Racial Disparities in Emergency Department Physical Restraint Use

Abstract

ImportanceRecent studies have demonstrated that people of color are more likely to be restrained in emergency department (ED) settings compared with other patients, but many of these studies are based at a single site or health care system, limiting their generalizability.ObjectiveTo synthesize existing literature on risk of physical restraint use in adult EDs, specifically in reference to patients of different racial and ethnic backgrounds.Data SourcesA systematic search of PubMed, Embase, Web of Science, and CINAHL was performed from database inception to February 8, 2022.Study SelectionIncluded peer-reviewed studies met 3 criteria: (1) published in English, (2) original human participants research performed in an adult ED, and (3) reported an outcome of physical restraint use by patient race or ethnicity. Studies were excluded if they were conducted outside of the US, or if full text was unavailable.Data Extraction and SynthesisFour independent reviewers (V.E., M.M., D.D., and A.H.) abstracted data from selected articles following Meta-Analysis of Observational Studies in Epidemiology guidelines. A modified Newcastle-Ottawa scale was used to assess quality. A meta-analysis of restraint outcomes among minoritized racial and ethnic groups was performed using a random-effects model in 2022.Main Outcome(s) and Measure(s)Risk of physical restraint use in adult ED patients by racial and ethnic background.ResultsThe search yielded 1597 articles, of which 10 met inclusion criteria (0.63%). These studies represented 2 557 983 patient encounters and 24 030 events of physical restraint (0.94%). In the meta-analysis, Black patients were more likely to be restrained compared with White patients (RR, 1.31; 95% CI, 1.19-1.43) and to all non-Black patients (RR, 1.27; 95% CI, 1.23-1.31). With respect to ethnicity, Hispanic patients were less likely to be restrained compared with non-Hispanic patients (RR, 0.85; 95% CI, 0.81-0.89).Conclusions and RelevancePhysical restraint was uncommon, occurring in less than 1% of encounters, but adult Black patients experienced a significantly higher risk of physical restraint in ED settings compared with other racial groups. Hispanic patients were less likely to be restrained compared with non-Hispanic patients, though this observation may have occurred if Black patients, with a higher risk of restraint, were included in the non-Hispanic group. Further work, including qualitative studies, to explore and address mechanisms of racism at the interpersonal, institutional, and structural levels are needed.

Physical Restraint Usage in Hospitals Across the United States: 2011-2019

“…We only included those covariates that had a theoretical or practical connection. For instance, studies have identified race as a risk factor for patients being physically restrained, 19 and older hospitalized patients who required PRs have been found to have longer hospital stays. 20 Some studies also suggest males, perhaps because of greater overall strength, are more frequently physically restrained.…”

A history of the community mental health movement and individuals with serious mental illness: A vision for the future.

“…Though the field has come so far, and there has been action induced from across multiple disciplines, and the Global Alliance has been part of that history to make a much-needed change, there is still so much more change that is needed. There are still great disparities for those with SMI and experiences of marginalization, stigma, oppression, trauma and death, and racism, impacting outcomes for those with SMI (Daniels et al, 2023; Eswaran et al, 2023; Frueh et al, 2005; Kersting et al, 2019; Perlin, 2013; Smith et al, 2022; Sturmey, 2015; Waldemar et al, 2019). For example, those with SMI are more likely to be put in restraints just because they have a diagnosis of schizophrenia (in comparison to those without that diagnosis) despite no prior history of violence or indication of current violence upon presentation to an emergency room in crisis, with higher incidents among individuals who are Black (Daniels et al, 2023; Eswaran et al, 2023).…”

“…There are still great disparities for those with SMI and experiences of marginalization, stigma, oppression, trauma and death, and racism, impacting outcomes for those with SMI (Daniels et al, 2023; Eswaran et al, 2023; Frueh et al, 2005; Kersting et al, 2019; Perlin, 2013; Smith et al, 2022; Sturmey, 2015; Waldemar et al, 2019). For example, those with SMI are more likely to be put in restraints just because they have a diagnosis of schizophrenia (in comparison to those without that diagnosis) despite no prior history of violence or indication of current violence upon presentation to an emergency room in crisis, with higher incidents among individuals who are Black (Daniels et al, 2023; Eswaran et al, 2023). Sadly, a recent review of coercive measures in hospitals continues to report documented deaths due to restraints in over 42 studies reviewed (Kersting et al, 2019).…”

“…Relatedly, there is no evidence demonstrating that seclusion and/or restraints are methods associated with healing and serve as treatment mechanisms, but rather are mainly a form of containment and control, which is associated empirically with trauma for the individual experiencing seclusion and/or restraints and for those clinical staff administering such methods (Frueh et al, 2005; Hawsawi et al, 2020). For many, there is grave concern about continuing such methods in our systems of care when they still lead yearly to trauma and deaths and are disproportionately used on people of color as a means of control (Daniels et al, 2023; Eswaran et al, 2023; Kersting et al, 2019; Smith et al, 2022; Sturmey, 2015).…”

“…When entering inpatient and outpatient psychiatric settings, there are concerns about racist events and actions that lead to great harm, trauma, and even death via policing, seclusion, and restraints (Eswaran et al, 2023; Kersting et al, 2019). Many of these disparities are the worst for Black men, demonstrating a microcosm of structural racism that occurs nationally and globally.…”