Disparities in Physical Restraints and Antipsychotic use in Hospitalized Patients with Limited English Proficiency

Physical restraints and antipsychotics should only be used as a last resort in hospitalized individuals at risk of harm to themselves or others. Since verbal reorientation and de-escalation are first-line management in these scenarios, patients with limited English proficiency (LEP) may be at higher risk of physical restraint and antipsychotic use. We aimed to examine the relationship between English proficiency, physical restraints, and antipsychotic use in hospitalized adults.

Retrospective cohort study of adults discharged from an academic medical center between 1/2019 and 6/2023. LEP was defined by non-English primary language listed in the electronic medical record. The primary outcome was use of either physical restraints or antipsychotics during the hospitalization, defined by orders and pharmacy charges, respectively. Multivariable generalized estimating equations were used to examine the relationship between primary language and outcomes, controlling for demographic, hospitalization, and clinical characteristics.

The cohort consisted of 132,767 hospitalizations (mean age 62.9 years, 48.3% female, 10.8% with LEP). Either physical restraints or antipsychotics were used in 14,802 (11.2%) hospitalizations. Unadjusted outcome rates in LEP and non-LEP groups were similar (10.1% vs. 11.3% for either physical restraints or antipsychotics, 7.9% vs. 8.9% for physical restraints, and 4.9% vs. 4.9% for antipsychotics). However, LEP patients had higher adjusted odds of either physical restraint or antipsychotic use (aOR 1.18; 95% CI, 1.08-1.28), physical restraint use (aOR 1.30; 95% CI 1.17-1.43), and antipsychotic use (aOR 1.12; 95% CI 1.01-1.25). Subgroup analysis among patients with diagnosed delirium revealed an even stronger association between LEP and the primary outcome (aOR 1.42; 95% CI 1.22-1.65).

This single center study found language-based disparities in orders for physical restraints and antipsychotics among hospitalized patients. Given the potential risks associated with both physical restraints and antipsychotics, causes and mitigators of this disparity should be investigated.