In the chaotic environment of an emergency room, hospital staffers sometimes face the question of whether to use physical restraints when a patient is experiencing a behavioral crisis. Using restraints is meant to be a last resort in the face of a patient’s agitation in order to keep health care workers and others around them safe. But restraints can also lead to severe adverse outcomes for patients, including physical and psychological trauma.
A new study, published Monday in JAMA Internal Medicine, highlights how restraint use can both arise from, and further contribute to, racial bias against patients.
Researchers at the University of California, San Francisco, and University of California, Davis, found that Black patients are more likely to be physically restrained than adults from other racial groups. According to the paper, a systematic review that performed a meta-analysis of six studies and looked at over 1.6 million patient encounters, restraints were used in ERs in less than 1% of clinical encounters. But Black patients were 31% more likely to be placed in restraints than white patients.
The study did not directly address the underlying reasons that Black adults are at greater risk of being physically restrained than other groups. But “we hypothesize that structural racism plays an important role,” said Alison Hwong, a psychiatrist and assistant professor at UCSF who is one of the study authors.
Earlier research suggested that patients with a history of mental health disorders were more likely to be restrained. This new study also found that Black patients are less likely to have access to outpatient behavioral health treatment, which could increase their risk of agitation in the ER and their risk of being restrained.
Hwong also said that even the language used to describe an agitated Black patient in their chart compared to an agitated non-Black patient could have stark differences because of underlying biases. Those Black patients may be viewed differently by providers, leading health care workers to more readily order the use of restraints.
“In events of acute agitation, health care providers must make rapid decisions for the safety of patients and staff. Without standardized protocols, it’s possible for bias to creep into decision-making,” she told STAT.
Vidya Eswaran, the lead author of the study and an emergency medicine physician and assistant professor at Baylor College of Medicine, noted that Black communities, in particular, have a long history of unjust criminalization and restraint by law enforcement, further contributing to the trauma they may experience in mental health crises and medical emergencies.
“Emergency care begins not in the emergency department itself, but in the community, often when 911 is called,” she said. “More research is needed to explore how interactions with police and/or EMS influence restraint use in the prehospital setting and how that may influence what happens in the ED.”
Experts are also concerned that these disparities may prevent Black patients from seeking care in the future.
“The racial and ethnic disparities we identified in physical restraint use in the ED are only one piece of the larger health care disparities experienced by patients of color,” said Melanie Molina, one of the study’s authors and an emergency medicine physician and assistant professor at UCSF. “Not only is it mistreatment, but it certainly leads to decreased trust in the health care system as a whole, not just emergency care.”
At a time where visits to emergency rooms for mental health care have skyrocketed in recent years, physicians told STAT that there is a pressing need to implement solutions to tackle these disparities.
“This study highlights the need for establishing a set of equity-informed quality measures to monitor disparities and outcomes related to ED restraint use while ensuring institutional accountability,” said Dana Im, an emergency medicine physician and director of quality and safety in the department of emergency medicine at Brigham and Women’s, who was not involved with the study.
Some health centers around the country have specialized teams trained in methods of verbal de-escalation that will respond when there is a concern that a patient may need to be restrained. Other hospitals have an EmPATH unit, a dedicated space for patients seeking mental health care that’s equipped to help them in a crisis.
“We have to shift our focus to recognizing impending signs of agitation in order to prevent it from further escalating,” said Ambrose Wong, an emergency medicine physician at Yale Medicine.
A structured, organized clinical response team can help minimize use of restraints on patients, Ambrose said. He and his research team recently received a grant that will identify how peer support services — patients with lived experience of mental health conditions and a history of physical restraint — can help ED staffers and approach patients dealing with behavioral crises.
Eswaran said she is optimistic that change is possible. “The motto of emergency medicine is anyone, anything, any time — meaning that we are here to care for any patient who walks through our doors seeking emergent care,” she said. “We should strive to ensure that care is equitable to all who seek it.”