Black patients more likely to be flagged as aggressive in emergency departments

As doctors and nurses face more violence in hospitals, health systems have encouraged clinicians to utilize a notification or “flag” in health records to indicate that patients may be potentially unsafe or aggressive.

However, a new study indicates that Black patients are more likely to receive a flag in their electronic health records than white patients.

Researchers with the University of Pennsylvania found Black patients with a flag received less treatment, were less likely to be admitted, and were more likely to leave before a full evaluation than white patients. The findings were published in Jama Network Open on Jan. 19.

“Behavioral flags have important implications for patient care: they may introduce cognitive bias from clinicians providing acute care, since they often serve as alerts or advisory notifications when opening a patient’s EHR,” the researchers wrote.

“Understanding when, and for whom, these flags are being implemented is important in how health systems think about providing equitable care while maintaining staff safety.”

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Very few patients are being flagged in electronic health records, the researchers found.

Among 195,601 patients studied in emergency departments, only 683 patients (0.3%) had a behavioral flag notification in their electronic health records.

However, Black patients were nearly twice as likely to get a flag in their records. Black patients received the notifications at a rate of 4 per 1,000 patients, while white patients received flags at a rate of 2.4 per 1,000, according to the study.

Among those with a flag, Black patients waited 28 minutes to be placed in a room, while white patients with a notification waited 18 minutes. Black patients with a flag spent more time waiting to see a clinician than white patients (42 minutes vs. 33 minutes). And Black patients were more than five times more likely to have no laboratory orders, the study found.

The researchers said the greater use of flags for Black patients suggests bias could be a factor.

“Questions also arise from this study as to why Black patients were more likely to be flagged; the reasons for this, including structural factors and racial bias, require further study,” the researchers wrote. “This analysis demonstrated that flags were associated with care, which may in turn be associated with diagnostic error.”

Health systems understandably want to do more to protect healthcare workers. Most emergency doctors said they have seen increased violence in the last five years, according to a poll by the American College of Emergency Physicians. Roughly half of all nurses report an increase in workplace violence, according to a poll by National Nurses United.

The disparities in using flags in health records represent an unintended consequence of a policy aimed at protecting doctors and nurses, the researchers noted.

To avoid bias, health systems could consider using a team approach to determine if a patient’s record should include a notification about a potential problem, the authors wrote. Researchers also suggested removing the flags from records if patients exhibit no problems in subsequent visits, or setting a time limit on how long the flags should remain in the health records.

Researchers examined three emergency departments in Philadelphia between Jan. 1, 2017 through Dec. 31, 2019.

Electronic health records have revealed suggestions of bias in the past. Black patients were more than twice as likely to have at least one negative description in their health records than white patients, according to a study published in Health Affairs in January 2022.