#BlackLivesMatter to C-L Psychiatrists: Examining Racial Bias in Clinical Management of Behavioral Emergencies in the Inpatient Medical Setting

Friday, November 12, 2021

4:00 PM – 5:00 PM US Eastern Time

Background: CL psychiatrists are uniquely positioned to combat structural racism in medicine Currently, there are no published papers examining racial bias in the management of psychiatric emergencies in the general medical hospital. Given the potential for restrictive clinical interventions that directly challenge a patient’s autonomy (including intramuscular injections and restraints), our group embarked on a long-term, quality improvement project to detect and address racial bias affecting the clinical management of these psychiatric emergencies.

Methods: Our institution has a multidisciplinary behavioral code team known as the Behavioral Emergency Response Team (BERT) that responds to behavioral emergencies throughout the medical hospital. Secondary BERT event data occurring from 2017 to 2020 was combined with demographic data from the electronic medical record. Race and ethnic data were collapsed into unique, phenotypic categories. BERT events were coded based on the most restrictive intervention utilized. Descriptive statistics were used to describe the sample and examine whether race / ethnicity correlated with BERT intervention utilized, diagnostic impression, reason for BERT activation, or recurrent BERTs.

Results: Our sample included 1532 BERT events representing N = 902 unique patients. The main interaction of BERT intervention by Race / Ethnic category reached statistical significance (p=0.04). Though most BERTs only required verbal de-escalation (n=419, 46.45%), 3% of BERTs (n = 29) escalated to 4-pt restraints (most restrictive intervention). Though reaching level 5 was rare, Black patients had a statistically significant higher likelihood of receiving this intervention compared with White patients (6% v 2%, p=0.027) and compared with all other non-Black patients (6% v 2%, p=0.040). Although the overall comparison for Race/Ethnicity and the diagnostic impression “Psychosis” did not reach significance (p=0.086), targeted analysis showed that Black patients were significantly more likely to have “Psychosis” listed as a contributing factor compared with White patients (p=0.009) and all other non-Black patients (p=0.016). Several other comparisons with Race / Ethnic category reached statistical significance: Age (p=0.048), and need for interpreter yes/no (p<0.001). Closer examination of the interaction of Race/Ethnicity x Need for Interpreter revealed that half of events involving Asian patients (n=22, 53.66%) and a third of events involving Hispanic patients (n=29, 30.53%) required interpreter services.

Discussion: This study demonstrates the feasibility of investigating racial bias in behavioral emergency management. The results of this preliminary analysis suggest multiple areas for enhanced education, self-awareness development, and programmatic improvement to target systemic racism, decrease racial bias, and improve patient care. These areas include bias in restraints use, the role of language in behavioral emergencies, and the influence of race on perception of underlying diagnosis.

Learning Objectives:

Recognize the importance and feasibility of examining racial bias in the management of behavioral emergencies

Presenting Author(s)

Rachel A. Caravella, MD

Associate Director, CL Psychiatry Service, NYULH Manhattan Campuses
NYU Langone Health
New York, New York, United States

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Co-Author(s)

PY

Patrick Ying, MD, DFAPA

Assistant Professor of Psychiatry
NYU Grossman School of Medicine
New York, New York, United States
Marra Ackerman, MD

Director, CL Psychiatry, NYULH Manhattan
NYU Langone Health
New York, New York, United States
AD

Allison Deutch, MD

Site Director For Women's Mental Health, Attending Psychiatrist, Consultation Liaison Service
NYU Langone Health
New York, NY, United States
CS

Carole Siegel, PhD

Research Professor, NYU Grossman Medical School
NYU Grossman School of Medicine
New York, NY, United States
ZL

Ziqiang Lin

Biostatistician
New York University School of Medicine
Rahway, New Jersey, United States
Rubi Vaughn, MD, MPH

Director, Consult and Emergency Psychiatry - Einstein Division of Montefiore Medical Center Program Director, CL Psychiatry Fellowship - Montefiore Medical Center Assistant Professor of Psychiatry & Behavioral Sciences
Einstein Division - Montefiore Medical Center
New York, New York, United States
SM

Sharon Madanes, MD, MFA

Resident
NYU School of Medicine
NEW YORK, New York, United States
AC

Aviva Caroff, MD

Resident Physician
NYU Langone Health
New York, New York, United States
MS

Mara Storto, MD

Psychiatry Resident
NYU Langone Health
New York, New York, United States
PP

Philip Polychroniou, MD

Psychiatry Resident
New York University Grossman School of Medicine
New York, New York, United States
CL

Crystal Lewis, PhD

Associate Professor and Laurie M. Tisch Scholar for Racial Equity in Mental Health
NYU Grossman School of Medicine
New York, New York, United States
AK

Adam Kozikowski, MS, PMHNP-BC

Nurse Practitioner
New York Langone Health
Glen Rose, Texas, United States