ArticlePDF Available

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

Authors:

Abstract and Figures

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.
Content may be subject to copyright.
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, 18 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
listed at the end of this article.
Open Access. This is an open access article distributed under the terms of the CC-BY License.
JAMA Network Open. 2021;4(1):e2035241. doi:10.1001/jamanetworkopen.2020.35241 (Reprinted) January 25, 2021 1/6
Downloaded From: https://jamanetwork.com/ on 01/25/2021
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
JAMA Network Open. 2021;4(1):e2035241. doi:10.1001/jamanetworkopen.2020.35241 (Reprinted) January 25, 2021 2/6
Downloaded From: https://jamanetwork.com/ on 01/25/2021
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
JAMA Network Open. 2021;4(1):e2035241. doi:10.1001/jamanetworkopen.2020.35241 (Reprinted) January 25, 2021 3/6
Downloaded From: https://jamanetwork.com/ on 01/25/2021
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
Downloaded From: https://jamanetwork.com/ on 01/25/2021
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.
REFERENCES
1. Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus
statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup.
West J Emerg Med. 2012;13(1):3-10.doi:10.5811/westjem.2011.9.6863
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 5/6
Downloaded From: https://jamanetwork.com/ on 01/25/2021
2. Miner JR, Klein LR , Cole JB, Driver BE, Moore JC, Ho JD. The characteristics and prevalence of agitation in an
urban county emergency department. Ann Emerg Med. 2018;72(4):361-370.doi:10.1016/j.annemergmed.2018.
06.001
3. Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. Can J Psychiatry. 2003;48(5):
330-337. doi:10.1177/070674370304800509
4. Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department.
J Emerg Med. 2003;24(2):119-124. doi:10.1016/S0736-4679(02)00738-2
5. Wong AH, Taylor RA, Ray JM, Bernstein SL. Physical restraint use in adult patients presenting to a general
emergency department. Ann Emerg Med. 2019;73(2):183-192. doi:10.1016/j.annemergmed.2018.06.020
6. Wong AH, Ray JM, Rosenberg A, et al. Experiences of individuals who were physically restrained in the
emergency department. JAMA Netw Open. 2020;3(1):e1919381. doi:10.1001/jamanetworkopen.2019.19381
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 6/6
Downloaded From: https://jamanetwork.com/ on 01/25/2021
... Pearson c 2 tests and ANOVA tests were used to compare the distribution of restraint use across the 3 study phases for all visits and within predetermined categories of behavioral primary chief complaints according to groupings within the Anatomical Therapeutic Chemical classification and prior agitation studies. 5,38 The categories consisted of mental health, substance use or intoxication, cognitive or neurological, and undifferentiated agitation (ie, if labeled as "agitation" or "aggressive behavior"). All other primary chief complaints were grouped together as nonbehavioral (eg, medical or trauma). ...
... For example, our results suggested higher restraint rates for patients of Black race and male sex, and previous studies have identified higher risk of restraint use in the ED for marginalized populations, including Blacks and those with housing insecurity or a lack of private insurance. 38 One specific strategy suggested to combat perceived "difficult" patient encounters and prevent bias is to use a team management approach, which capitalizes on unique strengths from different professions and offloads frustrations from individual staff members to a team of clinicians caring for the behavioral patient together. 55 Our team-based intervention's effect on decreasing restraints may have derived from a similar strategy for agitated patients. ...
Article
Study objective Agitation, defined as excessive psychomotor activity leading to violent and aggressive behavior, is becoming more prevalent in the emergency department (ED) amidst a strained behavioral health system. Team-based interventions have demonstrated promise in promoting de-escalation, with the hope of minimizing the need for invasive techniques, like physical restraints. This study aimed to evaluate an interprofessional code response team intervention to manage agitation in the ED with the goal of decreasing physical restraint use. Methods This quality improvement study occurred over 3 phases, representing stepwise rollout of the intervention: (1) preimplementation (phase I) to establish baseline outcome rates; (2) design and administrative support (phase II) to conduct training and protocol design; and (3) implementation (phase III) of the code response team. An interrupted time-series analysis was used to compare trends between phases to evaluate the primary outcome of physical restraint orders occurring during the study period. Results Within the 634,578 ED visits over a 5-year period, restraint use significantly declined sequentially over the 3 phases (1.1%, 0.9%, and 0.8%, absolute change −0.3% between phases I and III, 95% confidence interval [CI] −0.4% to 0.3%), which corresponded to a 27.3% proportionate decrease in restraint rates between phases I and III. For the interrupted time-series analysis, there was a significantly decreasing slope in biweekly restraints in phase II compared to phase I (slope, −0.05 restraints per 1,000 ED visits per 2-week period, 95% CI −0.07 to −0.03), which was sustained in an incremental fashion in phase III (slope, −0.05, 95% CI −0.07 to −0.02). Conclusion With the implementation of a structured agitation code response team intervention combined with design and administrative support, a decreased rate of physical restraint use occurred over a 5-year period. Results suggest that investment in organizational change, along with interprofessional collaboration during the management of agitated patients in the ED, can lead to sustained reductions in the use of an invasive and potentially harmful measure on patients.
