Reducing Inequities in Restraint Use in the Pediatric Emergency Department

Restraints are used in emergency departments to treat acute agitation and prevent harm but can cause injury. Local data demonstrated racial and ethnic disparities in restraint use. Of non-Hispanic Black and Hispanic patients, 2.7% were physically restrained, compared with 1.1% of non-Hispanic White patients. Intramuscular chemical restraint rates were highest among non-Hispanic Black patients at 6.0%, compared with 3.7% in Hispanic patients and 2.6% in non-Hispanic White patients. We sought to reduce these differences to less than 1% within 12 months.

We identified drivers to managing agitation, including improved staffing, standardized care protocols, enhanced deescalation training, and early assessment. A multidisciplinary team implemented interventions through Plan-Do-Study-Act cycles, including a standardized pathway, 24/7 access to behavioral health counselors, care plans, deescalation training, and education on racial disparities. Statistical process control charts were used to track restraint use. Process measures included staff knowledge of racial disparities in restraint use. The balancing measure included the frequency of staff injuries.

Physical restraint rates remained unchanged for non-Hispanic Black and non-Hispanic white but decreased to 1.3% for Hispanic patients. We observed reductions in intramuscular restraint disparities: rates decreased to 1.4% for non-Hispanic Black and 1.2% for Hispanic patients, with 8 consecutive points below the centerline, whereas rates for non-Hispanic white patients remained at 2.6%. Staff injuries did not increase.

Targeted quality improvement interventions led to reduction in disparities in restraint use. Ongoing work includes simulation-based training and addressing structural drivers.