Hospital Security Team Involvement in Emergency Mental Health Care of Patients.

Importance: Hospital-based security teams assist emergency department (ED) staff when there is a risk to staff or patient safety. Objective: To describe the current practice of hospital security assistance during emergency mental health care. Design, Setting, and Participants: This qualitative study with mixed methods was a secondary analysis of a retrospective cohort study of patients in the ED for mental health concerns who received involuntary sedation from 2020 to 2021. Any ED note documenting security presence or calls was abstracted as a text snippet. Hospital security data logs were also queried for the same time frame and summarized. Data were analyzed from February to November 2024. Main Outcomes and Measures: Outcomes included type and quantity of hospital security calls to the ED. A deductive quality analysis was performed with the goal of assessing current clinical documentation practices as an initial step toward improvement. The deductive coding of text snippets began with 10 codes, including verbal threats, physical aggression, and elopement. Results: Over the 2 years, hospital security had 9288 clinical support encounters in the ED (mean, 12.7 encounters per day). The parent electronic health record abstraction study included 334 patients, of which 244 patients (73.1%) had hospital security involved in their care and so were included in this analysis (146 men [59.8%]; mean [SD] age, 34.5 [13.6] years). Among the study subset, 135 patients (55.3%) were brought to the ED by police. Security was most often called for physical violence (82 patients [33.6%]). De-escalation attempts occurred by ED staff for 29 patients (11.9%) and security personnel for 17 patients (7.0%). Theme 1 was safety: patient-on-patient violence was a new finding: "...this patient stood up out of her chair, ran over to another patient and started punching another patient." Theme 2 was patients who are unwilling or unable to adhere to the care plan. Disagreement with disposition plans or medical care was a frequent trigger of violence. Theme 3 was that de-escalation attempts were not well documented. "Security called to bedside… [nurse] able to talk patient down at this time." Theme 4 included legal issues: security assisted with the disposal of illicit substances and use of security body cameras to document patient belongings. Conclusions: In this study, security teams contributed to the safety of ED staff and patients. This single-center study's findings suggest the need for future improvements, including improving the documentation of de-escalation techniques used and developing better ways to reduce violence from care plan disagreements.