Article
Background: Security emergency responses (SERs) are utilized by hospitals to ensure the safety of patients and staff but can cause unintended morbidity. The presence of racial and ethnic inequities in SER utilization has not been clearly elucidated. Objective: To determine whether Black and Hispanic patients experience higher rates of SER and physical restraints in a non-psychiatric inpatient setting. Design: Retrospective cohort study. Participants: All patients discharged from September 2018 through December 2019. Exposure: Race and ethnicity, as reported by patients at time of registration. Main outcomes: The primary outcome was whether a SER was called on a patient. The secondary outcome was the incidence of physical restraints among patients who experienced a SER. Key results: Among 24,212 patients, 18,755 (77.5%) patients identified as white, 2,346 (9.7%) as Black, and 2,425 (10.0%) identified with another race. Among all patients, 1,827 (7.6%) identified as Hispanic and 21,554 (89.0%) as non-Hispanic. Sixty-six (2.8%) Black patients had a SER activated during their first admission, compared to 295 (1.6%) white patients. In a Firth logit multivariable model, Black patients had higher adjusted odds of a SER than white patients (adjusted odds ratio (aOR) 1.37 [95% confidence interval: 1.02, 1.81], p = 0.037). Hispanic patients did not have higher odds of having a SER called than non-Hispanic patients. In a Poisson multivariable model among patients who had a SER called, race and ethnicity were not found to be significant predictors of restraint. Conclusion: Black patients had higher odds of a SER compared to white patients. No significant differences were found between Hispanic and non-Hispanic patients. Future efforts should focus on assessing the generalizability of these findings, the underlying mechanisms driving these inequities, and effective interventions to address them.
Article
Background Patients with severe agitation are frequently encountered in the emergency department (ED). At times, these patients are physically restrained and given calming medications; however, little is known about the effects of medications and other predictors on restraint duration. Objective Our aim was to compare restraint duration when haloperidol or ziprasidone was used as the primary antipsychotic with or without concomitant medications, and to identify predictors of restraint duration. Methods We performed a review of a retrospective cohort of physically restrained ED patients between January 1, 2013 and November 30, 2017. An unadjusted analysis and adjusted linear regression model were used to evaluate the effect of antipsychotic choice on restraint duration, controlling for sex, age, race, homelessness, arrival in restraints, re-restraint during visit, concomitant medications (i.e., benzodiazepines or anticholinergics), additional medications given during restraint, time of day, and patient disposition. Results In 386 patients (319 haloperidol, 67 ziprasidone), the average restraint duration was 2.4 h (95% confidence interval [CI] 2.2 to 2.6 h). There were no differences in physical restraint times between ziprasidone and haloperidol groups in the unadjusted (mean difference 0.12 h; 95% CI –0.42 to 0.66 h) or adjusted analyses (–12.7%; 95% CI –33.9% to 8.6%). Haloperidol given with diphenhydramine alone was associated with decreased restraint duration (–30.8%; 95% CI –50.6% to –11.1%) The largest association with restraint duration was administration of additional sedating medications during restraint, prolonging restraint by 62% (95% CI 27.1% to 96.9%). In addition, compared with White patients, Black patients spent significantly more time restrained (mean difference 33.9%; 95% CI 9.0% to 58.9%). Conclusions Restraint duration of agitated ED patients was similar when haloperidol or ziprasidone was used as the primary antipsychotic. However, race and additional medications given during restraint were significantly associated with restraint duration.
