WEBB FELLOW: Racial disparity in the application of physical restraints to psychiatric patients boarding in the Emergency Department

Abstract: Background
Racial disparities within healthcare practices have drawn increasing attention. The prevalence of emergency department (ED) visits for mental illness has escalated. In psychiatric emergencies, patients may exhibit severe agitation necessitating the application of physical restraints to ensure patient and staff safety. While previous studies have explored racial disparities in applications of physical restraints within the general ED settings, there remains a paucity of data about applications of physical restraints specifically in psychiatric boarders (1,2). We aimed to investigate disparity in the application of physical restraints to Black versus non-Black psychiatric patients boarding in the ED.

Methods
We conducted a retrospective chart review of adults admitted to an acute inpatient psychiatric unit through an academic tertiary care center ED over a one-year timeframe. Sociodemographic data, including age, sex, marital status, race, and insurance type, were collected, with race classified as Black or non-Black. Clinical variables, including primary psychiatric diagnosis, current suicide attempt or self-injurious behaviors, history of suicide attempts, history of psychiatric hospitalizations, involuntary status, and application of physical restraints, were extracted. Temporal data about the presentation timeframe was collected. Logistic regression models were employed to investigate the association between race and the application of physical restraints while controlling for other variables.

Results
A total of 530 patient encounters were included in the study (mean age: 34.4±11.0) with a female-to-male ratio of 0.82 (238:292). 78 (15%) encounters involved a patient identified as Black. Physical restraints were used in 35 encounters (6.6%). Factors associated with an increased likelihood of receiving physical restraints included presenting to the ED on the weekend (OR, 3.93; 95% CI, 1.58-9.80; p=0.003), involuntary status (OR, 14.96; 95% CI, 5.72-39.11; p< 0.001), and Black race (OR, 2.96; 95% CI, 1.06-8.23; p=0.04).

Discussion
Our findings indicate a racial disparity in the application of physical restraints within ED psychiatric boarders. Unlike previous studies, there was no significant difference in the application of physical restraints amongst different psychiatric diagnoses (3). This study's strengths include focusing on the psychiatric ED boarding patients rather than generic ED visits, as was seen in previous studies. Limitations include retrospective design, modest sample size, and granularity of racial data. Additional studies on system, staff, and patient-level factors are needed to better understand this association and ultimately address this disparity.

Conclusions
The odds that Black patients experienced physical restraint while boarding in the ED for psychiatric reasons were three-fold higher than non-Black patients. This association remained significant after adjusting for sociodemographic and clinical factors, including involuntary status and weekend presentation.