Exploring bias in restraint use: Four strategies to mitigate bias in care of the agitated patient in the emergency department

Abstract

On May 25, 2020, George Floyd was killed in Minnesota by police officers. 1 The Minneapolis Police have cited that he was intoxicated, agitated, and resisting arrest. 1 The bystander video footage shows Mr. Floyd being killed brutally on the scene under physical restraints. 2 Imagine, instead, if the scenario had developed differently: The paramedics, accompanied by police, bring in a middleaged Black man for "agitation and intoxication" to a busy emergency department (ED). He is cuffed to the gurney, struggling with the restraints, and screaming to be released. Would medical professionals treat him as every other patient, regardless of race? This scenario, in which an individual is determined to be agitated by authorities and placed in restraints, is not uncommon in EDs across the country. In fact, agitation is a routine and increasingly frequent presentation, with 1.7 million events occurring annually in U.S. EDs, 3 representing 2.6% of all presentations. 4 Restraints, whether chemical or physical, were used in the management of over 80% of these cases, impacting over 2% of all ED patients. 4 While the racial breakdown of restraint use is not clearly understood on a systemic scale, racial biases are generally well documented in the medical system and likely influence how agitation is managed in the ED. 5-7 Several recent regional studies have found that Black patients were 13% to 22% more likely to be restrained when compared to White patients, suggesting racial differences in chemical and physical restraint use. [5][6][7] Although agitation is a common occurrence, the specific clinical scenarios can be as unique as the patients themselves. The management can be nuanced, oftentimes aimed at addressing potential threats of violence for staff as well as other patients. 8 In fact, compared to the general population, health care providers are at high risk of workplace violence, with 75% of all workplace violence incidents found in the health care field. 9 Compared to other health care specialties, emergency medicine practitioners are especially vulnerable. 10 As such, in these difficult scenarios of heightened emotions and desire for self-protection, biases may easily influence the management of agitation. 11 In caring for the agitated patient, verbal deescalation is the preferred primary intervention. 12 However, when deescalation fails, providers may be required to employ physical and chemical restraints for patient and staff safety. 13 Although safety is a common rationale for the use of restraints, they are not without potential harm. Restraints,

Racial Disparities in Emergency Department Physical Restraint Use

“…Project BETA, a group convened by the American Association of Emergency Psychiatrists, proposed guidelines for the management of agitation, specifically noting that avoidance of seclusion and restraint should be prioritized . Restraint checklists may be useful in addressing bias and disparities, and early verbal deescalation is recommended to avoid the use of restraints. However, although many are trained in these practices, few believe these methods to be effective in maintaining safety and preventing restraint use .…”

Qualitative study of patient experiences and care observations during agitation events in the emergency department: implications for systems-based practice

“…This approach has allowed for a shift away from presumed fault or blame on individuals, and instead placed a larger emphasis on mediators of structural bias through institutional practices, healthcare system policies, and societal culture. 42 For example, evidence suggests that decision making based on heuristics and biases versus a more rational, methodical approach is more likely to occur under stressful conditions. A recent study found that prowhite/antiblack bias increased preshift to postshift among emergency resident physicians when the ED was more overcrowded and during times of higher patient load.…”

Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol

“…These peer support workers have a history of mental health and substance use disorders and have received training to become employed as patient advocates on community-based treatment teams. Finally, our design team will interview informatics and behavioural health experts to solicit ideas and relevant CDS design strategies to improve decision-making during agitation management 49 50…”