Article
Black adult patients are more likely to be physically restrained in the emergency department (ED).¹ For pediatric ED visits, physical restraint is an uncommon but serious intervention associated with injury, trauma, and death.² Physical restraint is indicated for youth at risk of harming themselves or others, often due to acute exacerbation of a neuropsychiatric disorder. Physical restraint should only be used after trialing behavioral deescalation and/or chemical restraint.³ Limited literature has examined physical restraint of children in the ED.
Article
Many children are sensitive to the feeling of tags in their clothes, seek out swinging on the swing set at the playground, or refuse to try certain textures of foods.”
Article
Agitation is a routine and increasingly common presentation to the emergency department (ED). In the wake of a national examination into racism and police use of force, this article aims to extend that reflection into emergency medicine in the management of patients presenting with acute agitation. Through an overview of ethico‐legal considerations in restraint use and current literature on implicit bias in medicine, this article provides a discussion on how bias may impact care of the agitated patient. Concrete strategies are offered at an individual, institutional and health system level to help mitigate bias and improve care.
Article
Full-text available
Importance Individuals with behavioral disorders are increasingly presenting to the emergency department (ED), and associated episodes of agitation can cause significant safety threats to patients and the staff caring for them. Treatment includes the use of physical restraints, which may be associated with injuries and psychological trauma; to date, little is known regarding the perceptions of the use of physical restraint among individuals who experienced it in the ED. Objective To characterize how individuals experience episodes of physical restraint during their ED visits. Design, Setting, and Participants In this qualitative study, semistructured, 1-on-1, in-depth interviews were conducted with 25 adults (ie, aged 18 years or older) with a diverse range of chief concerns and socioeconomic backgrounds who had a physical restraint order associated with an ED visit. Eligible visits included those presenting to 2 EDs in an urban Northeast city between March 2016 and February 2018. Data analysis occurred between July 2017 and June 2018. Main Outcomes and Measures Basic participant demographic information, self-reported responses to the MacArthur Perceived Coercion Scale, and experiences of physical restraint in the ED. Results Data saturation was reached with 25 interviews (17 [68%] men; 18 [72%] white; 19 [76%] non-Hispanic). The time between the patient’s last restraint and the interview ranged from less than 2 weeks to more than 6 months. Of those interviewed, 22 (88%) reported a combination of mental illness and/or substance use as contributing to their restraint experience. Most patients (20 [80%]) said that they felt coerced to present to the ED. Three primary themes were identified from interviews, as follows: (1) harmful experiences of restraint use and care provision, (2) diverse and complex personal contexts affecting visits to the ED, and (3) challenges in resolving their restraint experiences, leading to negative consequences on well-being. Conclusions and Relevance In this qualitative study, participants described a desire for compassion and therapeutic engagement, even after they experienced coercion and physical restraint during their visits that created lasting negative consequences. Future work may need to consider more patient-centered approaches that minimize harm.
Article
Full-text available
Numerous medical and psychiatric conditions can cause agitation; some of these causes are life threatening. It is important to be able to differentiate between medical and nonmedical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in nonmedical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear.
Article
Study objective: The prevalence of agitation among emergency department (ED) patients is increasing. Physical restraints are routinely used to prevent self-harm and to protect staff, but are associated with serious safety risks. To date, characterization of physical restraint use in the emergency setting has been limited. We thus aim to describe restraint patterns in the general ED to guide future investigation in the management of behavioral disorders. Methods: We conducted a cross-sectional study of adult patients presenting to 5 adult EDs within a large regional health system for 2013 to 2015, and with a physical restraint order during their visit. We undertook descriptive analyses and cluster analysis to determine unique meaningful groups within our sample. Results: In 956,153 total ED visits, 4,661 patients (0.5%) had associated restraint orders, representing 3,739 unique patients. The median age was 47 years (interquartile range 32 to 59 years), 66.7% of patients were men, 61.9% had a psychiatric history, and 91.1% arrived by ambulance. For chief complaints, 33.7% were alcohol or drug use, 45.4% medical, 12.3% psychiatric, and 8.5% trauma. Cluster analysis identified 2 distinct cohorts. A younger, predominantly male population presented with alcohol or drug use, whereas an older group arrived with medical complaints. Conclusion: Our data found strong association of alcohol or drug use with physical restraints and identified a unique elderly population with behavioral disturbances in the ED. Further characterization of causal links and safer practices to manage agitation for these vulnerable populations are needed.
