Americans dial 911 about 600,000 times a day, on average. And nearly one in 10 of those calls – 7% – require EMS personnel to restrain the patient.
Those calls present unique challenges that include a host of safety concerns – for patients, first responders, and even innocent bystanders. Sometimes, that means employing physical restraints or chemical sedation to keep all those people safe. But those safety interventions come with risks, too, including respiratory depression, hypoxia, or (in the absolute worst cases) cardiac arrest.
Physical restraints or sedation can trigger psychological distress and exacerbate a patient’s already festering distrust of the people trying to help them. Because of that, the National Association of EMS Physicians has recommended that EMS agencies adopt protocols to guide the management of behavioral health emergencies (BHEs), especially those involving restraint and/or sedation.
While anecdotal evidence has suggested that ethnic and racial disparities have long plagued emergency restraint practices in emergency department (ED) settings, researchers have ignored similar variances in prehospital care. ED studies have shown that Black and Hispanic patients are more likely to receive physical restraints. But the research has produced conflicting findings surrounding chemical sedation use among Hispanic patients. Driven by concerns over the restraint risks, a group of Boston researchers wanted to find out whether racial and ethnic disparities extend to prehospital EMS encounters for BHEs.
Methodology
This retrospective cohort study analyzed EMS encounters for patients with BHEs, using data from the ESO Data Collaborative, which includes de-identified records from roughly 2,000 EMS agencies across the United States.
The researchers focused on EMS encounters between Jan. 1 to Dec. 31, 2021, involving patients aged 16 to 90 who were transported by ground EMS units following a 911 call. The team excluded encounters that involved interfacility transfers, air transports, or seizures. What they wanted to see were the primary outcomes of incidents of physical restraint and/or chemical sedation – along with secondary outcomes regarding the specific use of physical restraint, chemical sedation, or both.
Other considerations included:
- EMS clinicians determined the patient’s race and ethnicity based on their impressions rather than a patient’s self-identification, which served as the primary independent variable.
- The researchers established categories that included Hispanic, non-Hispanic Black, non-Hispanic White, non-Hispanic other, and unknown.
- Finally, for the purposes of this study, they defined “chemical sedation” as the use of ketamine, benzodiazepines, or antipsychotic agents, while “physical restraint” included any documented use of restraints.
A Quick Look at the Numbers
Working with a study sample size of more than 660,000 BHEs, the team found that 7% of those encounters involved the use of a restraint and/or chemical sedation. Specifically:
- 4.5% of those events required physical restraints.
- 3.9% demanded chemical sedation.
- 1.4% of encounters called for both.
In short, the researchers confirmed the persistence of racial and ethnic disparities in the prehospital use of physical restraints and/or chemical sedation, with non-Hispanic Black patients facing much greater odds of being restrained or sedated compared to their non-Hispanic White counterparts. This lined up with the established research on ED care, which also shows greater rates of restraint and sedation for Black patients.
The findings also highlight disparities in physical restraint use among Hispanic patients, though the results for chemical sedation were more mixed.
As the team broke down those disparities, the researchers made several observations, including:
- Non-Hispanic Black patients had the highest likelihood of being restrained or sedated, with 7.9% of encounters involving these interventions. That’s compared to 6.1% of non-Hispanic White patients.
- Hispanic patients were more likely to be physically restrained than non-Hispanic White patients.
- They uncovered no notable difference in chemical sedation use.
Speaking of chemical sedation, researchers found that:
- Advanced life support (ALS) units favored it more than any other responding personnel.
- Benzodiazepines was the most popular choice, administered in 71.3% of chemical restraint cases.
- Among all racial and ethnic groups, Hispanic patients endured the highest overall rate of chemical restraint or sedation at 10.6%, followed by non-Hispanic Blacks at 7.9%, and non-Hispanic Whites, which made up 6.1% of patients.
Digging Deeper
The authors added that EMS agency-level practices – along with clinician training – might help explain these differences. Variable protocols, training, and cultural competence could influence how EMS personnel respond to BHEs, making things even worse.
Additionally, the researchers suggest implicit bias could sway decision-making, since earlier studies have argued that variations in treatment could stem from racial and ethnic perceptions.
The use of restraints and sedation in the prehospital setting might also influence the care patients receive once they make it into the ED, since ED personnel tend to leave the restraints in place. This obviously raises concerns about how prehospital practices influence ED management and whether such interventions contribute to broader healthcare disparities.
Finally, this research underscores the need for standardized protocols and better training, including de-escalation techniques, to address these disparities. Future research, the authors added, should focus on understanding the factors driving these differences so that first responders can develop strategies to ensure more equitable care for all patients.
Further Reading
Use of Physical Restraints in the Emergency Department
Trend in Emergency Department Visits Among Children and Youth With Autism Spectrum Disorder
Study Finds 25% of Emergency Room Visits by Older Adults Attributed to Dementia
