Data offers critical self-examination, allows for implementation of interventions to address disparity
Black and Latinx people in the United States face a disproportionate burden of violence by police. But what happens inside the hospital? When hospital staff face a situation that requires the intervention of police or security, they can place a call for a security emergency response (SER) and hospital security officers will be summoned to the bedside. A new study by researchers at Brigham and Women’s Hospital analyzed data from patients treated at the Brigham in 2018 and 2019 to determine whether Black and Hispanic patients experience higher rates of SER and/or physical restraint. The researchers found that Black patients had higher odds of an SER than white patients but were not more likely to be physically restrained. SER and physical restraint rates did not differ between Hispanic and non-Hispanic patients. Results of the study are published in The Journal of General Internal Medicine.
“We wanted to understand when and how and on whom we tend to call security at our hospital,” said corresponding author Yannis Valtis, MD, of the Division of General Internal Medicine & Primary Care. “This kind of critical examination can help us to understand our own biases and the role that structural racism may play, even within the walls of our own hospital. This will empower us to design and implement interventions to help us address them.”
Health care workers have experienced an increase in workplace violence over the last 10 years. When there is concern that a patient is a threat to themselves or to others, any staff member of the hospital (including physicians, nurses, unit coordinators and patient care assistants) can call the hospital operator and request an SER activation. A staff member might call an SER if a patient uses threatening language, threatens physical violence toward staff, or if the patient may pose a risk to themselves. Security officers respond to all SER calls that are placed by staff and will attempt to de-escalate the situation. If de-escalation is unsuccessful, a physician may place an order for physical restraints or medications.
Working in collaboration with the Brigham’s security team, Valtis and colleagues obtained and reviewed all security reports filed for Brigham patients discharged between September 1, 2018 and December 31, 2019. During the study period, there were more than 24,000 patients discharged from the Brigham, of whom 77 percent identified as white, 9.7 percent identified as Black, 10 percent identified with another race and the rest had an unknown race. Approximately 7.6 percent identified as Hispanic. Overall, 423 patients experienced an SER, including 66 Black patients (2.8 percent of Black patients in the analyzed data) compared to 295 white patients (1.6 percent of white patients in the analyzed data).
The team adjusted for cofounders — such as age, sex, length of stay, mental health/substance use disorder diagnoses and insurance status — and still found that Black patients were about 30 percent more likely to experience an SER. Hispanic patients did not have statistically significant different odds of having an SER than non-Hispanic patients.
“Our analysis indicates that, while Black patients make up a much smaller proportion of the patient population seen at the Brigham, they were nearly twice as likely to have security called on them as white patients,” said Valtis. “While our study did not uncover the mechanisms that lead to this inequity, we have some hypotheses. It is possible that hospital staff perceive Black patients as more threatening as a result of bias and racism, leading to more frequent security activation. It is also possible that some patients perceive the hospital environment as more threatening, because of prior negative experiences. Those experiences might also be a result of structural racism in U.S. health care. And there might be other reasons that we just haven’t identified yet.”
Valtis and colleagues are now working on potential next steps to address identified inequities. After similar disparities were documented in the Emergency Department (ED), ED colleagues put in place an Antiracism and Trauma-informed Interdisciplinary De-escalation Training Program, supported by Mass General Brigham’s United Against Racism commitment, which has so far trained approximately 70 providers and nursing staff. Valtis and colleagues are exploring expanding such trainings to inpatient bedside providers as well as other strategies for identifying and addressing the role of bias in SERs.
“We know that all human systems are subject to bias and we want to find ways to work together to identify it and address it – the goal is to do better by our patients,” said Valtis.
“This is just the type of data we need to propel our efforts to eliminate racism from our systems of care,” said Zara Cooper, MD, MSc, co-chair of the Brigham and Women’s Hospital Board of Trustees Committee on Diversity, Equity, Inclusion and Health Equity and Community Health.
“Every one of us has a role to play in changing our behavior to make the Brigham and other health care settings more equitable, inclusive and welcoming for all of our patients. As an international leader in clinical care and innovation, the Brigham and Mass General Brigham must set the example for self-reflection, transparency and hard conversations necessary to move toward a future with better health for all.”
The authors note several limitations to the study, including the single-site nature of the work — the team’s findings may not be generalizable to other hospitals or health care settings. SER events are rare, and physical restraint even rarer, which may mean that the study was not adequately powered to detect differences in restraint events based on race. The researchers note that further investigation is needed to better understand whether differences in SER rates represent a broader problem across health care institutions. Valtis would also like to engage directly with patients to inform future studies.
“One thing that is missing from these discussions so far is the voice of the patient,” he said. “Their perspective on how we can respond to these situations could help us make improvements.”
Funding: This project was awarded the Rappaport Award from the Department of Medicine of Brigham and Women’s Hospital.
Paper cited: Valtis, Yannis et al. “Race and Ethnicity and the Utilization of Security Responses in a Hospital Setting” Journal of General Internal Medicine DOI: 10.1007/s11606-022-07525-1