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

Rachel E Gonzales; Emily F Seeburger; Ari B Friedman; Anish K Agarwal

doi:10.1111/acem.14887

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

Acad Emerg Med. 2024 Mar 21. doi: 10.1111/acem.14887. Online ahead of print.

Authors

Rachel E Gonzales^{1

2

3

4}, Emily F Seeburger^{1

2

3

5}, Ari B Friedman^{1

2}, Anish K Agarwal^{1

2

3

4}

Affiliations

¹ Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
² Center for Emergency Care Policy and Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
³ Penn Medicine Center for Health Care Transformation and Innovation, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁴ Penn Medicine Center for Insights to Outcomes, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
⁵ Penn Urban Health Lab, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

PMID: 38511415
DOI: 10.1111/acem.14887

Abstract

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.

Keywords: bias; well‐being; workplace safety.