Association of Race/Ethnicity and Other Demographic Characteristics With Use of Physical Restraints in the Emergency Department

Abstract

Our study found significant associations between Black or African American race, male sex, non-Hispanic ethnicity, lack of private insurance, and homelessness and increased risk of being physically restrained during an ED visit. In addition, visits involving behavioral chief concerns, higher acuity, and later time of day at presentation were associated with higher odds of use of restraints. This study has limitations. Our cross-sectional design limited our ability to make causal inferences from the study results. Our work describes restraint use overall and does not identify inappropriate restraint use, which may be more salient.

The increased odds of physical restraint associated with demographic variables, particularly race/ethnicity, may reflect potential implicit and systemic bias regarding decisions to physically restrain patients as well as upstream systemic biases and social determinants of health that may influence the likelihood of patients experiencing these situations. Further work is needed to identify structural factors contributing to potential disparities in treatment and interventions to avoid further marginalization of disadvantaged individuals.

Full text

Research Letter | Emergency Medicine
Association of Race/Ethnicity and Other Demographic Characteristics
With Use of Physical Restraints in the Emergency Department
Ambrose H. Wong, MD, MSEd; Travis Whitfill, MPH; Emmanuel C. Ohuabunwa, MD, MBA; Jessica M. Ray, PhD; James D.Dziura, PhD;
Steven L. Bernstein, MD; Richard Andrew Taylor, MD, MHS
Introduction
Patient encounters in the emergency department (ED) commonly include symptoms of agitation,
defined as excessive psychomotor activity leading to aggressive and violent behavior, that can cause
serious injuries to staff and patients.
1
A recent study
2
at an urban level 1 trauma center found that
2.6% of all ED visits involved agitation. Physical restraints are routinely used and indicated during
management of agitation in situations in which danger is imminent or when de-escalation measures
have failed. However, physical restraints are associated with minor injuries to more serious
complications, including apnea and cardiac arrest.
3,4
This association is especially important given
that ED patients with behavioral disturbances often represent socioeconomically distressed
populations,
5,6
thus placing them at risk for differential treatment. This study aimed to assess factors
that may be associated with a higher risk of receiving physical restraint during an ED visit. We
hypothesized that socioeconomic and demographic factors would have significant associations with
the odds of restraint use.
Methods
We conducted a cross-sectional study of all adult (age, ⱖ18 years) patient visits to the ED at 3
hospitals within the Yale-New Haven Health System in Connecticut from January 2013 to August
2018. Our primary outcome was the presence of a physical restraint order in the electronic health
record during an ED visit. The study was approved by the Yale University human investigation
committee. Informed consent was waived because the study posed minimal risk to individuals. This
study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
reporting guideline.
We conducted a descriptive analysis of the data and used a generalized linear mixed model with
a binary logistic link for the presence of a restraint order. Variables in the model included
demographic characteristics (collected during intake questionnaire), which consisted of sex, race/
ethnicity, age, insurance status, alcohol use, illicit drug use, and homelessness (Table 1). Visit
characteristics consisted of discharge diagnosis, chief concern, use of the Emergency Severity Index
level at triage, arrival time of the day, number of prior ED visits, and number of prior admissions to
an inpatient unit. Our model incorporated nesting by site and patient. All tests were 2-tailed, and
P< .05 was considered statistically significant. Analyses were conducted using SPSS statistical
software, version 22.0 (IBM Corp).
Results
A total of 726 417 total ED visits occurred during the study period, of which 7090 (1%) had associated
physical restraint orders. Of individuals with restraint orders during their visit, 4597 (64.8%) were
male, 2494 (35.2%) were female, 2041 (28.8%) were Black or African American, 1042 (14.7%) were
Hispanic or Latino, 5034 (71%) had Medicaid or Medicare insurance, and 164 (2.3%) were homeless.
In our model, Black or African American individuals were more likely to be restrained than were White
individuals (adjusted odds ratio [AOR], 1.13; 95% CI, 1.08-1.21). Hispanic or Latino individuals (AOR,
Author affiliations and article information are
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Open Access. This is an open access article distributed under the terms of the CC-BY License.
