Bound by Bias: Racial Inequities in Prehospital Emergency Care

In pre-hospital emergency settings, EMTs (emergency clinicians) must make difficult decisions under intense time pressure. Their decisions affect the safety of the patient and those around them, as well as their personal safety. In behavioral health emergencies, clinicians can face the difficult decision of whether or not to restrain an agitated patient. Restraints are meant to be a last resort, used only to keep those around the patient safe. Unfortunately, this decision can be clouded by the clinician’s biases, leading to disproportionate use of this “last resort” among certain patients.

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Previous research has demonstrated that there are racial disparities in the use of physical restraints and chemical sedation among patients experiencing behavioral health emergencies in emergency departments in the US. In particular, Black and Hispanic patients are restrained chemically or physically at higher rates than their White counterparts. 

However, the literature is lacking on the use of chemical and physical restraints in pre-hospital services (emergency medical services encounters outside of hospitals). A recent study sought to identify racial and ethnic trends in the use of restraints during pre-hospital behavioral health emergencies.

What are the impacts of restraining patients having behavioral health emergencies?

Physical and chemical restraints are useful when a patient poses a risk to themselves or others. However, restraints themselves also pose a risk to the patient. Restraints can lead to respiratory depression (preventing the patient from taking full, deep breaths), hypoxia (lack of oxygen), physical trauma, and, in extreme cases, cardiac arrest. 

Using restraints can also increase a patient’s psychological distress, which could worsen their behavioral health condition. Being restrained also contributes to distrust in the health system and can prevent patients from seeking care in the future. 

Finally, restraints act as a barrier to proper care. The use of restraints in pre-hospital settings affects the treatment that patients receive on their way to and in the hospital. Restraints can cloud the judgment of healthcare providers in the hospital setting. For example, when a patient is brought to the hospital in physical restraints, it can contribute to the perception that the patient is dangerous, leading healthcare providers to treat the patient with less empathy than they may have otherwise.

Given the myriad of risks associated with using restraints, they should only be used when the safety of the patient or others is in jeopardy. Unfortunately, when decisions to use restraints become racially motivated, patients of color continue to suffer disproportionately worse health outcomes. 

What did this study do?

This nationwide retrospective cohort study looked at patients with documented behavioral health emergency (BHE) encounters using the ESO Data Collaborative research dataset for January- December 2021. The dataset included patients treated by Emergency Medical Services (EMS) for a BHE following a 911 call. The researchers identified BHEs through the emergency clinicians’ documented impressions, including symptoms of suicidal ideation, a behavioral or psychotic episode, hallucinations, violent behavior, or toxic drug use.  

The primary outcome of interest was the use of physical restraint, chemical sedation, or both. The researchers defined a physical restraint as any mechanical tool used to impede a patient’s voluntary movement. Chemical sedation encompassed the administration of ketamine, benzodiazepines (midazolam, lorazepam, diazepam), or antipsychotic agents (haloperidol, droperidol, olanzapine, ziprasidone) by any route (e.g., intramuscular, intravenous, oral).

This study used a composite of race and ethnicity to categorize patients as non-Hispanic White [White], non-Hispanic Black [Black], Hispanic/Latino, non-Hispanic other, and unknown. In pre-hospital emergencies, a patient’s race is recorded based on the clinician’s impression instead of the patient’s self-identification. Therefore, the recorded race may not always be accurate. However, it does reflect the clinician’s perception of the patient and may reveal potential biases in decisions regarding who is restrained and who is not.

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 What were the main findings?

This study found that the highest percentage of encounters for behavioral health emergencies  (BHEs) were for White patients (59%), followed by Black patients (20.2%). Physical and/or chemical restraints were used in 7% of encounters. Physical restraints were more commonly used than chemical restraints (4.5% vs 3.9%). The combination of physical and chemical restraints was rarely used (1.4% of cases).

Despite a higher proportion of BHEs among White patients, Black patients experienced more incidences of restraint use than White patients. Black patients were restrained or sedated in 7.9% of cases compared to 6.1% of cases involving White patients. In the results adjusted for demographic and neighborhood-level factors, Black patients had 17% higher odds of having either chemical or physical restraints used on them in pre-hospital emergency settings (AOR=1.17). There were no significant differences between other races. This pattern aligns with results from a 2023 study, which found that Black patients were 31% more likely to be restrained in a hospital setting compared to patients of any other race.

In the unadjusted results, Hispanic and Black patients had the highest odds of having restraints used on them. However, the use of restraints on Hispanic patients was not statistically significant after adjustment. The authors note that this difference could be due to how clinicians identify and categorize Hispanic patients based on brief impressions.