Article
Study objective: We seek to determine the characteristics and prevalence of agitation among patients in an urban county emergency department (ED). Methods: This was a prospective observational study of ED patients at an urban Level I trauma center. All ED patients were screened during daily randomized 8-hour enrollment periods. Adult agitated patients, defined as having an altered mental status score greater than 1, were included. Trained research volunteers collected demographics and baseline data, including the presenting altered mental status score, use and type of restraints, and whether any initial sedative was given. The altered mental status score, vital signs, and any medications or treatments given were recorded every 5 minutes thereafter until the patient had an altered mental status score less than 1. Providers were asked to describe clinical events resulting in an intervention occurring during the patient course, including hypotension, vomiting, increased monitoring, use of supplemental oxygen or airway adjunct, or intubation. The provider also completed a checklist to determine the presence of delirium symptoms. Results: A total of 43,838 patients were screened (45.1% women; median age 33 years; range 0 to 102 years). The prevalence of agitation was 2.6% (1,146/43,838; median altered mental status score 2). Of these patients, 84% (969/1,146) required physical restraint and 72% (829/1,146) required sedation with an intramuscular injection. Sedative agents were olanzapine in 39% of patients (442/1,146), droperidol in 20% (224/1,146), haloperidol in 20% (226/1,146), a benzodiazepine in 6% (68/1,146), and ketamine in 5% (52/1,146). Delirium characteristics were observed in 0.6% of patients (260/43,838), representing 23% of agitated patients in the ED. Clinical events were observed in 13% of agitated patients (114/866) without delirium symptoms and 26% (68/260) with delirium symptoms. Characteristics associated with a clinical event included delirium symptoms (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.2 to 2.4), a cause related to a drug other than alcohol (OR 1.7; 95% CI 1.1 to 2.9), or a nondrug-induced cause of agitation (OR 3.5; 95% CI 2.3 to 5.6). Conclusion: The prevalence of agitation in the ED was 2.6%. Agitated patients frequently required restraint and sedation, with significant rates of clinical events requiring intervention.
Article
Patients are frequently involuntarily, physically restrained in the emergency department (ED). The purpose of this study was to determine the type and rate of complications experienced by patients physically restrained in the ED. A prospective, observational study was performed on consecutive patients who were restrained in a community, inner-city teaching hospital ED for a 1-year period. The ED nurses or physicians completed a restraint study checklist. The checklist included the reasons for restraints, restraint duration, method and number of restraints, use of chemical restraint, and complications resulting from the use of restraints. The 298 patients were accumulated during a 1-year period. The mean age was 36.5 years (range 14-89). Sixty-eight percent were men; 73% were African-Americans, 16% Hispanic, and 11% Caucasian. One hundred six patients had more than one indication for patient restraint. Patients were restrained for a mean of 4.8 h (range 0.2-25.0 h), with psychosis being the most frequent discharge diagnosis (33%). Patients were most frequently restrained on a cart with two restraints (59%), in the supine position (86%), and 27.5% had chemical restraint added. There were 20 complications (7%); getting out of restraints was the most common (10) and the remainder included vomiting (3), injured others (2), spitting (2), injured self (1), increased agitation (1), and other (1). These complications were not correlated with age, gender, race, number of restraints, use of chemical restraint, diagnosis, or duration of restraint. This study demonstrates a low rate of minor complications. We found that male patients were most often restrained for violent and disruptive behavior. Most commonly, two restraints were used in combination with chemical restraints for a duration of almost 5 h.
Article
Restraint use is not monitored in the US, and only institutions that choose to do so collect statistics. In 1999, investigative journalists reported lethal consequences proximal to restraint use, making it a life-and-death matter that demands attention from professionals. This paper reviews the literature concerning actual and potential causes of deaths proximal to the use of physical restraint. Searching the electronic databases Medline, Cinahl, and PsycINFO, we reviewed the areas of forensics and pathology, nursing, cardiology, immunology, psychology, neurosciences, psychiatry, emergency medicine, and sports medicine. Research is needed to provide clinicians with data on the risk factors and adverse effects associated with restraint use, as well as data on procedures that will lead to reduced use. Research is needed to determine what individual risk factors and combinations thereof contribute to injury and death.