Physical restraints in the emergency department and attendance at subsequent outpatient psychiatric treatment

Risk management or racial Bias? The disparate use of restraints in the Emergency Department of an Urban Safety-Net Hospital

OBJECTIVES

Limited data exist on racial-ethnic differences in the application of restraints for patients visitng the emergency department (ED). This study examines whether there is an association between race and patient ED visit type with the application of four-point mechanical restraints in a high acuity safety-net urban academic hospital.

METHODS

The study retrospectively reviewed 198,610 visits to the ED at Boston Medical Center made by patients between 18 and 89 years old between May 1, 2014 and May 1, 2019. ED visit type was categorized based on primary billing code for the visit as either medical or behavioral; behavioral visits were further categorized into 5 groups based on corresponding primary psychiatric billing code category. The relationships between race/ethnicity and four-point mechanical restraints were analyzed using binary logistic regression models in SPSS.

RESULTS

1.4% of unique visits involved the use of four-point mechanical restraints. Patients with a behavioral visit were significantly over 16 times more likely to be restrained than those with a medical visit. Black patients were significantly more likely to be restrained than white patients for behavioral visits but less likely for medical visits. Black and Hispanic patients were also significantly more likely to be restrained for a behavioral visit regardless of psychiatric diagnosis. Asian patients were less likely to be restrained regardless of ED visit type.

CONCLUSIONS

Significant racial differences in restraints for White patients with medical visits and Black and Hispanic patients with behavioral visits prompts further investigation on the role of clinician bias when managing acute patients.

Disparities in use of physical restraints at an urban, minority-serving hospital emergency department

BACKGROUND

Recent reports have identified associations between patient race and ethnicity and use of physical restraint while receiving care in the emergency department (ED). However, no study has assessed this relationship in hospitals primarily treating patients of color and underserved populations. The primary objective of this study was to evaluate the association between race/ethnicity and the use of restraints in an ED population at a minority-serving, safety-net institution.

METHODS

For this cross-sectional study, chart review identified all adult patients presenting to the Boston Medical Center ED between January 2018 and April 2021. Generalized estimating equation logistic regression modeling was conducted to evaluate associations between race and use of restraints.

RESULTS

Of 348,384 ED visits (22.9% White, 46.7% Black, 23.1% Hispanic), 1852 (0.5%) had an associated physical restraint order. Multivariable models showed significant interactions (p = 0.02) between race/ethnicity, behavioral health diagnosis, and sex on the primary outcome of physical restraint. Stratified analysis revealed that among patients with no behavioral health diagnoses, Black (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.34-0.72, p = 0.0003) and Hispanic (OR 0.35, 95% CI 0.20-0.63, p = 0.0004) patients had lower odds of restraint than White patients. Among female patients with a mental health and/or substance use disorder diagnosis, Black (OR 1.95, 95% CI 1.49-2.54, p < 0.0001) and Hispanic (OR 2.13, 95% CI 1.49-3.03, p < 0.0001) patients had higher odds of restraint than White patients. Similar trends were observed for Black male patients (OR 1.60, 95% CI 1.34-1.91, p < 0.0001) but not for Hispanic male patients (OR 0.96, 95% CI 0.73-1.26, p = 0.77) with behavioral health diagnoses who had similar odds of restraint to White patients. Additional factors associated with physical restraint include younger age, public or lack of insurance, and ED visits during the pandemic.

CONCLUSIONS

Racial disparities exist in restraint utilization at this minority-serving safety-net hospital; however, these disparities are modified by sex and by behavioral health diagnoses. The reasons for these disparities may be multifactorial and warrant further investigation.

Racial Disparities in Emergency Department Physical Restraint Use: A Systematic Review and Meta-Analysis

Importance

Recent studies have demonstrated that people of color are more likely to be restrained in emergency department (ED) settings compared with other patients, but many of these studies are based at a single site or health care system, limiting their generalizability.

Objective

To synthesize existing literature on risk of physical restraint use in adult EDs, specifically in reference to patients of different racial and ethnic backgrounds.

Data Sources

A systematic search of PubMed, Embase, Web of Science, and CINAHL was performed from database inception to February 8, 2022.