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Table 1. Demographicand Visit Characteristics of Patients Visiting the ED by Presence
of a Physical Restraint Order in the Electronic Medical Record, January 2013 to August2018
Characteristic
Restraint use
a
No (n = 719327) Yes (n = 7090)
ED type
Suburban 93 219 (13.0) 31 (0.4)
Community 207 119 (28.8) 917 (12.9)
Urban 418 989 (58.2) 6142 (86.6)
Sex
Male 321 706 (44.7) 4597 (64.8)
Female 397 620 (55.3) 2494 (35.2)
Age, mean (SEM) 49.61 (0.02) 45.63 (0.22)
Race
Asian 7106 (1.0) 36 (0.5)
Black or African American 202 943 (28.2) 2041 (28.8)
White 383 979 (53.4) 2852 (54.3)
Other
b
125 299 (17.4) 1161 (16.4)
Ethnicity
Hispanic or Latino 120 325 (16.7) 1042 (14.7)
Non-Hispanic Black or White 593 822 (82.6) 5981 (84.4)
Unknown 5180 (0.7) 67 (0.9)
Insurance status
Private 238 742 (33.2) 1251 (17.6)
Medicaid 248 958 (34.6) 3486 (49.2)
Medicare 156 041 (21.7) 1548 (21.8)
Self-pay 3661 (0.5) 80 (1.1)
Other 71 925 (10.0) 725 (10.2)
Illicit substance use
No 526 439 (73.2) 3905 (55.1)
Yes 106 809 (14.8) 2604 (36.7)
Not asked 86 089 (12.0) 581 (8.2)
Alcohol use
No 391 708 (54.5) 3067 (43.3)
Yes 268 727 (37.4) 3641 (51.4)
Not asked 58 892 (8.2) 382 (5.4)
Homeless
No 716 521 (99.6) 6926 (97.7)
Yes 2806 (0.4) 164 (2.3)
Discharge diagnosis
c
Medical 566 460 (78.7) 4854 (68.5)
Psychiatric 228 625 (31.8) 4141 (58.4)
Alcohol or drugs 72 782 (10.1) 2103 (29.7)
Cognitive or neurologic 62 106 (8.6) 1201 (16.9)
Trauma 49 018 (6.8) 1045 (14.7)
Chief concern
c
Medical 326 633 (45.3) 1057 (14.9)
Psychiatric 20 543 (2.9) 1321 (18.6)
Alcohol or drugs 16 142 (2.2) 1430 (20.2)
Cognitive or neurologic 10 003 (1.4) 502 (7.1)
(continued)
JAMA Network Open | Emergency Medicine Demographic Characteristics and Use of Physical Restraints in the ED
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Table 1. Demographicand Visit Characteristics of Patients Visiting the ED by Presence
of a Physical Restraint Order in the Electronic Medical Record, January 2013 to August2018 (continued)
Characteristic
Restraint use
a
No (n = 719327) Yes (n = 7090)
Trauma 52 864 (7.3) 409 (5.8)
Emergency Severity Index level
d
1 7045 (1.0) 570 (8.0)
2 202 233 (28.1) 5692 (80.3)
3 315 031 (43.8) 760 (10.7)
4 161 067 (22.4) 61 (0.9)
5 33 951 (4.7) 7 (0.1)
Arrival time
3AM to 6 AM 41 152 (5.7) 492 (6.9)
7AM to 10 AM 131 979 (18.3) 668 (9.4)
11 AM to 2 PM 185 870 (25.8) 1438 (20.3)
3PM to 6 PM 167 525 (23.3) 1707 (24.1)
7PM to 10 PM 128 417 (17.9) 1707 (24.1)
11 PM to 2 AM 64 384 (9.0) 1078 (15.2)
ED visits, mean (SEM) 3.31 (0.01) 7.5 (0.27)
Hospital admissions, mean (SEM) 0.83 (0.003) 1.22 (0.03)
Abbreviations: ED, emergency department; SEM,
standard error of the mean.
a
Data are presented as number (%) of patients unless
otherwise indicated. Percentages may not total
100% due to rounding.
b
The “other” group included American Indian or
Alaska Native, Native Hawaiian, other Pacific
Islander, and unknown categories.
c
Chief concerns and diagnoses were grouped into 5
categories in accordance with prior work regarding
use of restraints in the ED.
