Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting

Abstract

Objective: Race-based bias in health care occurs at organizational, structural, and clinical levels and impacts emergency medical care. Limited literature exists on the role of race on patient restraint in the emergency setting. This study sought to examine the role of race in physical restraint in an emergency department (ED) at a major academic medical center. Methods: Retrospective chart analysis was performed, querying all adult ED visits over a 2-year period (2016-2018) at Massachusetts General Hospital. The associations between race and restraint and selected covariates (sex, insurance, age, diagnosis, homelessness, violence) were analyzed. Results: Of the 195,092 unique ED visits by 120,469 individuals over the selected period, 2,658 (1.4%) involved application of a physical restraint by health care providers. There was a significant effect of race on restraint (p < 0.0001). The risk ratio (RR) for Asian patients compared to white patients was 0.71 (95% confidence interval [CI] = 0.55 to 0.92, p = 0.009). The RR for Black patients compared to white patients was 1.22 (95% CI = 1.05 to 1.40, p = 0.007). Visits with patients having characteristics of male sex, public or no insurance, younger age, diagnoses pertaining to substance use, diagnoses pertaining to psychotic or bipolar disorders, current homelessness, and a history of violence were more likely to result in physical restraint. Conclusions: There was a significant effect of race on restraint that remained when controlling for sex, insurance, age, diagnosis, homelessness, and history of violence, all of which additionally conferred independent effects on risk. These results warrant a careful examination of current practices and potential biases in utilization of restraint in emergency settings. † Equal contributions.

Considering trends of restraints and seclusions by patient race

“…Studies in adult populations have demonstrated significant associations between Black race and an increased risk of being physically restrained in an emergency department setting (Wong et al, 2020). This association between race and restraint usage has also been shown in adult emergency settings, even when controlling for sex, insurance, age, diagnosis, homelessness, and history of violence (Schnitzer et al, 2020). Data is limited in pediatric settings, though some recent studies have found associations between restraint/seclusion usage and race as well as gender and psychiatric diagnosis in inpatient and residential settings (Vidal et al, 2020; Braun et al, 2020; Donovan et al, 2003).…”

Massachusetts general hospital Covid-19 registry reveals two distinct populations of hospitalized patients by race and ethnicity

“…Among patients hospitalized for Covid-19 at MGH, 35% were Hispanic, although Hispanic patients comprised 8% of inpatient discharges at MGH in 2017, 1% of emergency department visitors in 2018, and 20% of the population of Boston [9][10][11]. This reflects the disproportionate burden of Covid-19 among communities in the MGH catchment area as well as at other Boston area academic medical centers, who also observed a high proportion of hospitalized Table 1.…”

Race and Use of Physical Restraints: Premature Conclusions for "Disparities in Care"?

“…We read with interest the manuscript by Schnitzer et al 1 on the role of race in physical restraint use and the accompanying invited commentary by Corbin et al 2 We commend the effort put forth in this study as management of agitated patients is a challenging but often overlooked problem. In addition, we agree that racial bias likely exists with regard to physical restraint use, as described in the mental health literature 3 and by Dr. Corbin's personal experiences as an African American emergency physician.…”