Study Selection

Included peer-reviewed studies met 3 criteria: (1) published in English, (2) original human participants research performed in an adult ED, and (3) reported an outcome of physical restraint use by patient race or ethnicity. Studies were excluded if they were conducted outside of the US, or if full text was unavailable.

Data Extraction and Synthesis

Four independent reviewers (V.E., M.M., D.D., and A.H.) abstracted data from selected articles following Meta-Analysis of Observational Studies in Epidemiology guidelines. A modified Newcastle-Ottawa scale was used to assess quality. A meta-analysis of restraint outcomes among minoritized racial and ethnic groups was performed using a random-effects model in 2022.

Main Outcome(s) and Measure(s)

Risk of physical restraint use in adult ED patients by racial and ethnic background.

Results

The search yielded 1597 articles, of which 10 met inclusion criteria (0.63%). These studies represented 2 557 983 patient encounters and 24 030 events of physical restraint (0.94%). In the meta-analysis, Black patients were more likely to be restrained compared with White patients (RR, 1.31; 95% CI, 1.19-1.43) and to all non-Black patients (RR, 1.27; 95% CI, 1.23-1.31). With respect to ethnicity, Hispanic patients were less likely to be restrained compared with non-Hispanic patients (RR, 0.85; 95% CI, 0.81-0.89).

Conclusions and Relevance

Physical restraint was uncommon, occurring in less than 1% of encounters, but adult Black patients experienced a significantly higher risk of physical restraint in ED settings compared with other racial groups. Hispanic patients were less likely to be restrained compared with non-Hispanic patients, though this observation may have occurred if Black patients, with a higher risk of restraint, were included in the non-Hispanic group. Further work, including qualitative studies, to explore and address mechanisms of racism at the interpersonal, institutional, and structural levels are needed.

Ethnic disparities in the use of restrictive practices in adult mental health inpatient settings: a scoping review

PURPOSE

To identify and summarise extant knowledge about patient ethnicity and the use of various types of restrictive practices in adult mental health inpatient settings.

METHODS

A scoping review methodological framework recommended by the JBI was used. A systematic search was conducted in APA PsycINFO, CINAHL with Full Text, Embase, PubMed and Scopus. Additionally, grey literature searches were conducted in Google, OpenGrey and selected websites, and the reference lists of included studies were explored.

RESULTS

Altogether, 38 studies were included: 34 were primary studies; 4, reviews. The geographical settings were as follows: Europe (n = 26), Western Pacific (n = 8), Americas (n = 3) and South-East Asia (n = 1). In primary studies, ethnicity was reported according to migrant/national status (n = 16), mixed categories (n = 12), indigenous vs. non-indigenous (n = 5), region of origin (n = 1), sub-categories of indigenous people (n = 1) and religion (n = 1). In reviews, ethnicity was not comparable. The categories of restrictive practices included seclusion, which was widely reported across the studies (n = 20), multiple restrictive practices studied concurrently (n = 17), mechanical restraint (n = 8), rapid tranquillisation (n = 7) and manual restraint (n = 1).

CONCLUSIONS

Ethnic disparities in restrictive practice use in adult mental health inpatient settings has received some scholarly attention. Evidence suggests that certain ethnic minorities were more likely to experience restrictive practices than other groups. However, extant research was characterised by a lack of consensus and continuity. Furthermore, widely different definitions of ethnicity and restrictive practices were used, which hampers researchers' and clinicians' understanding of the issue. Further research in this field may improve mental health practice.

Patient and Provider Perspectives on Emergency Department Care Experiences among People with Mental Health Concerns

Emergency departments (EDs) are an important source of care for people with mental health (MH) concerns. It can be challenging to treat MH in EDs, and there is little research capturing both patient and provider perspectives of these experiences. We sought to summarize the evidence on ED care experiences for people with MH concerns in North America, from both patient and provider perspectives. Medline and EMBASE were searched using PRISMA guidelines to identify primary studies. Two reviewers conducted a qualitative assessment of included papers and inductive thematic analysis to identify common emerging themes from patient and provider perspectives. Seventeen papers were included. Thematic analysis revealed barriers and facilitators to optimal ED care, which were organized into three themes each with sub-themes: (1) interpersonal factors, including communication, patient–staff interactions, and attitudes and behaviours; (2) environmental factors, including accommodations, wait times, and restraint use; and (3) system-level factors, including discharge planning, resources and policies, and knowledge and expertise. People with MH concerns and ED healthcare providers (HCPs) share converging perspectives on improving ED connections with community resources and diverging perspectives on the interplay between system-level and interpersonal factors. Examining both perspectives simultaneously can inform improvements in ED care for people with MH concerns.