5
d
The Emergency Severity Index is a 5-level ED triage
algorithm that provides clinically relevant
stratification of patients into 5 groups from 1 (most
urgent) to 5 (least urgent) on the basis of acuity and
resource needs.
Table 2. Odds of Receivinga Physical Restraint Order by Variable in a Logistic Regression Model
Characteristic Adjusted OR (95% CI) Pvalue
Sex
Male 1 [Reference] NA
Female 0.75 (0.71-0.79) <.001
Age 0.99 (0.98-0.99) <.001
Race
Asian 0.78 (0.56-1.09) .15
Black or African American 1.13 (1.07-1.21) <.001
White 1 [Reference] NA
Other 1.11 (0.99-1.24) .07
Ethnicity
Hispanic or Latino 0.78 (0.70-0.88) <.001
Non-Hispanic Black or White 1 [Reference] NA
Unknown 1.83 (1.42-2.37) <.001
Insurance status
Private 1 [Reference] NA
Medicaid 1.55 (1.45-1.67) <.001
Medicare 1.67 (1.54-1.82) <.001
Self-pay 1.55 (1.22-1.97) <.001
Other 1.45 (1.31-1.60) <.001
Illicit substance use
No 1 [Reference] NA
Yes 1.55 (1.47-1.65) <.001
Not asked 1.13 (0.99-1.28) .05
(continued)
JAMA Network Open | Emergency Medicine Demographic Characteristics and Use of Physical Restraints in the ED
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0.78; 95% CI, 0.70-0.88) had lower odds of being restrained compared with non-Hispanic
individuals (Table 2). Female individuals (AOR, 0.75; 95% CI, 0.71-0.79) had lower odds of being
restrained than male individuals, and patients with Medicaid (AOR, 1.55; 95% CI, 1.45-1.67) or
Medicare coverage (AOR, 1.67; 95% CI, 1.54-1.82) had increased odds compared with patients with
private insurance. Patients who were homeless (AOR, 1.35; 95% CI, 1.14-1.16) also had increased odds
of restraint use.
Discussion
Our study found significant associations between Black or African American race, male sex,
non-Hispanic ethnicity, lack of private insurance, and homelessness and increased risk of being
physically restrained during an ED visit. In addition, visits involving behavioral chief concerns, higher
acuity, and later time of day at presentation were associated with higher odds of use of restraints.
Table 2. Odds of Receivinga Physical Restraint Order by Variable in a Logistic Regression Model (continued)
Characteristic Adjusted OR (95% CI) Pvalue
Alcohol use
No 1 [Reference] NA
Yes 1.13 (1.07-1.20) <.001
Not asked 0.89 (0.77-1.04) .14
Homeless
No 1 [Reference] NA
Yes 1.35 (1.14-1.16) <.001
Discharge diagnosis
Medical 0.63 (0.58-0.65) <.001
Psychiatric 1.74 (1.64-1.85) <.001
Alcohol or drugs 1.14 (1.07-1.21) <.001
Cognitive or neurologic 1.30 (1.21-1.39) <.001
Trauma 1.11 (1.03-1.19) .005
Chief concern
Medical 0.43 (0.40-0.46) <.001
Psychiatric 1.42 (1.32-1.52) <.001
Alcohol or drug use 2.48 (2.30 2.67) <.001
Cognitive to neurologic 3.14 (2.84-3.48) <.001
Trauma 1.09 (0.98-1.21) .12
Emergency Severity Index level
1 1 [Reference] NA
2 0.25 (0.22-0.27) <.001
3 0.04 (0.04-0.05) <.001
4 0.006 (0.004-0.007) <.001
5 0.003 (0.001-0.006) <.001
Arrival time
3AM to 6 AM 1.38 (1.22-1.56) <.001
7AM to 10 AM 1 [Reference] NA
11 AM to 2 PM 1.18 (1.07-1.29) .001
3PM to 6 PM 1.34 (1.23-1.47) <.001
7PM to 10 PM 1.44 (1.31-1.58) <.001
11 PM to 2 AM 1.47 (1.33-1.63) <.001
No. of emergency department visits 1.00 (1.00-1.00) .39
No. of hospital admissions 0.96 (0.94-0.97) <.001
JAMA Network Open | Emergency Medicine Demographic Characteristics and Use of Physical Restraints in the ED
JAMA Network Open. 2021;4(1):e2035241. doi:10.1001/jamanetworkopen.2020.35241 (Reprinted) January 25, 2021 4/6
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This study has limitations. Our cross-sectional design limited our ability to make causal inferences
from the study results. Our work describes restraint use overall and does not identify inappropriate
restraint use, which may be more salient.
