Study Shows EMS Use of Restraints and Sedation Vary with Patient Race, Ethnicity
The recently-published research paper "Racial and Ethnic Disparities in EMS Use of Restraints and Sedation for Patients With Behavioral Health Emergencies" opens with, “Emergency medical services (EMS) clinicians commonly care for patients with behavioral health emergencies (BHEs), including acute agitation. There are known racial and ethnic disparities in the use of physical restraint and chemical sedation for BHEs in emergency department settings, but less is known about disparities in prehospital use of restraint or sedation.”
Investigating whether such disparities occur in EMS settings was the stated goal of this research paper. To learn more, EMS World spoke with one of its authors, Diana M. Bongiorno, MD, MPH. She is a chief resident in the Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital/Brigham and Women's Hospital in Boston, Massachusetts.
EMS World: Please tell us about your study. What is it all about?
Bongiorno: This was a nationwide study of EMS encounters that investigated if there are racial and ethnic disparities in the use of prehospital physical restraints and chemical sedation for patients who present with behavioral health emergencies, such as acute agitation.
EMS World: Why did you decide to do this study?
Bongiorno: There are known racial disparities in the use of physical restraint and chemical sedation among emergency department patients experiencing behavioral health emergencies. We were interested in whether there were similar disparities observed in the prehospital setting, recognizing prehospital restraint or sedation could potentially influence subsequent ED care.
EMS World: How was the data in the study compiled and analyzed?
Bongiorno: This was a retrospective study of EMS encounters in the ESO Data Collaborative research dataset. ESO is a vendor of prehospital electronic health record software across the country, and agencies that utilize ESO can choose to have their data included in this annual research dataset.
We specifically limited our study population to encounters for prehospital behavioral health emergencies. Our primary outcome of interest was the use of any physical restraint and/or chemical sedation (i.e., antipsychotic medications, benzodiazepine, or ketamine). We used logistic regression to compare the odds of restraint/sedation by racial and ethnic groups, while accounting for similarity between encounters from the same EMS agency and controlling for a range of factors such as patient age and gender.
EMS World: What conclusions did you draw from the research?
Bongiorno: We found that there are racial and ethnic disparities in prehospital use of physical restraint and chemical sedation in a large nationwide dataset. Specifically, non-Hispanic Black patients had significantly greater odds of receiving physical restraint, chemical sedation, or both, compared to non-Hispanic white patients, during EMS encounters for behavioral health emergencies. We also found that clustering was associated with agency-level variation in restraint and sedation use.
EMS World: Why do you think there is a difference in use of restraints and sedation across ethnic and racial groups?
Bongiorno: We suspect that there are multiple factors contributing to our results. EMS agency protocols and training guiding the management of agitated patients likely play a substantial role. For example, if certain agencies that treat more racial/ethnic minorities also have less robust protocols and training to guide agitation management and subsequently have increased rates of restraint/sedation use, this could contribute to our findings. While we suspect that structural factors have a substantial contribution to these disparities, it’s also possible that individual factors and implicit bias may play a role.
EMS World: Given your findings, what does the EMS community need to do to ensure equitable treatment of all patients?
Bongiorno: Given our finding that agency was associated with variation in restraint and sedation use, EMS agencies should evaluate their protocols, training, and organizational culture related to behavioral health emergency management.
The National Model EMS guidelines include guidance on prehospital management of behavioral health emergencies, including safety considerations such as recommendations for monitoring after restraint/sedation and physical restraint techniques to avoid. EMS agencies should review their protocols to determine whether they follow these model EMS guidelines.
Training is also essential and varies widely. De-escalation training is increasingly utilized in the ED and hospital setting and has the potential to decrease restraint and sedation use overall. While there is no national standard requiring de-escalation training for prehospital providers, agencies should consider implementing such training.
Finally, as agencies review instances of prehospital restraint and sedation use from a quality improvement standpoint, they should also consider evaluating the extent to which such strategies are employed equitably within the population they serve.
EMS World: What response have you had to your study's results? Is anyone stepping up to change their protocols to address the problems you identified?
Bongiorno: This study was very recently published, but we hope that our results encourage further discussions regarding prehospital management of behavioral health emergencies and future work to address the disparities we identified.
