Behavioral Flags in ED Charts Have Unintended Consequences
By Stacey Kusterbeck
If a patient attacked an ED nurse, the next ED nurse caring for that individual probably would want to know specifics about what happened. Some EDs place behavioral flags in ED charts to warn other providers. “These notifications are designed to alert someone in the future caring for the aggressive patient, as sort of an early warning for future encounters,” says Anish K. Agarwal, MD, MPH, MS, assistant professor and chief wellness officer in the Department of Emergency Medicine at University of Pennsylvania’s Perelman School of Medicine. At the University of Pennsylvania Health Systems’ EDs, if a behavioral flag pops up, clinicians must acknowledge it before they can even get into the chart.
Agarwal and colleagues wondered if the flags were associated with differences in clinical care, and whether there were differences between use of behavioral flags in Black and white patients.1 The researchers analyzed 426,858 visits of 195,601 patients at three Philadelphia EDs from 2017-2019. “We found that the flags are actually not used that often,” says Agarwal. “The incidence of how often flags are used is very low.” Only 0.3% of patients had a behavioral flag in the electronic health record (EHR). There were 16 behavioral flags per 1,000 patients.
There were some disparities in which patients had behavior flags. “It is an unintended consequence, unfortunately, of these notifications. The mechanism to keep clinicians safe might have unintended consequences we want to keep our eye out for,” observes Agarwal. Male patients, Black patients, and patients with Medicaid insurance were more likely to have a flag. Patients with flags were more likely to leave against medical advice or without being seen, were less likely to have imaging tests ordered, and had fewer medications ordered than patients with no behavioral flag. “The potential implications are that the flags may impact care delivery at a very high level, but we do not know much about the individual’s care — that remains to be seen or studied,” says Agarwal.
Of 6,851 patients with a behavioral flag, Black patients had longer waiting times to be placed in a room and waited longer to see a clinician, but had shorter lengths of stay, compared to white patients. Black patients with a flag were less likely to undergo lab tests and imaging compared to white patients with a flag. “The fact that we see these disparities unfortunately reveal another example of implicit or unconscious bias and likely structural racism within healthcare. The broad metrics we see here, changing among patients who are Black and have a flag vs. white patients with a flag show that there are differences in how care is managed and what is done for the patient,” says Agarwal.
In a follow-up qualitative study, the researchers interviewed 25 emergency nurses at an academic urban ED in 2022 to understand their attitudes toward behavioral flags.2 Some nurses thought the flag was a useful advisory and spurred them to use more caution. One nurse saw a behavioral flag reporting that the patient had concealed a weapon during a previous ED visit — and it turned out a knife was discovered during a search of the patient’s belongings. However, more than half of the nurses viewed flags as unhelpful and would not prevent a patient from becoming violent. Some nurses worried that it could negatively affect their perception of the patient before they even went to the room. Other nurses expressed concern that staff may have escalated the situation during the previous ED visit, noting that some patients had flags from an ED visit years ago, but were calm and cooperative during subsequent ED visits. One nurse raised the question of whether behavioral flags should have a time limit and be removed from the chart at some point.
The researchers currently are conducting a study on patients’ views on behavioral flags. Preliminary findings indicate many patients think behavioral flags in general are a good idea, but not for themselves, reports Agarwal.
“Unfortunately, the EHR is part of the interaction between a clinician and the patient. The EHR is a middleman in that workflow. How it helps, influences, or hurts clinicians is important to study and make it better,” offers Agarwal. It is clear that EDs must continue to mitigate the risks of violence and keep staff safe. “We need to be thoughtful about how to use flags so that they help staff but don’t worsen care,” Agarwal concludes.
Standardized criteria for determining if behavioral flags are used consistently are needed, according to Jeffrey Lubin, MD, MPH, vice chair of research in the Department of Emergency Medicine at Penn State Health Milton S. Hershey Medical Center. “The criteria should be developed at the departmental or hospital level to promote consistency and equity,” says Lubin.
The goal is not to stigmatize patients but, rather, to be able to provide better and safer care for them. “It is important to note that behavioral flags simply serve as markers to identify patients with behavioral health concerns or special needs,” says Lubin. Without the use of behavioral flags, future providers may be unaware of these specific patient characteristics. “That can lead to potential risks, such as delayed or missed interventions, increased risk of adverse events, inadequate triage prioritization, lack of standardized communication, and reduced quality of care,” says Lubin.
For ED providers, training and education on understanding and interpreting behavioral flags can mitigate these risks. This could be as simple as a short in-service or, more ideally, woven into more comprehensive education about patients with behavioral health issues. “The dignity, autonomy, and confidentiality of the patients must be respected while providing care and support, avoiding bias and ensuring equal treatment,” underscores Lubin.
Behavioral flags work best in organizations with a strong patient safety culture, says Susan L. Montminy, MPA, RN, BSN, CPHRM, director of risk management and analytics at Coverys. “This culture allows for a proactive de-escalation approach before potential violence occurs. A behavioral rapid response team, including a member with a psychiatric background, is useful in these scenarios,” advises Montminy.
Montminy says that if behavioral health flags are not used, it puts healthcare providers at risk. “Escalations of behavior can happen in seconds — what some have described as like turning on a light switch, catching the staff member off guard,” says Montminy. ED patients with a behavioral health diagnosis may exhibit subtle behavioral cues that indicate the potential for a violent response. “Sharing these cues through the behavioral health flag system, with associated de-escalation and calming strategies, is key to prevent future violence,” says Montminy.
Some members of the ED team, such as environmental services, lack access to the EHR. “Many organizations have had success using generic color-coded alert signs placed outside of the patient room, for staff reference, that protect the dignity of the patient for whom they are intended,” says Montminy.
- Agarwal AK, Seeburger E, O’Neill G, et al. Prevalence of behavioral flags in the electronic health record among Black and white patients visiting the emergency department. JAMA Netw Open 2023;6:e2251734.
- Seeburger EF, Gonzales R, South EC, et al. Qualitative perspectives of emergency nurses on electronic health record behavioral flags to promote workplace safety. JAMA Netw Open 2023;6:e239057.
If a patient attacked an ED nurse, the next ED nurse caring for that individual probably would want to know specifics about what happened. Some EDs place behavioral flags in ED charts to warn other providers.
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