Police transport may influence restraint use in the emergency department

Patients brought to the emergency department (ED) under police transport are more likely to be restrained in the ED, a new Yale study finds. And it may explain, at least in part, why racial disparities exist in the use of restraint, the researchers say.

The findings were published Feb. 21 in JAMA Network Open.

Even among patients with similar medical and demographic backgrounds, Black patients are more likely to be restrained in the ED than white patients, previous research has shown. Uncovering what drives this inequity will help inform interventions to prevent it, explained Dr. Ambrose Wong, assistant professor of emergency medicine at Yale School of Medicine and senior author of the new study.

"We began looking into police transport as a possible mediator of these racial disparities of restraint use in the ED because it was something I and my colleagues had suspected might play a role," said Wong. "It was a potential pattern that we had started noticing, but without data we couldn't be sure if it was true."

To assess whether there was a relationship between police transport and patient restraint, the researchers analyzed data from 13 hospital EDs in the southeastern and northeastern regions of the United States. Data included adult ED visits between Jan. 1, 2015 and Dec. 31, 2022, totaling over 4.2 million ED visits by more than 1.2 million patients.

The researchers found that Black patients were 33% more likely to be restrained than white patients, a finding that was consistent with the results of previous studies.

Overall, patients arriving to the ED by police transport were more than 550% as likely to be restrained in the ED as patients arriving by other means, and Black patients were 38% more likely than white patients to be brought to the ED by police transport.

These trends were consistent at hospitals in both the southeastern U.S. and the northeastern U.S.

To better understand the connections between these initial findings, the researchers performed a "mediation analysis," an advanced statistical technique that aims to determine whether the relationship between two factors (race and restraint use, in this case) might be influenced, or mediated, by a third factor (police transport). They found that the racial disparity in frequency of restraint use in the ED was mediated, in part, by police transport, and they proposed a few explanations.

Police transport may lead to a perception of threat that influences decisions made by clinicians, researchers said. And because Black individuals experience higher rates of injury and death during interactions with police, police transport may escalate patients' distress, leading to restraint.

Further, racial and ethnic minority populations tend to have less access to outpatient medical treatment. When they do experience a medical emergency or mental health crisis, police are often the first to arrive on scene.

"So immediately, minority populations that suffer mental health crises are linked with something criminal," said Wong. "These communities, therefore, are disproportionately labeled as potentially criminalizing, which can perpetuate use of restraint."

That this external factor is potentially influencing the ED environment—and that this relationship was observed in multiple hospitals in two regions of the U.S.—suggests there are structural drivers underlying this racial disparity, said the researchers.

"This is not about a few racist individuals or racist hospital policies, but, rather, evidence of structural and system factors that are present in society and affecting the way patients present to and receive emergency care," said Dr. Jane Gagliardi, professor of psychiatry and behavioral sciences at Duke University School of Medicine and a co-author of the study.

"While individual training on implicit bias and interpersonal equity may have a role, we are interested in exploring upstream structural factors that may be amenable to modification to improve patient and staff safety and wellness."

These upstream modifications could include reducing the role of law enforcement in emergency medical transport, particularly in response to mental health emergencies. Finding ways to address these disparities and reduce the use of restraint overall is important for both patients and clinicians, said the researchers.

"Aside from patients sustaining physical injuries from being restrained, there's lasting psychological trauma that comes along with it," said Erika Chang-Sing, a medical student at Yale School of Medicine and lead author of the study.

For clinicians and hospital staff, restraining patients can lead to what's known as "moral injury," said Wong, which is a term that describes the feeling of having violated one's own personal ethics.

"We as clinicians really thrive on the fact that we are able to help others, and when restraint is used, it's almost like we're being asked to do something that's harmful," said Wong. "Restraint is used in the context of us trying to make sure a patient is safe and the staff around us are safe, and it's something that's done with serious decision and as minimally as possible. But it adds toil and stress, and a lot of times clinicians carry a burden, wondering if they're at fault."

Efforts to address these issues can also be made within hospitals and emergency departments, said the researchers. Making strides to reduce ED crowding is one example, as overcrowded EDs are more stressful and can affect decision-making. Another potential solution is reflected in a trial program by Yale's Department of Emergency Medicine, which is adding individuals with lived experience of mental illness to the behavioral crisis response team to see if this type of peer support can better help patients in emotional and psychiatric distress.

"We know that racial concordance between patients and people deescalating situations can be more effective, so we're specifically recruiting minorities and folks from indigent populations," said Wong. "We're excited to hopefully see some positive improvements."