Racial and ethnic disparities in emergency department restraint use: A multicenter retrospective analysis

BACKGROUND

Research regarding disparities in physical restraint use in the emergency department (ED) is limited. We evaluated the role of race, ethnicity, and preferred language on the application of physical restraint among ED patients held under a Massachusetts section 12(a) order for mandatory psychiatric evaluation.

METHODS

We identified all ED patient encounters with a section 12(a) order across a large integrated 11-hospital health system from January 2018 through December 2019. Information on age, race, ethnicity, preferred language, insurance, mental illness, substance use, history of homelessness, and in-network primary care provider was obtained from the electronic health record. We evaluated for differences in physical restraint use between subgroups via a mixed-effect logistic regression with random-intercept model.

RESULTS

We identified 32,054 encounters involving a section 12(a) order. Physical restraints were used in 2,458 (7.7%) encounters. Factors associated with physical restraint included male sex (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI] = 1.28 to 1.63), Black/African American race (aOR = 1.22, 95% CI = 1.01 to 1.48), Hispanic ethnicity (aOR = 1.45, 95% CI = 1.22 to 1.73), Medicaid insurance (aOR = 1.21, 95% CI = 1.05 to 1.39), and a diagnosis of bipolar disorder or psychotic disorder (aOR = 1.51, 95% CI = 1.31 to 1.74). Across all age groups, patients who were 25 to 34 years of age were at highest risk of restraint (aOR = 2.01, 95% CI = 1.69 to 2.39). Patients with a primary care provider within our network (aOR = 0.81, 95% CI = 0.72 to 0.92) were at lower risk of restraint. No associations were found between restraint use and language, history of alcohol or substance use, or homelessness.

CONCLUSION

Black/African American and Hispanic patients under an involuntary mandatory emergency psychiatric evaluation hold order experience higher rates of physical restraint in the ED. Factors contributing to racial disparities in the use of physical restraint, including the potential role of structural racism and other forms of bias, merits further investigation.

Characteristics and clinical outcomes for mental health patients admitted to a behavioural assessment unit: Implications for model of care and practice

Behavioural assessment units (BAU) have been established in emergency departments (EDs) to provide short-term observation, treatment, and care to people experiencing acute behavioural disturbance. A prospective observational study was conducted in a cohort of adult patients admitted to one BAU located within an ED (July-December 2017) to compare clinical characteristics, treatment outcomes, and use of restrictive interventions for those who received a specialist mental health (MH) assessment with those who did not. Of the 457 patients, 61.5% received a specialist MH assessment. This group had a lower acuity (Australasian Triage Score 10.4%; CI 0.2-2.0% vs 13.6%; CI 9.3-19.5%); more arrived with police (28.8%; CI 23.8-34.3 vs 5.1%; CI 2.7-9.4%); and were subjected to restrictive interventions while in the BAU. Security responses for unarmed threat (code grey) were higher (10.9%; CI 7.8-15.0% vs 4.4%; CI 2.3-8.5%), as was the use of chemical restraint (4.2%; CI 2.4-7.2 vs 0.0% CI 0.0 - 2.1%). Those requiring specialist MH assessment had a longer length of stay (12.7 vs 5.2 hours). Further development of the BAU model of care must include targeted, evidence-based strategies to minimize the use of restrictive interventions and ensure timely access to acute mental health services.

Use of the Safewards Model in healthcare services: a mixed-method scoping review protocol

INTRODUCTION

Safewards is an organisational approach to delivering inpatient mental health services. The aim of Safewards is to minimise the number of situations in which conflict arises between healthcare workers and patients that lead to the use of coercive interventions (restriction and/or containment).The Safewards Model has been developed, implemented and evaluated for its impact on all forms of containment. Safewards has been adopted as the recommended approach to preventing patient agitation and clinical aggression in some jurisdictions. Notwithstanding these recommendations, the outcomes of Safewards for staff and patients have not been comprehensively described.The aim of the scoping review is to describe (1) Safewards interventions; (2) how Safewards interventions have been implemented in healthcare settings; (3) outcome measures used to evaluate the effectiveness of Safewards; (4) barriers and enablers to the uptake and sustainability of Safewards. This review will provide a foundation for further research and/or systematic review of the effectiveness of Safewards.