The increased odds of physical restraint associated with demographic variables, particularly
race/ethnicity, may reflect potential implicit and systemic bias regarding decisions to physically
restrain patients as well as upstream systemic biases and social determinants of health that may
influence the likelihood of patients experiencing these situations. Further work is needed to identify
structural factors contributing to potential disparities in treatment and interventions to avoid further
marginalization of disadvantaged individuals.
ARTICLE INFORMATION
Accepted for Publication: December 8, 2020.
Published: January 25, 2021. doi:10.1001/jamanetworkopen.2020.35241
Open Access: This is an open access article distributed under the terms of the CC-BY License.©2021WongAHetal.
JAMA Network Open.
Corresponding Author: Ambrose H. Wong, MD, MSEd, Department of Emergency Medicine, Yale School of
Medicine, 464 Congress Ave, Ste 260, New Haven, CT 06519 (wongambrose@gmail.com).
Author Affiliations: Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
(Wong, Whitfill, Ohuabunwa, Ray, Dziura, Bernstein, Taylor); Department of Pediatrics, Yale School of Medicine,
New Haven, Connecticut (Whitfill).
Author Contributions: Dr Wong had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Wong, Ray, Taylor.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Wong, Whitfill, Ohuabunwa, Taylor.
Critical revision of the manuscript for important intellectual content: Wong, Whitfill, Ray, Dziura, Bernstein,Taylor.
Statistical analysis: Whitfill.
Obtained funding: Wong.
Administrative, technical, or material support: Wong, Ohuabunwa,Bernstein.
Supervision: Ray, Bernstein, Taylor.
Conflict of Interest Disclosures: Dr Wong reported receiving grants from the Robert E. Leet and Clara Guthrie
Patterson TrustMentored Research Award and the National Institutes of Health (NIH) National Center for
Advancing TranslationScience s (NCATS) during the conduct of the study and receiving grants from the Agency for
Healthcare Research and Quality (AHRQ) outside the submitted work. Dr Ray reported receiving grants from the
Robert E. Leet and Clara Guthrie Patterson Trust and the NIH NCATS during the conduct of the study and receiving
grants from the AHRQ, the Centers for Disease Control and Prevention, the National Institute of Minority Health
and Health Disparities, and the American Medical Association outside the submitted work. No other disclosures
were reported.
Funding/Support: This study was supported by the Robert E. Leet and Clara Guthrie Patterson Trust Mentored
Research Award (Dr Wong) and Clinical and Translational Science Award KL2 TR001862 (Dr Wong) from the
NCATS, components of the National NIH, the NIH Roadmap for Medical Research.
Role of the Funder/Sponsor:The Robert E. Leet and Clara Guthrie Patterson Trust, the NCATS, and the NIH had
no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data;
preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official
views of the Robert E. Leet and Clara Guthrie Patterson Trust or the NIH.
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JAMA Network Open | Emergency Medicine Demographic Characteristics and Use of Physical Restraints in the ED
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