Although the use of physical restraint was generally uncommon in the emergency department (ED), Black patients were more likely to experience this during patient encounters compared with white patients, according to a systematic review and meta-analysis.
The analysis, which reviewed more than 2.5 million patient encounters, calculated a relative risk [RR] of 1.31 (95% CI 1.19-1.43) for Black patients compared with white patients and 1.27 (95% CI 1.23-1.31) compared with all other racial groups, reported Vidya Eswaran, MD, of Baylor College of Medicine in Houston, and co-authors.
Hispanic patients were less likely to be restrained when compared with non-Hispanic patients (RR 0.85, 95% CI 0.81-0.89), they noted in JAMA Internal Medicine.
“Our findings agree with other reports of race-based differences, such as evidence that Black patients have higher odds of having a security response called on them in the hospital,” Eswaran and team wrote. “Others have reported similar disparities in restraint use in in-patient and pediatrics settings, suggesting that this association is not limited to adult EDs.”
In an email to MedPage Today, Eswaran said that EDs and “healthcare systems at large should consider investigating the presence of disparities in their practice settings, uncovering the mechanisms which lead to these differences in care, and taking action to address them in order to provide safe and equitable care for all patients.”
“Uncovering the reasons for this disparity is an incredibly important next step to this analysis,” she added. “It is not enough for us to say that differences in restraint use exist, but to investigate why and then take action to address them.”
In several of the included studies, restraint was defined as any physical equipment used to immobilize or reduce movement of a patient’s arms, legs, head, or body.
Overall, just 0.94% of the 2,557,983 patient encounters reviewed resulted in a patient being physically restrained.
Eswaran noted that it is important to consider the upstream factors that might be influencing this disparity in the use of physical restraint. Systemic racism is embedded in healthcare systems in the U.S., which has led to unequal access to care, she added, including the availability of mental health care providers, the proper prescription medications, and sufficient health insurance.
These factors may play a role in creating the disparity in the use of restraints between Black patients and all other patients, she said.
These findings highlight the need for more research, she noted, including qualitative studies, to understand and address mechanisms of racism at the interpersonal, institutional, and structural levels.
“Due to the mixed quality and small number of studies which met our inclusion criteria, we were unable to assess the impact of other factors, such as prior mental health diagnoses, degree of agitation, or housing status on the rate of restraint use,” Eswaran said. “We posit that racism at multiple levels — interpersonal, institutional, and systemic — may be behind the disparity seen, but the exact mechanisms were beyond the scope of our study.”
To conduct this systematic review and meta-analysis, the researchers searched PubMed, Embase, Web of Science, and the Cumulated Index to Nursing and Allied Health Literature (CINAHL) from inception to Feb. 8, 2022.
To be eligible for inclusion, studies needed to be peer-reviewed and published in English, and had to include original research on adult patients in EDs with data on the use of physical restraint and patient race or ethnicity, resulting in 10 studies included in the analysis.
Most of the studies were retrospective and cross-sectional, and seven were single-site studies. Seven of the studies were conducted in the Northeast region of the U.S., including Connecticut, Massachusetts, New Hampshire, New York.
Eswaran and colleagues noted that the method of categorizing patients by race and ethnicity differed among the studies, which could have led to some patients being mischaracterized. Also, they were not able to account for other demographic factors, such as gender, socioeconomic status, or other medical conditions.
They emphasized that further research with consistent definitions of race and ethnicity are needed to understand the generalizability of these findings.
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Disclosures
The study was supported by the National Clinician Scholars Program at the University of California San Francisco
Eswaran and colleagues reported non-financial support from the University of California San Francisco Resource Allocation Program. Co-authors also reported grants from the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative and the National Heart, Lung, and Blood Institute.
Primary Source
JAMA Internal Medicine
Source Reference: Eswaran V, et al “Racial disparities in emergency department physical restraint use: a systematic review and meta-analysis” JAMA Intern Med 2023; DOI: 10.1001/jamainternmed.2023.4832.
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