Black patients more often restrained by ED staff, meta-analysis finds

Black patients are more often physically restrained in emergency departments than white patients and those of all other races are, thereby increasing their risk of physical and psychological harm and driving potential distrust in the healthcare system, researchers wrote in a recently published meta-analysis.

Writing in JAMA Internal Medicine, the researchers noted that these incidents are infrequent and occurred during just 0.94% of the 2.5 million-plus patient encounters they reviewed in the analysis.

Physical restraint in a clinical setting “may be appropriate in specific circumstances,” the researchers noted. However, the significantly disproportionate application of restraints—as observed across six peer-reviewed studies and almost 1.6 million of the encounters—may “further exacerbate disparities in health outcomes and contribute to structural racism,” they wrote.

The analysis also found data suggesting that Hispanic ethnicity patients had lower risk of physical restraint than other non-Hispanic patients, though the researchers were less confident in the trend due to inconsistent racial classification methodology in the reviewed studies and the impact of Black patients being categorized as non-Hispanic.

These were among “several limitations” that hampered the analysis’ findings, many of which stemmed from the low number and “mixed quality” of the studies meeting inclusion criteria, the researchers wrote. The review also did not seek to answer the specific factors that may be driving the inequity.

Still, the researchers said the finding generally falls in line with other investigations across in-patient and pediatric settings as well as Black patients’ reported higher odds of encountering a hospital security response.

As for the “why,” they noted that many of the review’s included studies also found that individuals with a history of mental health disorders were more likely to be restrained.

“Black patients may be more likely to be misdiagnosed as having a psychotic disorder and less likely to have access to outpatient behavioral health treatment,” they wrote. “Less access to outpatient mental healthcare could increase the risk of higher illness severity, thus increasing the risk of restraint—one example of how systemic racism may play a role.”

Besides potential downstream factors, individual-level unconscious bias could “lead to differential treatment” during psychiatric emergencies when ED staff does not have structured protocols to follow, the researchers wrote.

Should this be the case, restraint checklists developed by professional groups or individual organizations “may be useful in addressing bias and disparities" as could recommendations to employ early verbal de-escalation, they wrote. Further investigation into these methods is needed as, currently, “few believe these methods to be effective in maintaining safety and preventing restraint use,” the researchers wrote.

Institutions like hospitals and EDs could also consider introducing and acting upon quality measures related to disparities in restraint use, they continued, while broader structural changes tackling mental health access in minority communities may also be worth consideration in light of the findings, they continued.

“Further work, including qualitative studies, to explore and address mechanisms of racism at the interpersonal, institutional and structural levels are needed,” the researchers wrote.