONS This study reveals six major patient-identified themes that supplement a growing body of quantitative evidence demonstrating that racialized minority groups endure disproportionate rates of coercive interventions during emergency psychiatric evaluation. Interdisciplinary systemic changes are urgently needed to address structural barriers to equitable psychiatric care.
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Affiliation(s)
- Colin M Smith
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Lori-Ann Daley
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Chris Lea
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Keith Daniel
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Damon S Tweedy
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Nathan M Thielman
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - B Lynette Staplefoote-Boynton
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Elizabeth Aimone
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
| | - Jane P Gagliardi
- Hubert-Yeargan Center for Global Health, Duke University, Durham, North Carolina (Smith); Department of Psychiatry and Behavioral Sciences (Daley, Tweedy, Staplefoote-Boynton, Gagliardi) and Department of Medicine (Thielman, Staplefoote-Boynton, Gagliardi), School of Medicine, Duke University, Durham, North Carolina; School of Medicine (Lea), Duke University, Durham, North Carolina; Duke Divinity School, Duke University, Durham, North Carolina (Daniel); Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill (Aimone)
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10
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Tang AS, Shieh MS, Pekow PS, Prentiss KA, Lindenauer PK, Westafer LM. Treatment of pediatric behavioral health patients with intravenous and intramuscular chemical restraints: Results from a nationwide sample of emergency departments. Acad Emerg Med 2023; 30:1029-1038. [PMID: 37259900 PMCID: PMC11075781 DOI: 10.1111/acem.14754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 05/18/2023] [Accepted: 05/25/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Behavioral health crises in pediatric emergency department (ED) patients are increasingly common. Chemical restraints can be utilized for patients who present imminent danger to self or others. We sought to describe the use of intravenous (IV)/intramuscular (IM) chemical restraints for pediatric behavioral health ED patients across a nationwide sample of hospitals and describe factors associated with restraint use. METHODS This was a retrospective study of patients ages 8-17 treated at 822 EDs contributing data to the Premier Healthcare Database between January 1, 2018, and December 31, 2020, with a behavioral health discharge diagnosis. The primary outcome was the use of IV/IM chemical restraint medication. We developed a hierarchical model to examine patient and hospital-level factors associated with treatment with IV/IM chemical restraint medications. RESULTS Of 630,384 cases, 4.8% received IV/IM chemical restraint. Patient factors associated with higher odds of chemical restraint were older age (ages 13-17 years [adjusted odds ratio {AOR} 1.53, 95% confidence interval {CI} 1.48-1.58]), anxiety disorders (AOR 1.69, 95% CI 1.64-1.74), disruptive disorders (AOR 1.61, 95% CI 1.53-1.69), suicide/self-injury (AOR 1.3, 95% CI 1.26-1.34), substance use (AOR 1.24, 95% CI 1.20-1.28), and bipolar disorder (AOR 1.23, 95% CI 1.17-1.30). Participants with complex comorbidities were more likely to receive chemical restraint (AOR 1.32, 95% CI 1.26-1.39). After patient and hospital factors were adjusted for, the median OR indicating the influence of the individual hospital on the odds of chemical restraint was 1.43 (95% CI 1.40-1.47). CONCLUSIONS We found that age and certain behavioral health diagnoses were associated with receipt of IV/IM chemical restraint during pediatric behavioral health ED visits. Additionally, whether a patient was treated with chemical restraints was strongly influenced by the hospital to which they presented for treatment.
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Affiliation(s)
- Andrew S Tang
- Pediatric Emergency Medicine, Rady Children's Hospital, San Diego, California, USA
- Pediatric Emergency Medicine, University of California-San Diego, San Diego, California, USA
| | - Meng-Shiou Shieh
- Department of Healthcare Delivery & Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - Penelope S Pekow
- Department of Healthcare Delivery & Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
- School of Public Health and Health Sciences, University of Massachusetts, Amherst, Massachusetts, USA
| | - Kimball A Prentiss
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - Peter K Lindenauer
- Department of Healthcare Delivery & Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Division of Hospital Medicine, Baystate Medical Center, Springfield, Massachusetts, USA
- Department of Population and Quantitative Health Science, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Lauren M Westafer
- Department of Healthcare Delivery & Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
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Im DD, Scott KW, Venkatesh AK, Lobon LF, Kroll DS, Samuels EA, Wilson MP, Zeller S, Zun LS, Clifford KC, Zachrison KS. A Quality Measurement Framework for Emergency Department Care of Psychiatric Emergencies. Ann Emerg Med 2022; 81:592-605. [PMID: 36402629 DOI: 10.1016/j.annemergmed.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 11/19/2022]
Abstract
As a primary access point for crisis psychiatric care, the emergency department (ED) is uniquely positioned to improve the quality of care and outcomes for patients with psychiatric emergencies. Quality measurement is the first key step in understanding the gaps and variations in emergency psychiatric care to guide quality improvement initiatives. Our objective was to develop a quality measurement framework informed by a comprehensive review and gap analysis of quality measures for ED psychiatric care. We conducted a systematic literature review and convened an expert panel in emergency medicine, psychiatry, and quality improvement to consider if and how existing quality measures evaluate the delivery of emergency psychiatric care in the ED setting. The expert panel reviewed 48 measures, of which 5 were standardized, and 3 had active National Quality Forum endorsement. Drawing from the measure appraisal, we developed a quality measurement framework with specific structural, process, and outcome measures across the ED care continuum. This framework can help shape an emergency medicine roadmap for future clinical quality improvement initiatives, research, and advocacy work designed to improve outcomes for patients presenting with psychiatric emergencies.
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