Racial, Ethnic Disparities in Restraint Use
By Stacey Kusterbeck
A researcher noticed Black patients seemed to be physically restrained in EDs more often than other patients. The authors of recent studies have reported higher rates of physical restraint in EDs among Black patients vs. white patients.1,2
“Most of these studies, however, were done within one ED or healthcare system and may not have been representative of what happens in other EDs,” says David Dillon, MD, MPhil, PhD, assistant professor in the department of emergency medicine at UC Davis Health.
Dillon and colleagues conducted a rigorous, systematic review of the literature to identify and summarize studies to confirm or dispute their clinical experiences. Researchers reviewed 1,597 articles, of which 10 met their inclusion criteria. Those 10 studies were analyzed by restraint use in EDs according to patients’ race or ethnicity.3
Overall, restraint was used in less than 1% of ED encounters. Black patients were more likely to be restrained vs. other racial groups. Hispanic patients were less likely to be restrained than non-Hispanic patients.
Initially, researchers intended to conduct a larger meta-analysis, including re-analysis of data from all the included studies, accounting for other factors that have been shown to be associated with physical restraint use (e.g., a known mental health diagnosis) to see if a difference in restraint use by race persisted. However, due to the mixed quality of the studies, only six of the 10 studies were included in the final meta-analysis. Thus, Dillon and colleagues could not comment on any specific factors that could have resulted in the differences in restraint use by race.
This is something that warrants further study, along with research on ED-specific disparities in general, according to Dillon.
“It is important that systems and structures are put in place to promote work confronting these issues, including ensuring funding mechanisms are available to support these investigations, and implementing clinical policies that address these disparities,” Dillon offers.
Another group of researchers analyzed physical restraint use in pediatric ED visits by race/ethnicity at 11 EDs that occurred from 2013 to 2020.4 Only 0.1% of pediatric patients had a physical restraint order. Black children were 1.8 times more likely to be physically restrained than white children. There was no difference in the frequency of restraint use in Hispanic and white non-Hispanic patients. Children with a history of a behavioral health condition, children who presented with a behavioral health concern, and children who were taking a psychotropic medication were more likely to be restrained.
Restraining an ED patient is dangerous for both the patient and staff, and always should be a last resort, underscores Jeffrey Lubin, MD, MPH, vice chair of research in the department of emergency medicine at Penn State Health Milton S. Hershey Medical Center.
“Not only can restraining a patient cause physical injuries, it can cause significant psychologic distress and even, in some cases, be a violation of patient rights,” Lubin warns.
Inadequate initial and recurrent training, lack of adequate personnel, and inadequate monitoring of restrained patients are problematic practices in EDs that can exacerbate risks. To alleviate those risks, Lubin offers these practice tips for EDs:
• Use restraints only when absolutely necessary, and in accordance with established protocols and regulations;
• Undergo training on appropriate restraint techniques;
• Ensure regular monitoring of restrained patients;
• Continuously reassess the need for restraints;
• Clearly document the rationale for restraint use.
Lubin gives this example of good documentation on this point: “The patient was exhibiting severe agitation and aggressive behavior. Verbal de-escalation techniques were employed, but proved ineffective. Given the severity of the patient’s agitation and the imminent risk of harm to himself and others, I determined that the use of restraints was necessary. After the environment was cleared of potential hazards, additional staff were called for assistance and four-point leather restraints were applied to the patient’s wrists and ankles. The patient was given medications to reduce agitation, and his condition was regularly reassessed, per hospital guidelines and standards, to determine the appropriateness of extending or discontinuing the use of restraints.”
Whenever restraint is used in the ED, says Lubin, “the goal should always be to provide safe and compassionate care — while minimizing the potential risks.”
1. Carreras Tartak JA, Brisbon N, Wilkie S, et al. Racial and ethnic disparities in emergency department restraint use: A multicenter retrospective analysis. Acad Emerg Med 2021;28:957-965.
2. Schnitzer K, Merideth F, Macias-Konstantopoulos W, et al. Disparities in care: The role of race on the utilization of physical restraints in the emergency setting. Acad Emerg Med 2020;27:943-950.
3. Eswaran V, Molina MF, Hwong AR, et al. Racial disparities in emergency department physical restraint use: A systematic review and meta-analysis. JAMA Intern Med 2023; Sep 25: e234832. doi: 10.1001/jamainternmed.2023.4832.
4. Tolliver DG, Markowitz MA, Obiakor KE, et al. Characterizing racial disparities in emergency department pediatric physical restraint by sex and age. JAMA Pediatr 2023;177:972-975.
Use restraints only when absolutely necessary, and in accordance with established protocols and regulations. Undergo training on appropriate restraint techniques. Ensure regular monitoring of restrained patients. Continuously reassess the need for restraints. Clearly document the rationale for restraint use.
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