METHODS AND ANALYSIS

Peer-reviewed manuscripts of quantitative, qualitative and mixed-method research in English with be included for the period 01 January 2013- December 31st 2020. Electronic databases including Cumulative Index to Nursing and Allied Health Literature, Cochrane, Embase, Emcare, Joanna Briggs Institute, Medline, Global Health, PsycINFO and Scopus will be searched. Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews checklist and explanation and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol will be followed. Publications will be excluded if they do not include the required participants, concept or context. Two reviewers will independently screen all titles and abstracts and full-text studies for inclusion.

ETHICS AND DISSEMINATION

Ethical approval for this review is not required as the information to be collected is publicly available. There are no participants or safety considerations in this review of published literature. Key findings for future research and clinical practice will be disseminated though peer-reviewed publication, stakeholder reporting and conference presentations.

Examining the impact of emergency care settings on suicidal patients: A call to action

OBJECTIVE

The emergency department (ED) offers a critical and unique opportunity to assess and intervene on suicide risk. Despite its potential benefits, the ED setting presents several potential sources of stress. The present paper calls attention to how suicidal patients may be especially vulnerable to stressful ED experiences.

METHOD

This research synthesis cites the growing literature on ED-related stressors, as they have been shown to affect both psychiatric and nonpsychiatric patient populations.

RESULTS

We identified specific interpersonal, physical, and temporal features of the ED that have been shown to affect multiple patient populations, including suicidal individuals. Beyond this, there appears to be broad underutilization of therapeutic care in ED settings.

CONCLUSIONS

It is important to consider how the ED setting may be both helpful and harmful toward suicidal patients. We conclude with recommended domains of study and methodological considerations when pursuing these future directions. The proposed research agenda would help address this known high risk period around hospitalization and discharge, and ultimately optimize suicide prevention efforts.

Brief interventions to de-escalate disturbances in emergency departments

This study aimed to systematically review evidence to assess the efficacy of non-pharmacological brief interventions in the emergency department to reduce the incidence, severity and impact of acute behavioural disturbances. The literature search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 18 articles were identified as meeting the inclusion criteria and read in full. Following a full read and a consensus discussion, it was subsequently considered the studies chosen had not met the inclusion criteria. Research into the use of non-pharmacological brief interventions in the management of acute behavioural disturbance in the emergency department is warranted given the absence of evidence found by this systematic review.

Management of Violence and Aggression in Emergency Environment; a Narrative Review of 200 Related Articles

CONTEXT

The aim of this study is to reviewing various approaches for dealing with agitated patients in emergency department (ED) including of chemical and physical restraint methods.

EVIDENCE ACQUISITION

This review was conducted by searching "Violence," "Aggression," and "workplace violence" keywords in these databases: PubMed, Scopus, EmBase, ScienceDirect, Cochrane Database, and Google Scholar. In addition to using keywords for finding the papers, the related article capability was used to find more papers. From the found papers, published papers from 2005 to 2018 were chosen to enter the paper pool for further review.

RESULTS

Ultimately, 200 papers were used in this paper to conduct a comprehensive review regarding violence management in ED. The results were categorized as prevention, verbal methods, pharmacological interventions and physical restraint.

CONCLUSION

In this study various methods of chemical and physical restraint methods were reviewed so an emergency medicine physician be aware of various available choices in different clinical situations for agitated patients.

Physical Restraint Use in Adult Patients Presenting to a General Emergency Department

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.

Effectiveness of a Multimodal Intervention Program for Restraint Prevention in an Acute Spanish Psychiatric Ward

BACKGROUND

International recommendations have called to implement strategies to reduce the use of coercion in psychiatric settings. However, in Spain there is a lack of research about intervention programs to reduce mechanical restraint in acute psychiatric units.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a multimodal intervention program based on the principles of six core strategies to reduce the frequency of use of mechanical restraint in an acute psychiatric ward.

DESIGN

The design was a retrospective analysis of the frequency and duration of episodes of mechanical restraint prior to the intervention program (2012) and during the intervention program (2013) in one acute psychiatric ward. The intervention was governed by four strategies: (1) leadership and organizational changes, (2) registration and monitoring of risk patients, (3) staff training, and (4) involving patients in the treatment program.

