Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2023 Nov 1;183(11):1229-1237.
doi: 10.1001/jamainternmed.2023.4832.

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

Vidya Eswaran  1   2   3 , Melanie F Molina  3   4   5 , Alison R Hwong  4   6   7 , David G Dillon  8 , Lizbeth Alvarez  9 , Isabel E Allen  10 , Ralph C Wang  3
Affiliations
Meta-Analysis

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

Vidya Eswaran et al. JAMA Intern Med. .

Abstract

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.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Eswaran reported nonfinancial support from the UCSF Resource Allocation Program. Dr Hwong reported non-financial support from University of California, San Francisco (UCSF) Resource Allocation Program and grants from Health Care Systems Research Network–Older Americans Independence Centers AGING Initiative (R33AG057806) outside the submitted work. Dr Dillon reported grants from NHLBI R38HL143581 during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. PRISMA Flow Diagram of Search Strategy
ED indicates emergency department.
Figure 2.
Figure 2.. Meta-Analysis of Risk of Restraint Use by Racial Categories
Risk of restraint use in Black vs non-Black patients. Meta−analysis was performed on a subset of 6 of 10 studies based on availability of restraint data by patient race. REML indicates restricted maximum likelihood.
Figure 3.
Figure 3.. Meta-Analysis of Risk of Restraint Use in Hispanic Ethnicity Patients vs Non-Hispanic Ethnicity Patients
Meta-analysis was performed on a subset of 6 of 10 studies based on availability of restraint data by patient ethnicity. REML indicates restricted maximum likelihood.
See this image and copyright information in PMC

References

    1. Santo L, Peters ZJ, DeFrances CJ. Emergency department visits among adults with mental health disorders: United States, 2017-2019. NCHS Data Brief. 2021;(426):1-8. - PubMed
    1. 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 - DOI - PubMed
    1. Downey LVA, Zun LS, Gonzales SJ. Frequency of alternative to restraints and seclusion and uses of agitation reduction techniques in the emergency department. Gen Hosp Psychiatry. 2007;29(6):470-474. doi: 10.1016/j.genhosppsych.2007.07.006 - DOI - PubMed
    1. Omar H, Yue R. Reassessment of violence against emergency physicians. Ann Emerg Med. 2018;72(4S):S144-S145. doi: 10.1016/j.annemergmed.2018.08.373 - DOI
    1. Emergency Doctors and Nurses Team Up on No Silence on ED Violence Campaign. Accessed May 18, 2022. www.acep.org/administration/violence-in-the-emergency-department-resourc...

MeSH terms