(046) Examining Racial Bias in the Use of Restraints During Behavioral Emergencies

Abstract:

Background: Recent papers have argued that establishing a Behavioral Emergency Response Team (BERT) in the general medical setting can lead to more equitable care for patients (Parker et al., 2020). An unpublished study by our own service on BERT outcomes found that restraints were used to deescalate 3% of patients (n = 29). Of those included in the study sample, Black patients were overrepresented. This was also a pattern in a 2021 study of Emergency Department visits (Wong et al, 2021). The purpose of this planned study is to examine possible racial, ethnic, gender, or language bias patterns in the use of 4-point restraints for behavioral control in the general medical setting when the BERT was activated versus during usual care (no BERT). We intend to use the data to find actionable targets for programmatic and / or institutional quality improvements.



Methods: This IRB approved study will utilize secondary analysis of an existing clinical dataset combined with retrospective chart review. We will examine all episodes of 4-point restraint use occurring in adult inpatients admitted to any medical or surgical unit from Feb 2017 – December 2021. The following variables will be collected: demographics (race, ethnicity, gender, language, age, height & weight), restraint use (indication, duration), and BERT / psychiatric variables (Psychiatry CL consulted Y/N, BERT involved Y/N, diagnosis). The new combined dataset will be analyzed using simple descriptive statistics. The pattern of restraint use in two subgroups (BERT involved versus BERT not involved) will be compared to investigate whether or not involvement of the BERT influences bias.



Results: Our study has been IRB approved. Fifty-seven unique patients have been identified for study inclusion, including 29 patients with restraints documented during a BERT activation and 28 patients with restraints without BERT activation. Preliminary chart review shows variability in documentation on events of restraint use. Data collection is ongoing.



Discussion: Preliminary data suggests there may be an important opportunity to improve clinical care by standardizing ordering requirements and documentation of restraint use. Given the ongoing harm that racism poses for both patients and staff, understanding how it influences restraint utilization and BERT activation will guide local programmatic and institutional change, and may help inform future research into bias in mental health care. This project is part of a long-term quality improvement project to examine racial bias in the management of behavioral emergencies throughout our hospital.



References:
Parker CB, Calhoun A, Wong AH, Davidson L, Dike C. A Call for Behavioral Emergency Response Teams in Inpatient Hospital Settings. AMA J Ethics. Nov 1 2020;22(11):E956-964. doi:10.1001/amajethics.2020.956

Wong AH, Whitfill T, Ohuabunwa EC, et al. Association of Race/Ethnicity and Other Demographic Characteristics With Use of Physical Restraints in the Emergency Department. JAMA Netw Open. 2021;4(1):e2035241.