Racial and Ethnic Disparities in Patient Restraint in Emergency Departments by Police Transport Status.

Importance: Black patients are more likely than White patients to be restrained during behavioral crises in emergency departments (EDs). Although the perils of policing mental health for Black individuals are recognized, it is unclear whether or to what extent police transport mediates the association between Black race and use of physical restraint in EDs. Objective: To evaluate the degree to which police transport mediates the association between Black race and use of physical restraint in EDs. Design, Setting, and Participants: This retrospective, cross-sectional study used electronic health record data from ED visits by adults (aged ≥18 years) to 3 hospitals in the southeastern US and 10 in the northeastern US between January 1, 2015, and December 31, 2022. Data were analyzed from September 1, 2022, to May 30, 2023. Exposures: Race, ethnicity, and police transport to the hospital. Main Outcomes and Measures: The primary outcome variable was the presence of an order for restraints during an ED visit. Results: A total of 4 263 437 ED visits by 1 257 339 patients (55.5% of visits by female and 44.5% by male patients; 26.1% by patients 65 years or older) were included in the study. Black patients accounted for 27.5% of visits; Hispanic patients, 17.6%; White patients, 50.3%; and other or unknown race or ethnicity, 4.6%. In models adjusted for age, sex, site, previous behavioral or psychiatric history, and visit diagnoses, Black patients were at increased odds of experiencing restraint compared with White patients (adjusted odds ratio [AOR], 1.33 [95% CI, 1.28-1.37]). Within the mediation analysis, Black patients had higher odds of being brought to the hospital by police compared with all other patients (AOR, 1.38 [95% CI, 1.34-1.42]). Patients brought to the ED under police transport had increased odds of experiencing restraint compared with all other modes of transport (AOR, 5.51 [95% CI, 5.21-5.82]). The estimated proportion of use of restraints for Black patients mediated by police transport was 10.70% (95% CI, 9.26%-12.53%). Conclusions and Relevance: In this cross-sectional study of ED visits across 13 hospitals, police transport may have mediated the association between Black race and use of physical restraint. These findings suggest a need to further explore the mechanisms by which transport to emergency care may influence disparate restrictive interventions for patients experiencing behavioral emergencies.

Formative evaluation of an emergency department clinical decision support system for agitation symptoms: a study protocol.

INTRODUCTION: The burden of mental health-related visits to emergency departments (EDs) is growing, and agitation episodes are prevalent with such visits. Best practice guidance from experts recommends early assessment of at-risk populations and pre-emptive intervention using de-escalation techniques to prevent agitation. Time pressure, fluctuating work demands, and other systems-related factors pose challenges to efficient decision-making and adoption of best practice recommendations during an unfolding behavioural crisis. As such, we propose to design, develop and evaluate a computerised clinical decision support (CDS) system, Early Detection and Treatment to Reduce Events with Agitation Tool (ED-TREAT). We aim to identify patients at risk of agitation and guide ED clinicians through appropriate risk assessment and timely interventions to prevent agitation with a goal of minimising restraint use and improving patient experience and outcomes. METHODS AND ANALYSIS: This study describes the formative evaluation of the health record embedded CDS tool. Under aim 1, the study will collect qualitative data to design and develop ED-TREAT using a contextual design approach and an iterative user-centred design process. Participants will include potential CDS users, that is, ED physicians, nurses, technicians, as well as patients with lived experience of restraint use for behavioural crisis management during an ED visit. We will use purposive sampling to ensure the full spectrum of perspectives until we reach thematic saturation. Next, under aim 2, the study will conduct a pilot, randomised controlled trial of ED-TREAT at two adult ED sites in a regional health system in the Northeast USA to evaluate the feasibility, fidelity and bedside acceptability of ED-TREAT. We aim to recruit a total of at least 26 eligible subjects under the pilot trial. ETHICS AND DISSEMINATION: Ethical approval by the Yale University Human Investigation Committee was obtained in 2021 (HIC# 2000030893 and 2000030906). All participants will provide informed verbal consent prior to being enrolled in the study. Results will be disseminated through publications in open-access, peer-reviewed journals, via scientific presentations or through direct email notifications. TRIAL REGISTRATION NUMBER: NCT04959279; Pre-results.

Testing the effect of summer camp on excess summer weight gain in youth from low-income households: a randomized controlled trial.

BACKGROUND: Children from racial and ethnic minority groups, low-income households, and those with overweight or obesity gain more weight during the summer than the school year. Summer day camps, which offer routine opportunities for physical activity and regular meal and snack times, have potential to mitigate excess weight gain. This randomized controlled trial was done to determine the feasibility and preliminary effectiveness of summer camp in preventing excess summer weight gain among youth from low-income households. METHODS: Children, ages 6 to 12 years, were randomized to attend 8-weeks of summer day camp (CAMP) or to experience an unstructured summer as usual (SAU) in 2017-2018. Primary feasibility outcomes included retention, engagement and completion of midsummer measures. Secondary outcomes included changes in BMIz, engagement in moderate to vigorous physical activity (MVPA) and sedentary behavior, and diet quality and energy intake from the school year to summer. Multivariable linear mixed models were used to assess group differences. RESULTS: Ninety-four participants were randomized to CAMP (n = 46) or SAU (n = 48), of whom 93.0 and 91.6% completed end of school and end of summer assessments, respectively. While CAMP participants attended only 50% of camp days offered, on average, they lost - 0.03 BMIz units while those in SAU gained 0.07 BMIz units over the summer (b = 0.10; p = .02). Group differences in change in energy intake from the school year to summer were borderline significant, as energy intake remained relatively unchanged in CAMP participants but increased among participants in SAU (p = 0.07). CONCLUSIONS: Randomizing children to attend summer day camp or experience an unstructured summer as usual was effective in this low-income sample. Our findings support the potential for summer camps in mitigating excess summer weight gain. A larger randomized trial is needed explore efficacy, cost-effectiveness and longer-term effects of attending summer camp on weight and weight-related behaviors. TRIAL REGISTRATION: ClinicalTrials.gov Registration: NCT04085965 (09/2019, retrospective registration).