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

Rates and risk factors of coercive measure use in inpatient child and adolescent mental health services: a systematic review and narrative synthesis

Reducing the use of coercive measures in inpatient child and adolescent mental health services (CAMHS) requires an understanding of current rates and associated factors. We conducted a systematic review of research published between Jan 1, 2010, and Jan 10, 2024, addressing rates and risk factors for mechanical, physical, or pharmacological restraint, seclusion, or forced tube feeding in inpatient CAMHS. We identified 30 studies (including 39 027 patients or admissions) with low risk of bias. Median prevalence was 17·5% for any coercive measure, 27·7% for any restraint, and 6·0% for seclusion. Younger age, male sex, ethnicity or race other than White, longer stay, and repeated admissions were frequently linked to coercive measure use. Variable rates and conflicting risk factors suggest that patient traits alone are unlikely to determine coercive measure use. More research, especially in the form of nationwide studies, is needed to elucidate the impact of care and staff factors. Finally, we propose reporting guidelines to improve comparisons over time and settings.

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.

Race-Based Disparities in the Frequency and Duration of Restraint Use in a Psychiatric Inpatient Setting

OBJECTIVE

Patients' race and age have each been identified as risk factors for experiencing restraint events during psychiatric hospitalization. Restraint duration is also an important variable in determining disparities in treatment. To the authors' knowledge, no studies to date have examined the effect of the interaction of race and age on restraint use and duration in inpatient psychiatric settings. This retrospective chart review of electronic medical records of patients admitted between 2012 and 2019 sought to examine whether race and age interacted in predicting differences in the use and duration of restraints in a psychiatric inpatient setting.

METHODS

Logistic and hierarchical regression analyses were conducted on data from a sample of 29,739 adolescent (ages 12-17 years) and adult (ages ≥18 years) inpatients to determine whether the interaction of race and age group (adolescent or adult) significantly predicted a restraint event or differences in restraint duration.

RESULTS

Black (adjusted OR [AOR]=1.85) and multiracial (AOR=1.36) patients were more likely to experience a restraint event than were their White peers. Black race was also significantly (p=0.001) associated with longer restraint duration. No significant interaction was detected between race and age in predicting restraint events or duration.

CONCLUSIONS

Although the interaction between race and age did not predict restraint events or duration, the findings indicate racial disparities in the frequency and duration of restraint events among Black and multiracial individuals and may inform efforts to reduce these events.

Is physical restraint unethical and illegal?: a qualitative analysis of Korean written judgments

BACKGROUND

Physical restraint (PR) is used to ensure the safety of care recipients. However, this causes an ethical dilemma between the autonomy and dignity of the recipients and the provision of effective treatment by health workers. This study aimed to analyze legal and ethical situations related to the use of PR using written judgments.

METHODS

This study uses a qualitative retrospective design. Qualitative content analysis was performed on South Korean written judgments. A total of 38 cases from 2015 to 2021 were categorized. The types of court decisions and ethical dilemma situations were examined according to the four principles of bioethics, and the courts' judgments were compared.

RESULTS

Written judgments related to PR were classified into three types according to the appropriateness of PR use, the presence or absence of duty of care, and legal negligence. Ethical dilemmas were categorized into three situations depending on whether the four principles of bioethics were followed. The courts' decisions regarding the ethical dilemmas differed depending on the situational factors before and after the use of PR and the conflicting conditions of the ethical principles.

CONCLUSIONS

Health workers should consider legal and ethical requirements when determining whether to use PR to provide the care recipient with the necessary treatment.

Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments

OBJECTIVES

Emergency department (ED) utilization by children with mental and behavioral health (MBH) conditions is increasing. During these visits, pharmacologic restraint may be used to manage acute agitation. Factors associated with pharmacologic restraint use are not well described.

METHODS

This was a retrospective cohort study of ED visits from the Pediatric Health Information System database, 2010-2020. We included visits by children 3-21 years with a primary MBH diagnosis and identified visits with pharmacologic restraint. Regression models were used to analyze the association between patient- and hospital-level factors and restraint.

RESULTS

Of 545 800 ED MBH visits over the study period, 22 194 visits (4.1%) involved pharmacologic restraint use. In multivariable analysis, restraint was associated with ages 18-21 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.59-2.22), male sex (OR, 1.25; 95% CI, 1.16-1.34), Black race (OR, 1.22; 95% CI, 1.09-1.35), visits starting overnight (OR, 1.68; 95% CI, 1.45-1.96), or the weekend (OR, 1.26; 95% CI, 1.22-1.30), and repeat ED visits (OR, 1.31; 95% CI, 1.17-1.47). Every 100-visit increase in average annual MBH volume was associated with a 0.09% decrease in restraint (95% CI, -0.15 to -0.04) with no significant association between average annual ED volume and restraint (95% CI, -0.25 to 0.25).

CONCLUSIONS

For children in the ED with MBH conditions, ages 18-21 years, male sex, Black race, visits starting overnight or the weekend, and repeat ED visits were associated with pharmacologic restraint. These results can inform strategies to reduce restraint use and ensure safe and equitable ED care.

Updates in the Assessment and Management of Agitation

Agitated patients can be dangerous to themselves and others. In fact, severe medical complications and death can occur with severe agitation. Because of this, agitation is considered a medical and psychiatric emergency. Regardless of the treatment setting, identifying the agitated patient early is a necessary skill. The authors review relevant literature regarding the identification and management of agitation and summarize current recommendations for adults, as well as children and adolescents.

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

OBJECTIVES

Agitation, defined as excessive psychomotor activity leading to aggressive or violent behaviour, is prevalent in the emergency department (ED) due to rising behavioural-related visits. Experts recommend use of verbal de-escalation and avoidance of physical restraint to manage agitation. However, bedside applications of these recommendations may be limited by system challenges in emergency care. This qualitative study aims to use a systems-based approach, which considers the larger context and system of healthcare delivery, to identify sociotechnical, structural, and process-related factors leading to agitation events and physical restraint use in the ED.

DESIGN

Qualitative study using a grounded theory approach to triangulate interviews of patients who have been physically restrained with direct observations of agitation events.

SETTING

Two EDs in the Northeast USA, one at a tertiary care academic centre and the other at a community-based teaching hospital.

PARTICIPANTS

We recruited 25 individuals who experienced physical restraint during an ED visit. In addition, we performed 95 observations of clinical encounters of agitation events on unique patients. Patients represented both behavioural (psychiatric, alcohol/drug use) and non-behavioural (medical, trauma) chief complaints.

RESULTS

Three primary themes with implications for systems-based practice of agitation events in the ED emerged: (1) pathways within health and social systems; (2) interpersonal contexts as reflections of systemic stressors on behavioural emergency care and (3) systems-based and patient-oriented strategies and solutions.

CONCLUSIONS

Agitation events represented manifestations of patients' structural barriers to care from socioeconomic inequities and high burden of emotional and physical trauma as well as staff members' simultaneous exposure to external stressors from social and healthcare systems. Potential long-term solutions may include care approaches that recognise agitated patients' exposure to psychological trauma, improved coordination within the mental health emergency care network, and optimisation of physical environment conditions and organisational culture.

Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation

Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.