Difficult Patients in the Emergency Department: Personality Disorders and Beyond

Residents' Experiences of Negative Emotions toward Patients: Challenges to their Identities

PhenomenonMedical learners are more likely than practicing physicians to experience negative emotions toward some patients whom they find challenging, and medical students experience such emotions related to their identity as learners. Little is known about experiences of residents, who are further along in their physician identity formation and have greater autonomy and competence. We explored and characterized how residents understand their experiences of the phenomenon of feeling negative emotions toward patients in relation to their identities as residents. Approach: In 2018, 305 final-year obstetrics and gynecology residents were invited to participate in interviews, which we conducted until reaching theoretical sufficiency. In semi-structured interviews conducted by phone, we probed interactions when residents felt negative emotions toward patients, including reasons for their feelings related to their professional identities, strategies, and curricular desires. The authors coded data and identified patterns using thematic analysis. Findings: Nineteen residents were interviewed by phone. Residents experienced negative emotions toward patients because of challenges to their identities as: physicians - wanting respect and specific unexpected patient behaviors; learners - desiring complete autonomy and experiencing challenges with attending physicians; teachers - wanting to be a role model and protect junior learners; and workers - trying to complete tasks. Among the strategies used to manage feelings toward patients, they struggled with "venting", or complaining about patients, which was not always helpful and residents recognized as perceived negatively by students. They desired curricular support for these interactions such as debriefs and other supported reflection, faculty modeling, and communication skills training. Insights: Like medical students and physicians in practice, residents experience negative emotions toward patients, often because of and made more difficult by their identities as physicians, learners, teachers, and workers. Educators should support residents' reflections about these interactions, model compassionate behavior when feeling challenged by patients, and address unhealthy coping strategies.

Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice

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.

Design and Implementation of an Agitation Code Response Team in the Emergency Department

STUDY OBJECTIVE

Agitation, defined as excessive psychomotor activity leading to violent and aggressive behavior, is becoming more prevalent in the emergency department (ED) amidst a strained behavioral health system. Team-based interventions have demonstrated promise in promoting de-escalation, with the hope of minimizing the need for invasive techniques, like physical restraints. This study aimed to evaluate an interprofessional code response team intervention to manage agitation in the ED with the goal of decreasing physical restraint use.

METHODS

This quality improvement study occurred over 3 phases, representing stepwise rollout of the intervention: (1) preimplementation (phase I) to establish baseline outcome rates; (2) design and administrative support (phase II) to conduct training and protocol design; and (3) implementation (phase III) of the code response team. An interrupted time-series analysis was used to compare trends between phases to evaluate the primary outcome of physical restraint orders occurring during the study period.

RESULTS

Within the 634,578 ED visits over a 5-year period, restraint use significantly declined sequentially over the 3 phases (1.1%, 0.9%, and 0.8%, absolute change -0.3% between phases I and III, 95% confidence interval [CI] -0.4% to 0.3%), which corresponded to a 27.3% proportionate decrease in restraint rates between phases I and III. For the interrupted time-series analysis, there was a significantly decreasing slope in biweekly restraints in phase II compared to phase I (slope, -0.05 restraints per 1,000 ED visits per 2-week period, 95% CI -0.07 to -0.03), which was sustained in an incremental fashion in phase III (slope, -0.05, 95% CI -0.07 to -0.02).

CONCLUSION

With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a 5-year period. Results suggest that investment in organizational change, along with interprofessional collaboration during the management of agitated patients in the ED, can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients.

Emergency Medicine Residents’ “Just World” Bias Is Not Associated with a Biased Case Mix

Introduction

Belief in a just world is the cognitive bias that “one gets what they deserve.” Stronger belief in a just world for others (BJW-O) has been associated with discrimination against individuals with low socioeconomic status (SES) or poor health status, as they may be perceived to have “deserved” their situation. Emergency medicine (EM) residents have been shown to “cherry pick” patients; in this study we sought to determine whether BJW-O is associated with a biased case mix seen in residency.

Methods

We assessed EM residents on their BJW-O using a scale with previous validity evidence and behavioral correlates. We identified chief complaints that residents may associate with low SES or poor health status, including psychiatric disease, substance use disorder (SUD); and patients with multidisciplinary care plans due to frequent ED visits. We then calculated the percentage of each of these patient types seen by each resident as well as correlations and a multiple linear regression.

Results

38 of 48 (79%) residents completed the BJW-O, representing 98,825 total patient encounters. The median BJW-O score was 3.25 (interquartile range 2.81–3.75). There were no significant correlations observed between BJW-O and the percentage of patients with multidisciplinary care plans who were seen, or patients with psychiatric, SUD, dental or sickle cell chief complaints seen; and a multiple linear regression showed no significant association.