In their analysis, the researchers also controlled for the EMS agency that responded to the 911 call. When the researchers looked at the data without adjusting for other factors—but still considered which EMS agency was involved—they found that Black patients were 24% more likely, Hispanic patients were 11% more likely, and patients whose race and ethnicity weren’t known were 5% more likely to be restrained or sedated during emergency encounters compared to White patients. While the agency involved influenced how often restraints or sedation were used, this was not the only factor involved in the decision. Other factors are likely at play, such as systemic bias, differences in how patients are perceived or treated, or broader structural inequalities in healthcare.

Why are there racial differences in the use of restraints for patients with BHEs?

Black patients may be more likely to be chemically or physically restrained during behavioral health emergencies (BHEs) due to a combination of structural inequities and racial biases.

Structural inequities

On a structural level, many clinicians lack the skills and resources to standardize their decisions to use restraints. There are no national standards dictating in which situations clinicians should use restraints, nor are there standards requiring de-escalation training for clinicians. Research has shown that EMTs who complete crisis intervention training are twice as likely to attempt verbal de-escalation before turning to restraints. Without standards or sufficient training, clinicians must use their own perceptions and experiences to help them make decisions, which can be clouded by unconscious racial bias. Racist narratives have historically depicted Black people as dangerous, and, whether implicit or explicit, clinicians may be more likely to use restraints on patients of color.

As mentioned above, the study found that the agency that responded to the BHE influenced the use of restraints. Some agencies were more likely to use restraints than others. However, racial differences in restraint use persisted even when accounting for the responding agency. More simply, Black patients were more likely to be restrained across many agencies than their White counterparts. Thus, while agency-level practices such as protocols, organizational culture, and training should be overhauled to limit restraints, this study points to more profound system-wide racial inequities that need to be addressed.

Racial biases

There are racial differences in how patients present with BHEs. Black patients are less likely to have access to outpatient mental health care as a result of structural racism and systematic underfunding of health and social services in predominantly Black communities. This lack of access to care can manifest in more severe symptoms, necessitating the use of restraints. It is important to emphasize that this is a structural and racial equity issue, not something to blame on the individual patient.

Finally, racism and racial violence may also impact Black patients’ behavior during BHEs. There is a long history of Black patients being mistreated or actively harmed by the medical system, which has eroded their trust in healthcare personnel and institutions.  Thus, Black patients may be more agitated in crisis situations and less responsive to verbal de-escalation, again leading clinicians to use restraints.

What are the implications of this research?

There are direct associations between using pre-hospital restraints and how patients are treated in the emergency department. Racially-motivated use of restraints on black patients compounds the poorer care they receive, especially in the case of psychiatric health. It serves to erode further the trust that Black patients have in the healthcare system and the likelihood that they will seek care in the future. Racially-biased use of restraints overall leads to poorer health outcomes for Black patients with behavioral health conditions.

Several improvements are needed to address racial biases in restraint use. Firstly, emergency services agencies and hospitals should develop and implement standards governing the use of restraints. Standards would take the onus off of clinicians to make rapid judgments during high-stress situations and mitigate the impact of their implicit racial biases on these decisions. Similarly, emergency clinicians must be trained in de-escalation techniques. This would hopefully lead to fewer instances where restraints are needed in general. Finally, emergency clinicians should also undergo racial health equity training to address any implicit biases they may hold about patients of color and to understand how these biases may impact their clinical judgment.

Key Takeaways

• Physical and chemical restraints for patients experiencing behavioral health emergencies are used more frequently among certain racial groups.
• Black patients are 17% more likely to be physically or chemically restrained during a pre-hospital behavioral health emergency than White patients.
• Racially biased decision-making contributes to poorer treatment and health outcomes for Black patients facing behavioral health emergencies.
• Implementing standardized guidelines for using restraints, along with de-escalation training for emergency clinicians, could help reduce the racial disparities in restraint usage.

References

Peterson, M. M., Anderson, E. S., & McCoy, T. H. (2024). Racial and ethnic differences in prehospital sedation and restraint among patients in the United States. JAMA Network Open, 7(4), e2410507.

Connolly, L. (2023, October 20). New study shows Black patients more likely to be restrained than other racial groups. UC Davis Health. https://health.ucdavis.edu/news/headlines/new-study-shows-black-patients-more-likely-to-be-restrained-than-other-racial-groups/2023/10

Gibbons, A. (2023, September 25). Emergency departments use restraints more often on Black patients, studies show. STAT. https://www.statnews.com/2023/09/25/emergency-departments-restraints-racial-disparities/

Urgent Matters. (n.d.). The role of race on restraint use: Racial bias in healthcare, psychiatric diseases, and utilization of restraints (Part 2 in a 3-part series). George Washington University School of Medicine and Health Sciences. https://urgentmatters.smhs.gwu.edu/news/role-race-restraint-use-racial-bias-healthcare-psychiatric-diseases-and-utilization-restraints