EHR Flags May Not Help Emergency Department Nurses with Violent Patients

 In Nurses Weekly

Behavioral flag features in electronic health records (EHRs) designed to assist nurses and clinicians managing difficult or dangerous patients may not always have the desired effect.

In new qualitative analysis from a group of University of Pennsylvania investigators, emergency department (ED) nurses were polarized on the value of EHR behavioral flags and their benefit in preventing patient-caregiver violence or harboring suitable care in potentially distressing circumstances.1 As violent and aggressive interactions are particularly heightened in ED care settings, the investigators stressed improvements could be made to features like EHR flagging.

Previous surveys have suggested approximately half of all physicians working in the ED have been physically assaulted while at work; many caregivers in the same setting have described patient-initiated violence as very commonplace. “I think people would be pretty horrified to know most emergency room nurses have been assaulted, that most feel scared in their workplace,” one physician told HCPLive.2

Because of the high prevalence of verbal harassment and physical assault in emergency care, many EHR systems feature a behavioral notification system that may flag an initial incident or potential issue with a patient to notify their future caregivers.

A team led by Emily F. Seeburger, MPH, of the Penn Urban Health Lab and Perelman School of Medicine at University of Pennsylvania, sought to assess the perceptions, beliefs and attitudes of ED nurses toward such EHR behavioral flags through a qualitative study. They noted that little is still understood about their effectiveness, use or incidental impact on ED care.

“Less is known about the perceptions and impact of behavioral flags in a clinical environment,” they wrote. “This study explores this issue by going to the source closest to these flags: emergency nurses, who have the most interaction with patients and who are at the highest risk of violence.”

Seeburger and colleagues conducted guided, semistructured interviews of registered nurses from an urban, academic trauma center ED in early 2022. The team’s interviews focused on nurses’ perceptions, beliefs and attitudes toward EHR behavioral flags through open-ended questions and subsequent probes.

The analysis included 25 nurses. Mean participant age was 33 years old; 19 (76%) were women and a majority (n = 15 [60%]) were White. Another 3 nurses each identified as Asian, Black and Hispanic or Latinx.

The team observed 3 themes serving as rationale for the benefit of EHR behavioral flagging among the surveyed nurses:

  • Useful advisory
  • Prevents violence
  • Engenders compassion

One surveyed nurse noted they recently had a patient who came into the ED complaining of homicidal ideations; they found the flagging notification helpful because it prompted a conversation about whether the patient was carrying a weapon on them during the visit.

“So I was able to, (because) like most of the time, if we have homicidal patients or suicidal patients for one, the patient care tech will sit on it and then go through their belongings,” the nurse told investigators. “And the patient was like, he literally told me, ‘They took my knife away. But if I had my knife, I would cut anybody that’s closest to me.’”

The team observed 5 themes serving as rationale for issues with EHR behavioral flagging among the surveyed nurses:

  • Administrative and process issues
  • Unhelpful
  • Unenforceable
  • Bias
  • Outdated or uncharacteristic

Among the complaints of nurses were that the feature resulted in excessive data-logging, little contribution to actually safer patient interactions, or even risk of bias prior to caring for the patient.

“I feel like sometimes different attitudes with different nursing staff, [the patient’s attitude] will come across a different way,” one nurse told investigators. “So whether the nurse was more aggressive or less tolerant of the behavior then maybe things escalated instead of trying to figure out the reason. And I’m not saying a lot of people don’t have reasons to put flags in, but I think sometimes I’m more tolerant.”

Nurses additionally commented on the risk of such features harming the patient-clinician relationship or possibly helping to keep patients more accountable by informing them of their reported transgressions—again speaking to the varied perspective on the tool. Among the system improvements they identified in their interviews, nurses hoped the behavioral system could become more streamlined, that it could result in better care environments that foster safer interactions (i.e., larger triage rooms) and better response and training from their human resources as it relates to patient assaults and altercations.

“The need to reconfigure triage was something mentioned in almost every interview, as its layout posed major staff and patient safety risks,” investigators wrote. “Other suggestions provided, especially those to improve documentation and communication, could also be implemented to remedy process complaints. These findings suggest that the issue of violence in the ED can be readily improved.”

Seeburger and colleagues concluded that necessary changes are apparent to improve the process of documented violence risk through follow-up and enforcement in the ED.

“One kind of intervention alone is not enough to prevent violence in the ED altogether; future research should explore what other procedures or policies, in concert with behavioral flags, are most effective in reducing incidents of harassment or assault in the ED,” they wrote.

The team now intends to assess outcomes associated with behavioral flags on patient care—focused on whether a patient flagged in the EHR receives perpetually affected care.


  1. Seeburger EF, Gonzales R, South EC, Friedman AB, Agarwal AK. Qualitative Perspectives of Emergency Nurses on Electronic Health Record Behavioral Flags to Promote Workplace Safety. JAMA Netw Open. 2023;6(4):e239057. doi:10.1001/jamanetworkopen.2023.9057
  2. Kunzmann K. Hurting Healers: Violence in the Hospital. HCPLive. Published May 14, 2019. Accessed April 20, 2023.


(This story originally appeared in Consultant Live.)

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