Racial and Ethnic Disparities in Physical Restraint Use for Pediatric Patients in the Emergency Department

Background: For pediatric emergency department (ED) visits, physical restraint is an uncommon, but serious intervention, associated with injury, trauma, and death. Physical restraint is indicated for youth at risk of harming themselves or others, often due to acute exacerbation of a neuropsychiatric disorder. Physical restraint should only be used after trialing behavioral de-escalation and/or chemical restraint. Black adult patients are more likely to be physically restrained in the ED, however, limited literature examines the characteristics of children who experience physical restraint in the ED.
Our objectives were to describe the characteristics of pediatric patients who are physically restrained in the ED and examine disproportionate physical restraint use in pediatric emergency department visits by race/ethnicity.

Methods: We conducted a cross-sectional study of pediatric visits (0-16 years) to 11 different EDs within a New England healthcare system, from 2013 to 2020. Our primary outcome was the proportion of ED visits with a physical restraint order. We reported visit characteristics with descriptive statistics. We examined the association between physical restraint and race/ethnicity using a generalized linear multivariable mixed model with a binary logistic link, incorporating nesting by patient, provider, and site. We controlled for the following covariates: age, sex, language, insurance, school month, behavioral health presenting problem, presence of an outpatient psychotropic medication, and history of behavioral health condition.

Results: Our sample included 551,208 pediatric patients, of which 532 (0.1%) had associated physical restraint orders. Of individuals who were restrained, 39.1% were Black Non-Hispanic, 37.6% were White Non-Hispanic, and 19.4% were Hispanic; 81.2% were 10-16 years, 66.2% were male, and 71.2 % were publicly insured; 80.8% had a behavioral health presenting problem, 73.9% had outpatient psychotropic medications, and 43.8% had a behavioral health diagnosis (Table 1).

In adjusted regression analyses, Black Non-Hispanic patients were more likely to be restrained compared to White Non-Hispanic patients (aOR 1.80; 95% CI 1.40, 2.32). There was no difference in restraint use between Hispanic and White Non-Hispanic patients. Patients presenting with a behavioral health concern, a past medical history of a behavioral health condition, and/or a psychotropic medication on their home medication list had increased odds of being restrained (Table 2).

Conclusion: Our study demonstrates that after adjusting for sociodemographic and clinical characteristics, Black Non-Hispanic children were more likely to be physically restrained in the ED compared to White Non-Hispanic children. Physical restraint is a traumatic experience that can have lasting consequences for a child’s development and well-being, and in our study, we found that it disproportionately impacts Black Non-Hispanic children. Further research should identify interventions that eliminate inequities in physical restraint use by addressing interpersonal and structural racism in order to create a healthcare system that is a therapeutic rather than traumatic environment.