Emergency psychiatry

Journal Article Annotations
2024, 1st Quarter

Emergency psychiatry

Annotations by Rida Khan, MD
April, 2024

  1. Racial and Ethnic Disparities in Patient Restraint in Emergency Departments by Police Transport Status.

Of interest:

PUBLICATION #1 — Emergency psychiatry

Racial and Ethnic Disparities in Patient Restraint in Emergency Departments by Police Transport Status.
Erika Chang-Sing, Colin M Smith, Jane P Gagliardi, Laura D Cramer, Leah Robinson, Dhruvil Shah, Morgan Brinker, Patelle Jivalagian, Yue Hu, Nicholas A Turner, Ambrose H Wong.


The finding:
This original retrospective, cross-sectional study extracted and analyzed electronic health record (EHR) data from ED visits at 13 US hospitals over 5 years to evaluate the racially disparate use of violent physical restraints in the ED. This was a large-scale EHR data analysis and included over 1 million patients accounting for over 4 million ED visits. In the analysis, the variable Black race was found with increased odds of physical restraints, as well as with increased odds of police transport to ED; separately, police transport to ED was with increased odds of physical restraint use, indicating a positive association between police transport to ED and both Black race and higher rates of physical restraints. Mediation analysis estimated that 10.70% of the racial-ethnic disparity in physical restraints use for Black patients in behavioral emergencies in the ED was mediated by police transporting them to ED.

Strength and weaknesses:
This is a large-scale multi-center retrospective EMR analysis which lends the findings robust power. The authors adjusted for a comprehensive set of demographic and diagnostic confounding factors; however, any number of other hypothetical possible confounders and mediators would not have been measured in this retrospective analysis. With respect to use of physical restraints, while in behavioral emergencies and for the uniform indication of acute safety risk to self or others, the specific nature of the behavioral emergencies or the character of the safety risk posed was not able to be assessed, thus we cannot gauge the appropriateness or lack thereof of physical restraints used as clinical intervention for any particular given situation.

This study adds to important emerging evidence on the impact of social determinants of health systemically on population health and in individual patient care. It sheds important focus on how Black patients who present to the ED in behavioral emergencies are at elevated risk of negative outcomes. This calls towards increasing physician literacy on healthcare inequities as well as an area for advocacy and public policy target.

PUBLICATION #2 — Emergency psychiatry

Postpartum Psychosis: A Preventable Psychiatric Emergency.

Annotation (unstructured):
This review summarizes literature on clinical features, treatment, and prevention of postpartum psychosis. Early identification and emergency intervention is critical to preventing mortality and decreasing morbidity. Insomnia is often the earliest and most common symptom; thus interventions to enhance and protect the mother’s sleep during this high risk period are key. Postpartum psychosis can have a delirium-like presentation with cognitive symptoms confusion, disorientation, and dissociation, impaired insight. A thorough assessment of acute safety risk must be conducted, and it is imperative to be mindful of patient perceptions, social stigma, and the mother-infant dyad. In diagnosing postpartum psychosis, a thorough medical workup must rule out medical causes of psychosis in the postpartum period, including infectious, metabolic, hormonal, and neurologic processes. Once diagnosed, postpartum psychosis usually requires acute inpatient hospitalization for safety and stabilization.