Meta-analysis: Black patients face higher risk of being physically restrained in ED
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Key takeaways:
- Physical restraint was rare, but when it did happen, Black patients were more likely to be restrained than non-Black patients.
- Structural changes in health care are necessary to combat these disparities.
Black patients were more likely to be physically restrained in the ED than their non-Black counterparts, according to the results of a systematic review and meta-analysis published in JAMA Internal Medicine.
Physical restraints — “any mechanical device that impedes a patient’s voluntary movement” — can sometimes be used in clinical settings to ensure the safety of both staff and patients, Vidya Eswaran, MD, MAS, an assistant professor of emergency medicine at Baylor College of Medicine, and colleagues wrote. However, “inequitable application” of these restraints could “further exacerbate disparities in health outcomes and contribute to structural racism.”
“Although placing a patient in physical restraints may be appropriate in specific circumstances, restraints can have serious adverse consequences, including aspiration, thromboembolic events, choking, physical trauma and psychological harm,” they wrote. “Some who are restrained also report decreased trust in the health care system. 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.”
For their systematic review and meta-analysis, the researchers searched sources like CINAHL, Embase, PubMed and Web of Science, and found 10 articles that met the inclusion criteria. The studies included 2,558,983 patient encounters and 24,030 physical restraint events.
Eswaran and colleagues found that, in general, physical restraint was rare, occurring in just 0.94% of visits. However, when it did happen, Black patients were more likely to be restrained than non-Black patients (RR = 1.27; 95% CI, 1.23-1.31) and white patients (RR = 1.31; 95% CI, 1.19-1.43).
The researchers also observed that, compared with non-Hispanic patients, Hispanic patients were less likely to be restrained (RR = 0.85; 95% CI, 0.81-0.89). However, they wrote that this “may have been a result of many Black patients being categorized as non-Hispanic ethnicity.”
“Although some studies included Hispanic as an exclusive racial category, others classified Hispanic as ethnicity, and thus we were only able to perform the meta-analysis on the ethnicity category,” Eswaran and colleagues wrote. “This speaks to the need for investigators to work with communities to ensure that race and ethnicity categories match patients’ identities, and to disaggregate data as much as possible.”
To combat the disparities among those who are restrained in the ED, the researchers suggested “structural changes to increase access to mental health care in racial and ethnically minoritized communities, addressing mental health stigma and assessing how prehospital interactions with first responders may affect patients’ treatment in the ED.”
Perspective
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Jossie Carreras Tartak, MD, MBA
This study adds to the growing literature showing that patients of certain racial groups are more likely to experience adverse outcomes in health care settings. Although there was heterogeneity in how race was collected across studies, as well as the specific racial groups that were at risk of being restrained, the study did find a significant association between restraint use and Black race. It’s important to note that some of these studies controlled for other clinical, demographic and socioeconomic factors that could potentially be associated with restraint use, such as history of mental health or substance use disorders and insurance type. Regardless, as the authors point out, even if these other factors could account for the racial disparities we see, it would mean that Black patients are at higher risk for these adverse structural factors, which increase their risk for being restrained.
Physical restraints are not a benign procedure, and they can lead to long-lasting physical and emotional trauma. Studies suggest that patients who are physically restrained are less likely to keep follow-up outpatient appointments. If we’re disproportionately restraining patients of certain racial and ethnic groups, then we need to further evaluate the role of structural racism and provider bias in the decision to restrain a patient. This study also highlights the need for clinician education around this topic to hopefully mitigate these disparities, as well as for higher investment in a behavioral health infrastructure that can keep our most vulnerable patients out of situations that might lead them to being restrained.
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