EDs Use Restraints on Black Patients More than White, But Data Is Scant

September 26, 2023 - There’s a gulf in how often emergency departments use restraints on Black patients compared to everybody else, an issue that’s alarming considering the physical and psychological harm such use can have on patients, researchers wrote in a new JAMA Internal Medicine article.

To be clear, use of restraints is often seen as a last result, and it only happens about 1 percent of the time. But that’s enough to raise alarm bells, the researchers from the University of California Davis, the University of California San Francisco, and Baylor College of Medicine said.

Physical restraints are defined as “any mechanic device that impedes a patient’s voluntary movement,” the researchers wrote in the study’s introduction. They can be essential to both staff and patient safety under certain circumstances, the researchers asserted. However, there can also be some adverse consequences to using restraints in the ED: aspiration, thromboembolic events, choking, physical trauma, and psychological harm.

“Some who are restrained also report decreased trust in the health care system,” the researchers said. “If historically racially and/or ethnically minoritized patients, who may already have reasons to mistrust the health care system, are restrained at higher rates in the ED, this could contribute to excess harm and avoidance of health care services.”

And that inequitable use of restraints is, in fact, the case, the researchers found.

The team conducted a literature of online databases to look at peer-reviewed studies meeting the following three criteria: published in English, original human participants research performed in an adult ED, and reported an outcome of physical restraint use by patient race or ethnicity.

Those criteria yielded a small sample size of just ten studies from which the researchers could glean further insights regarding racial disparities in the use of restraints.

Overall, use of physical restraints was not that common. Of the nearly 2.5 million patient encounters included in the analysis, there were 24,00 events of physical restraint, meaning ED clinicians used restraints around 1 percent of the time.

But even though use of restraints was rare, it did happen to Black patients more than White patients and patients of other races. Overall, Black patients were restrained 31 percent more often than White patients.

Four of the studies found a positive association between Black race and restraints, while another found no relation, and a sixth found a positive association between multiracial background and restraints. The researchers noted that this is consistent with the literature looking at pediatric emergency departments.

The study did not investigate the forces behind this racial disparity, but the researchers did posit some theories, not least of which include racial bias.

For example, these findings could illustrate race-based dynamics in the ED, as well as mental and behavioral health space, the researchers said.

Black patients might be more likely to be misdiagnosed as having a psychotic disorder and less likely to have access to behavioral health treatment, which could exacerbate symptoms. With limited access to outpatient mental healthcare, Black patients might face higher illness severity, which could increase the risk of restraint.

Implicit bias may also be at play, although the researchers did not dive as deeply into this topic. This is one of many key areas for further research, according to Vidya Eswaran, MD, MAS, corresponding author of the paper and assistant professor of emergency medicine at Baylor.

“Showing that differences in restraint use exist is not enough. We must now further assess the mechanism for why these differences occur and what can be done to prevent them from persisting,” Eswaran, who’s also an emergency medicine physician at UCSF, said in a statement.

Importantly, the team did point out the low quality of data they had available to them. Of the thousands of studies that touched on use of restraints in the ED, only a small handful met the broad criteria set up for this report.

This might suggest that racial disparities in the use of restraints in the ED is a vastly understudied area of medical and health equity research.

“The absolute event rate for restraint use was relatively low, less than 1%, but our results suggest that Black patients have a higher risk of restraint than patients of other racial groups,” Eswaran explained. “The small number of studies included in this review are of mixed quality and reveal that the assessment of race-based disparities in physical restraint use in the ED is understudied.”