Abstract
This cross-sectional study assesses the association of race/ethnicity and other demographic factors with risk of receiving physical restraint during an emergency department (ED) visit.
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 study2 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).
Table 1. Demographic and Visit Characteristics of Patients Visiting the ED by Presence of a Physical Restraint Order in the Electronic Medical Record, January 2013 to August 2018.
| Characteristic | Restraint usea | |
|---|---|---|
| No (n = 719 327) | 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) |
| Otherb | 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 diagnosisc | ||
| 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 concernc | ||
| 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) |
| Trauma | 52 864 (7.3) | 409 (5.8) |
| Emergency Severity Index leveld | ||
| 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 | ||
| 3 am to 6 am | 41 152 (5.7) | 492 (6.9) |
| 7 am to 10 am | 131 979 (18.3) | 668 (9.4) |
| 11 am to 2 pm | 185 870 (25.8) | 1438 (20.3) |
| 3 pm to 6 pm | 167 525 (23.3) | 1707 (24.1) |
| 7 pm 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.
Data are presented as number (%) of patients unless otherwise indicated. Percentages may not total 100% due to rounding.
The “other” group included American Indian or Alaska Native, Native Hawaiian, other Pacific Islander, and unknown categories.
Chief concerns and diagnoses were grouped into 5 categories in accordance with prior work regarding use of restraints in the ED.5
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.
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, 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.
Table 2. Odds of Receiving a Physical Restraint Order by Variable in a Logistic Regression Model.
| Characteristic | Adjusted OR (95% CI) | P value |
|---|---|---|
| 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 |
| 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 | ||
| 3 am to 6 am | 1.38 (1.22-1.56) | <.001 |
| 7 am to 10 am | 1 [Reference] | NA |
| 11 am to 2 pm | 1.18 (1.07-1.29) | .001 |
| 3 pm to 6 pm | 1.34 (1.23-1.47) | <.001 |
| 7 pm 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 |
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. 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.
References
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