The Intersection of Law Enforcement, Policy, and Patient Health Outcomes
Restraints in the pre-hospital and emergency department (ED) settings are used to manage patient and staff safety, particularly in severe agitation. Agitation, a condition typified by aggressive or violent behavior from excess psychomotor activity, may necessitate physical or chemical restraints. However, restraint use carries serious risks, including apnea, hypoxia, physical trauma, and even cardiac arrest.
Law enforcement involvement in pre-hospital settings is associated with increased restraint use and associated adverse risks. High-profile murders–including those of Eric Garner and George Floyd–have focused attention on police brutality and racial disparities in restraint practices for Black and Brown people.
A 2025 study by Bongiorno et al. analyzed the use of pre-hospital physical and chemical restraints across approximately 2,000 Emergency Medical Services (EMS) agencies in the United States. Among 661,307 pre-hospital encounters, Non-Hispanic Black patients had the highest adjusted odds ratio of restraint use compared to any other group (AOR, 1.17 [95% CI, 1.14–1.21]). Notably, race was collected using paramedic impression rather than patient self-report as a measure of implicit bias and/or structural racism. The study also revealed that restraint use wasn't consistent—agencies differed in how often they restrained patients.
Additionally, patients who arrived at the ED restrained were more likely to stay restrained when verbal de-escalation tactics could have been used. Taken together, these findings support future review of EMS agency protocols and the expansion of national EMS training efforts for behavioral health emergencies.
In 2023, California passed AB360 to counter negative racial outcomes and reduce the misuse of pseudoscientific terms such as "excited delirium," which has historically been used by law enforcement and medical examiners to justify excessive force in cases of sudden deaths of individuals in police custody, despite lacking clinical validity. AB360 prohibits recognizing "excited delirium" as a medical diagnosis or cause of death, and bans its use in official documentation or court proceedings. AB360 wasn't alone – by October 2023, ACEP withdrew support for the term, mirroring legislative reform. Other states have begun enacting similar laws.
Reducing police involvement in behavioral health emergencies and expanding EMS de-escalation training would advance AB360's goals. National policymakers and medical boards should lead in codifying standards that ban unscientific terms like "excited delirium" and require evidence-based protocols, reducing excessive restraint use and improving patient safety nationwide.
Abstract
Bongiorno DM, Peters GA, Samuels-Kalow ME, et al. Racial and ethnic disparities in EMS use of restraints and sedation for patients with behavioral health emergencies. JAMA Network Open. 2025;8(3):e251281.
Abstract Importance
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.
Objective
To investigate the association of patient race and ethnicity with the use of prehospital physical restraint and chemical sedation during EMS encounters for BHEs.
Design, setting, and participants
This nationwide retrospective cohort study used data from EMS agencies across the US that participated in the 2021 ESO Data Collaborative research dataset. Emergency medical services encounters among patients aged 16 to 90 years with a primary or secondary impression, sign or symptom, or protocol use associated with a BHE from January 1 to December 31, 2021, were included. Statistical analysis was conducted from July 2023 to March 2024.
Exposures
Patient race and ethnicity, which was categorized as Hispanic, non-Hispanic Black, non-Hispanic White, non-Hispanic other (American Indian or Alaska Native, Asian, Hawaiian Native or Other Pacific Islander, other, or multiracial), and unknown.
Main outcomes and measures
The primary outcome was administration of any physical restraint and/or chemical sedation (defined as any antipsychotic medication, benzodiazepine, or ketamine).
Results
A total of 661,307 encounters (median age, 41 years [IQR, 30-56 years]; 56.9% male) were included. Race and ethnicity were documented as 9.9% Hispanic, 20.2% non-Hispanic Black, 59.5% non-Hispanic White, 1.9% non-Hispanic other, and 8.6% unknown race and ethnicity. Restraint and/or sedation was used in 46,042 (7.0%) of encounters, and use differed across racial and ethnic groups (Hispanic, 10.6%; non-Hispanic Black, 7.9%; non-Hispanic White, 6.1%; non-Hispanic other, 10.9%; unknown race and ethnicity, 5.9%; P < .001). In mixed-effects logistic regression models accounting for clustering by EMS agency and adjusted for age, gender, urbanicity, and community diversity, patients who were non-Hispanic Black had significantly greater odds of being restrained or sedated across all categories compared with non-Hispanic White patients (eg, any restraint and/or sedation: adjusted odds ratio [AOR], 1.17 [95% CI, 1.14-1.21]; physical restraint: AOR, 1.22 [95% CI, 1.18-1.26]). There was no significant difference in adjusted odds of any restraint and/or sedation use for the remaining racial and ethnic groups compared to non-Hispanic White patients. Clustering was associated with agency-level variation in restraint or sedation use (intraclass correlation coefficient, 0.16 [95% CI, 0.14-0.17]).
Conclusions and Relevance
This nationwide retrospective cohort study of EMS encounters for patients with BHEs found differences in the use of prehospital restraint and/or sedation by patient race and ethnicity and an agency-level association with variation in restraint and/or sedation use. These data may inform improvements to protocols and training aimed at equitable care for BHEs.
EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA
As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care physicians, and the lack of mental health services - are universal problems. As EM residents and fellows, we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill. Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.