Conclusion

Higher BJW-O scores in EM residents are not significantly associated with a biased case mix of patients seen in residency.

Predictors of Frequent Emergency Department Utilization for Mental Health Reasons

Overcrowding in emergency departments (ED) jeopardizes quality and access to health care, which represents a major issue for service delivery. This study determined predictors of frequent ED utilization among 320 patients recruited from six hospital ED in Quebec (Canada). Data collection included patient interviews and administrative databanks. A hierarchical linear regression analysis was performed using the Andersen Behavioral Model as a framework, with variables organized into predisposing, enabling, and needs factors. Results showed that needs factors were most strongly associated with ED utilization, particularly schizophrenia and personality disorders. Predisposing and enabling factors each contributed one variable to the model: past hospitalization for Mental Health (MH) reasons, and having regular care from an outpatient psychiatrist over the 12 months prior to interview at the ED, respectively. Increasing integration of MH services in networks may reduce unnecessary ED utilization and overcrowding, while providing better accessibility and care continuity for patients who visit ED for MH reasons.

Psychotherapists' emotional reactions to patients' personality trait in personality disorder treatment settings: an exploratory study

BACKGROUND

Therapist's emotional reactions toward patients in clinical facilities are a key concept in the treatment of personality disorders. Considering only clinical settings specialized in treatment of personality pathology the present paper aimed at: (1) assessing any direct relationship between patient symptom severity and therapist emotional response; (2) exploring patients' functioning configurations that can be associated with specific therapist reactions (3) investigating whether these relationships remains significant when accounting for other setting variables related to patients or therapist.

METHODS

The present study included 43 outpatients with personality disorders who underwent a psychotherapy treatment in two Italian facilities dedicated to outpatients with personality disorders and their 19 psychotherapists. The Symptom Checklist-90-Revised (SCL-90R) was used to explore clinical severity condition. Psychotherapists completed the Therapist Response Questionnaire (TRQ) to identify pattern of therapists' response and the Shedler-Westen Assessment Procedure-200 (SWAP-200) in order to assess personality traits of the patients.

RESULTS

No significant relationship between the clinical severity of the symptoms and the therapist' responses was found. Even when controlled for clinical severity condition, duration of the treatment, age and educational level of the patient or years of therapist experience, most of SWAP-200 traits appeared to be significant predictors of therapist' emotional responses.

CONCLUSIONS

The present study confirms the value of therapists' emotional response as a useful tool in understanding psychological processes related to clinical practice highlighting its context-dependent dimension.

Patient satisfaction and acute psychiatric inpatient treatment

Background: Patient satisfaction (PS) with treatment is one of different outcome- and quality measures used by health care providers worldwide to improve service. We report from a study of patients admitted to the Department of Acute Psychiatry at the Oslo University Hospital where we investigated PS and difference between genders, days of hospital stay, diagnostic groups, voluntary-and involuntary admitted patients according to hospital records and perceived voluntary-and involuntary admittance.Materials and methods: All admitted patients during a 9-month period in 2014 were asked to participate by written consent. We used The Psychiatric Inpatient Questionnaire (PIPEQ), a self-report survey validated for assessment post-discharge. Analyses were conducted for a general dimension of PS and individual questions. A user representative was a part of the study from the beginning.Results: A total of 357 patients were asked and 256 consented. Results show that 68% were over all satisfied and 14% dissatisfied. Highest PS was found for cooperation with relatives and lowest for influence on choice of treatment and medication. We found no significant difference in PS between men and women, but patients with a personality disorder and with short stay were less satisfied. PS was significantly less for those perceiving involuntary admission regardless of legal status.Conclusion: The PIPEQ gives important input of patient's experience with the delivery of care. Answers range from very much satisfied to not at all depending on what was asked for. Exploring PS provides valuable information for quality improvements for different patient groups.

Le soutien postlogement transitoire auprès des femmes en situation d’itinérance : besoins, implantation et impact d’une étude pilote

Objectifs Les dispositifs de soutien en logement sont parmi les solutions soutenues pour contrer l’itinérance. Le logement transitoire (LT) offre une trajectoire séquentielle d’accès à la stabilité résidentielle : des refuges au LT, au logement permanent avec ou sans soutien. Le suivi post-LT permettrait d’améliorer la stabilité résidentielle et l’intégration communautaire. Néanmoins, peu d’informations sont disponibles sur les conditions de succès et la capacité du suivi post-LT à améliorer la stabilité résidentielle et l’intégration communautaire des personnes itinérantes, en particulier les femmes. Cette étude de cas pilote visait à identifier les besoins de femmes recevant du suivi post-LT, l’implantation des activités de suivi et ses conditions de succès, ainsi que son impact en réponse aux besoins exprimés.