RESULTS

There was a significant difference between the mean number of monthly episodes of mechanical restraint per 1,000 patient days, pre-intervention (18.54 ± 8.78) compared with postintervention (8.53 ± 7.00; p = .005). We found the probability that mechanical restraint would occur in a hospital admission decreased after performing the intervention (odds ratio = .587; confidence interval = 0.411-0.838; p = .003) after adjusting for confounding variables. The total percentage of restrained patients fell from 15.07% to 9.74%.

CONCLUSIONS

The main implication of the study is to support the effectiveness of specific intervention programs based on different measures to reduce mechanical restraint and without contemplating all the strategies that are considered effective.

Health service use and costs associated with aggressiveness or agitation and containment in adult psychiatric care: a systematic review of the evidence

BACKGROUND

Agitation and containment are frequent in psychiatric care but little is known about their costs. The aim was to evaluate the use of services and costs related to agitation and containment of adult patients admitted to a psychiatric hospital or emergency service.

METHODS

Systematic searches of four electronic databases covering the period January 1998-January 2014 were conducted. Manual searches were also performed. Paper selection and data extraction were performed in duplicate. Cost data were converted to euros in 2014.

RESULTS

Ten studies met inclusion criteria and were included in the analysis (retrospective cohorts, prospective cohorts and cost-of-illness studies). Evaluated in these studies were length of stay, readmission rates and medication. Eight studies assessed the impact of agitation on the length of stay and six showed that it was associated with longer stays. Four studies examined the impact of agitation on readmission and a statistically significant increase in the probability of readmission of agitated patients was observed. Two studies evaluated medication. One study showed that the mean medication dose was higher in agitated patients and the other found higher costs of treatment compared with non-agitated patients in the unadjusted analysis. One study estimated the costs of conflict and containment incurred in acute inpatient psychiatric care in the UK. The estimation for the year 2014 of total annual cost per ward for all conflict was €182,616 and €267,069 for containment based on updated costs from 2005.

CONCLUSIONS

Agitation has an effect on healthcare use and costs in terms of longer length of stay, more readmissions and higher drug use. Evidence is scarce and further research is needed to estimate the burden of agitation and containment from the perspective of hospitals and the healthcare system.

Methodological and ethical challenges in studying patients' perceptions of coercion: a systematic mixed studies review

BACKGROUND

Despite improvements in psychiatric inpatient care, patient restrictions in psychiatric hospitals are still in use. Studying perceptions among patients who have been secluded or physically restrained during their hospital stay is challenging. We sought to review the methodological and ethical challenges in qualitative and quantitative studies aiming to describe patients' perceptions of coercive measures, especially seclusion and physical restraints during their hospital stay.

METHODS

Systematic mixed studies review was the study method. Studies reporting patients' perceptions of coercive measures, especially seclusion and physical restraints during hospital stay were included. Methodological issues such as study design, data collection and recruitment process, participants, sampling, patient refusal or non-participation, and ethical issues such as informed consent process, and approval were synthesized systematically. Electronic searches of CINALH, MEDLINE, PsychINFO and The Cochrane Library (1976-2012) were carried out.

RESULTS

Out of 846 initial citations, 32 studies were included, 14 qualitative and 18 quantitative studies. A variety of methodological approaches were used, although descriptive and explorative designs were used in most cases. Data were mainly collected in qualitative studies by interviews (n = 13) or in quantitative studies by self-report questionnaires (n = 12). The recruitment process was explained in 59% (n = 19) of the studies. In most cases convenience sampling was used, yet five studies used randomization. Patient's refusal or non-participation was reported in 37% (n = 11) of studies. Of all studies, 56% (n = 18) had reported undergone an ethical review process in an official board or committee. Respondents were informed and consent was requested in 69% studies (n = 22).

CONCLUSIONS

The use of different study designs made comparison methodologically challenging. The timing of data collection (considering bias and confounding factors) and the reasons for non-participation of eligible participants are likewise methodological challenges, e.g. recommended flow charts could aid the information. Other challenges identified were the recruitment of large and representative samples. Ethical challenges included requesting participants' informed consent and respecting ethical procedures.