Racial Disparities in the Use of Physical Restraints and Intramuscular Medications for Patients Awaiting Psychiatric Hospitalization in the Emergency Department.

Abstract

Background: Racial disparities within health care practices have drawn increasing attention. In psychiatric emergencies, patients may exhibit severe agitation necessitating the application of physical restraints and administration of intramuscular medications to ensure patient and staff safety and reduce acute symptoms. While previous studies have explored racial disparities in these interventions within the general emergency department (ED) settings, there remains a paucity of data about their use specifically in patients awaiting psychiatric hospitalization in the ED.

Objective: We investigated disparity in the application of physical restraints and administration of intramuscular medications to Black versus non-Black patients awaiting psychiatric hospitalization 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's ED over a 1-year timeframe. Sociodemographic data, including age, sex, marital status, race (classified as Black or non-Black), and insurance types were collected. Clinical variables including primary psychiatric diagnosis, current suicide attempt or self-injurious behaviors, history of suicide attempts, history of psychiatric hospitalizations, involuntary status, application of physical restraints, and administration of acute intramuscular medications were extracted. Data on time of presentation were collected. Two logistic regression models were constructed with physical restraints and intramuscular medications as the outcomes, race as the independent variable, and other variables as covariates.

Results: A total of 525 patient encounters were included in the study (mean age = 34.4 ± 11.0) with a female-to-male ratio of 0.82 (236:289). Seventy-eight (14.9%) encounters involved a patient identified as Black. Physical restraints were used in 35 encounters (6.7%). Black race (odds ratio [OR] = 2.84; 95% confidence interval [CI] = 1.03-7.84; P = 0.04) was associated with an increased likelihood of receiving physical restraints after controlling for covariates including current self-injurious behaviors (OR = 4.15; 95% CI = 1.02-16.88; P = 0.047), involuntary status (OR = 15.16; 95% CI = 6.14-37.45; P < 0.001), and visit to the ED on the weekend (OR = 4.04; 95% CI = 1.61-10.11; P < 0.01). Black race was not associated with the administration of intramuscular medications after controlling for covariates.

Conclusions: Our findings indicate a racial disparity in the application of physical restraints in patients awaiting psychiatric hospitalization in the ED. The odds that Black patients experienced physical restraints were three times higher than for non-Black patients, even after adjusting for sociodemographic and clinical factors.