Méthode Deux organismes à but non lucratif ont été sélectionnés à Montréal. Une étude de cas à partir de méthodes mixtes a permis de trianguler les données provenant de femmes en situation d’itinérance, de leurs intervenantes et des gestionnaires de ressources de suivi post-LT. Deux entretiens ont été menés à un intervalle de 6 mois avec ces femmes (n = 10). Les besoins et l’impact du suivi post-LT ont été mesurés grâce à un questionnaire (questions ouvertes et fermées). Pour documenter l’implantation du suivi, des informations ont été colligées auprès des intervenantes (n = 2) sur les activités et l’intensité des services offerts à l’aide de fiches de contact. Des facteurs facilitant et entravant le suivi post-LT ont également été identifiés lors d’une entrevue de groupe avec les intervenantes (n = 2) et les gestionnaires (n = 4).

Résultats Les usagères ont identifié des besoins liés à la santé, aux activités quotidiennes et à l’intégration sociale. La plupart des femmes étaient satisfaites des activités et de la fréquence du suivi, de la facilité d’accès des intervenantes et de la capacité du suivi à répondre à leurs besoins. L’intensité du suivi, l’alliance thérapeutique usagère/intervenante et la motivation des usagères ont été identifiées comme des facteurs facilitants. Les facteurs entravants comprenaient : la durée limitée de l’insertion préalable en LT, particulièrement chez les usagères ayant subi un traumatisme majeur ; les comportements réfractaires ; la réticence à prendre des médicaments et la dépendance à des substances psychoactives ; les problèmes d’accès aux services, dont les services de santé mentale spécialisés ; et pour les intervenantes, les contraintes de temps, les difficultés logistiques, et le manque de logements permanents abordables adéquats. Après six mois, 80 % des usagères avaient conservé le même logement, et leur intégration communautaire n’avait pas changé.

Conclusion Le suivi post-LT semble adapté pour promouvoir la stabilité résidentielle chez les femmes en situation d’itinérance chronique et ayant des problèmes de santé mentale ou de dépendance, première étape essentielle vers l’intégration communautaire. L’étude a souligné l’importance d’offrir des modalités de services adaptés aux besoins des usagères. Un meilleur financement du suivi post-LT, une collaboration plus étroite avec d’autres services publics, une formation accrue des intervenantes et une augmentation du nombre de logements permanents abordables et adéquats favoriseraient un déploiement plus efficace du suivi post-LT.

Predictors of Emergency Department Use among Individuals with Current or Previous Experience of Homelessness

This study assessed the contributions of predisposing, enabling, and needs factors in predicting emergency department (ED) use among 270 individuals with current or previous experience of homelessness. Participants were recruited from three different types of housing (shelter, temporary housing and permanent housing) in Montreal, Quebec (Canada). They were interviewed at baseline (T0), and again 12 months after recruitment (T1). Longitudinal data analyses were conducted on associations between a set of baseline predictors (T0) with the dependent variable (ED users vs. non-users) from T1. Predictors were identified according to the Gelberg-Andersen Behavioral Model. Findings revealed two needs factors associated with ED use: having a substance use disorder (SUD) and low perceived physical health. Two enabling factors, use of ambulatory specialized services and stigma, were also related to ED use. No predisposing factors were retained in the model, and ED use was not associated with type of housing. Improvements are needed in SUD and physical health management in order to reduce ED use, as well as interventions aimed at stigma prevention for this vulnerable population.

What makes a difficult patient so difficult? Examining the therapist's experience beyond patient characteristics

The primary aim of this study is to improve our understanding of therapists' experience of a "difficult patient" and consider the different variables involved in this label. What makes a patient be perceived as difficult by a therapist in public health services? Results of our analysis of 10 qualitative semistructured interviews of therapists working in public health service in Chile indicated that therapists' perceptions of a "difficult patient" depend on variables that go beyond the patient's intrinsic characteristics, including patients' negative attitude toward the therapist and treating team, patients' negative effects on therapists, and a difficult treatment context (e.g., work overload, scarce resources, limited number, and frequency of sessions). We illustrate the interaction of these dimensions and focus on the impact of the treating context on therapists' experience of a "difficult patient" through the case of a therapist working with a patient with complex depression in the public health system of Chile.