Black patients at Brigham and Women’s Hospital were nearly twice as likely as white patients to have security called on them, according to a new study led by researchers at the hospital.
The findings, published May 13 in the Journal of General Internal Medicine, will propel efforts within the Brigham to address the problem, executives and researchers said.
Dr. Yannis Valtis, lead author of the study and senior resident in the Division of General Internal Medicine & Primary Care, said residents began looking at how race played into the use of security after George Floyd’s murder at the hands of police officers two years ago.
“A lot of our conversations had been looking outwards and saying how does police violence affect patients outside the hospital and what is our role?” Valtis said. “We decided it was also important to turn our gaze inward, in our own hospital — [how] do we interact with patients in inequitable or unjust ways?”
The Brigham findings follow similar inequities reported by other groups, including a study of three hospitals within the Yale-New Haven Health System in Connecticut that showed Black patients were more likely to be restrained in emergency department settings than white patients and a 2004 study of inpatient psychiatric patients that showed Asian and Black racial groups were more likely to have experienced forced seclusion. Even in pediatrics, Black children were more likely to be restrained compared to white patients, according to a study of a New England health care system — a traumatic experience that can have lasting consequences on a child’s development, the authors said. (The study did not name the health care system).
A 2018 study in a Midwestern hospital also showed that Black patients who had visitors were more likely to have security called on them than white patients with visitors.
When staff members at Brigham and Women’s perceive a patient to be a threat to themselves or others, they can call for a “security emergency response activation.” The call prompts security officers to come to the patient’s room and for members of the medical team to be paged. If security fails to de-escalate the encounter, physicians can place an order for the patient to be physically restrained or given medication.
The authors analyzed 423 security reports filed for more than 24,000 Brigham patients discharged between Sept. 1, 2018 and Dec. 31, 2019. Security calls for visitors were excluded, and researchers said they only counted the first admission for patients who were repeatedly in the hospital in the time period.
According to the data, 2.8 percent of Black patients had calls placed for them, compared with 1.6 percent of white patients.
When adjusted for different factors — such as age, sex, length of stay, a diagnosis of mental health or substance use disorders, and insurance status — Black patients were 36 percent more likely to experience a security emergency response than white patients. Hispanic patients did not have higher odds than non-Hispanic patients of having security called on them, according to the study.
Valtis said the research wasn’t designed to identify the causes for potential disparities, but a leading hypothesis is that bias and racism cause health care providers to perceive Black patients as more threatening. Researchers also said it was possible that cultural and language barriers between providers and patients of different races or ethnicities might lead to more frequent security requests. Another possibility was that some patients perceive the hospital environment as more threatening because of prior negative experiences.
The recent findings are in line with a study that Massachusetts General Brigham researchers published in 2020 and expanded upon in 2021, that found that Black, African-American, and Hispanic patients under an involuntary mandatory emergency psychiatric evaluation hold order at Mass General Brigham emergency departments were subject to higher rates of physical restraint.
In response, emergency departments at the Brigham, Brigham and Women’s Faulkner, and Massachusetts General Hospital launched a de-escalation training program. Participants review the impact of physician restraint on patients and staff, the factors associated with the use of physical restraint in the emergency department, practice de-escalation with actors posing as patients, and talk through how to reduce racial bias when managing agitated patients.
Dr. Dana Im, director of quality and safety for the Department of Emergency Medicine at Brigham and Women’s, said a pilot program for this training within the department successfully changed people’s perception of implicit bias and their comfort level in de-escalating situations. The training has since been expanded as part of the health system’s United Against Racism initiative, and clinicians are tracking the use of restraint and violence against staff to see if the training is effective.
“The data is shocking but also not shocking. I wanted our staff to have a safe space to review the data and reflect on the data and discuss it and ask honest questions,” Im said.
Valtis said that simulation-based training has a lot of potential to address disparate rates of security calls within the hospital.
While the specific response to the latest study is still being discussed, Tom Sequist, chief medical officer at Mass General Brigham, said the health system is open to looking inward at its own biases. The emergency department study, in particular, was part of equity improvement projects happening across all 18 clinical departments as part of the system’s United Against Racism mission, which is working to identify and address racism in many aspects of medicine.
“The United Against Racism platform is going to be awkward,” Sequist said. “It’s going to be uncomfortable for us as a health system. If we aren’t uncomfortable, we’re not addressing the real issues.”
Usha Tummala-Narra, director of Community-Based Education at the Albert & Jessie Danielsen Institute at Boston University and a research professor in BU’s Department of Psychological and Brain Sciences, said the research being shared with clinicians should be expanded to include studies that detail disparities of care that Black patients face.
Tummala-Narra added that it was important to collect data from patients and have patients’ own experiences and narratives play a role in training to address biases more sustainably.
Ultimately, solutions have to go further than training alone.
“Training is only one part of the approach,” said Tummala-Narra, who is an expert on the intersection of race, immigration, trauma and mental health care. “Another would be to include more diverse staff. Diversity in staff allows for people to see a diversity of perspective.”