>>Thousands of patients restrained in hospital ERs and wards with limited oversight

At least 50 hospital patients were improperly restrained in New York between 2015 and 2018, spanning men and women handcuffed, hit with batons, drugged, and left strapped to beds up to 12 hours without regular check-ups and water, a USA TODAY Network New York investigation found.

The newly reported details of restraint violations include hospital security officers who injured patients while handcuffing them to wheelchairs and beds. Some officers also sprayed patients’ eyes with pepper gel and used pressure-point holds more typical of police tactics on the street, records show.

Some of the patient-restraint incidents also lacked a licensed health provider’s order as required by law. Other cases involved hospital workers and security officers who lacked required training for safely using physical and mechanical restraint techniques on patients.

But the true scope of restraint use, and misuse, in hospitals — including suspected racial disparities among patients subjected to it — remains shrouded in secrecy because the incidents are not fully tracked by authorities.

The only mandatory reporting of restraint use in hospital settings consists of cases connected to deaths, or cases in psychiatric units. But that information lacks crucial details needed to determine how many patients are restrained and for how long.

In other words: Thousands of patients are restrained in emergency rooms and other hospital wards across New York with limited independent oversight.

The need to close that void in restraint-use transparency and accountability, however, has become increasingly urgent as reports of violent clashes between patients and medical workers skyrocketed during the COVID-19 pandemic, according to national experts and advocates.

“Restraints, especially restraints with a device or mechanical restraints, are really something we would like to avoid almost at all costs in terms of not harming patients and not traumatizing patients,” said Vincent Staggs, a University of Missouri-Kansas City medical school professor.

“But if you don’t know what too much restraint use looks like, you can have hospitals using it far more often than is acceptable, or necessary,” added Staggs, who studies gaps in restraint-use reporting nationally.

Against that backdrop, USA TODAY Network New York analyzed hundreds of pages of hospital-inspection reports obtained via public-records requests, reviewed federal records, and questioned 15 hospitals in New York about restraint-use violations.

State health officials, however, took nearly two years to release hospital-inspection documents in response to a public-records request from January 2020. And a request for inspection records during the pandemic is pending, delaying review of complaints and violations amid the public-health emergency.

Still, the months-long investigation revealed state and federal laws allow hospitals to withhold many details about restraint use, despite mounting questions about harm done to patients and medical workers, as well as potential racial injustices connected to the practice.

Among the findings

• Independent review of hospital-restraint incidents consists primarily of state Health Department inspections, which focus on specific complaints and safety violations rather than racial disparity and potential overuse.
• A groundbreaking Yale study in 2021, however, found Black patients faced an increased risk of being restrained in some Connecticut emergency rooms. But the lack of national data hinders further research into potential bias elsewhere.
• A total of 15 hospitals in New York faced a combined $54,000 in fines connected to at least 50 patient-restraint violations since 2015. It is a penalty that advocates say gives hospitals generating billions of dollars in revenue, collectively, limited incentive to seek positive change.
• The hospitals are implementing corrective action plans to address the violations, as required to avoid losing Medicare and Medicaid funding. But none of them provided detailed answers to USA TODAY Network questions about the effort.
• Prior efforts to enact federal laws and regulations to require hospitals to publicly report details about each restraint-use incident have stalled under pushback from powerful health care lobbying groups.

How COVID increased workplace violence in health care

After decades of advocates’ failed attempts to improve hospital restraint-use transparency, the potentially dangerous secrecy is gaining renewed attention due to spikes in workplace violence in health care settings since 2020.

In September, for example, 31% of nurses said they faced increases in workplace violence, up from 21% earlier in 2021, the National Nurses United union reported.

Many frontline nurses, including Lucy Dawson, a 47-year-old nurse at Maine Medical Center in Portland, Maine, asserted the mix of decreased staffing levels and waves of COVID-related pressures contributed to the uptick in patient attacks on medical workers.

“It’s just a lot of fear and anxiety,” Dawson said, “and feeling anxious driving into work and not knowing if today is going to be the day that I’m going to get choked or I’m going to get punched.”

The trend is striking considering health care workers were already five times as likely than workers overall to suffer workplace violence injuries before the pandemic, the latest federal data from 2018 show.

“Right now, it’s not clear that there is enough work being done to track the actual impact of efforts to keep hospital staff members safe,” said Dr. Ambrose Wong, a Yale Medical School professor.

Amid the violence, Wong, who led the 2021 study into racial disparity in restraint use at Yale-New Haven Health System emergency rooms, has called for hospitals nationally to track and report more details linking restraint-use incidents to worker injuries.

The trend of increased violence in hospitals, Wong said, also suggested more patient-restraint incidents are endangering both patients and medical workers.

“The restraint is getting placed in response to a violent event, and we’ve seen a spike in mental health related visits that could lead to violent events during COVID,” he said, “But we don’t have enough nurses nationwide and don’t have enough capital to take care of people.”

A Black doctor’s fight for answers

Meanwhile, Dr. Isaac Agboola, the 31-year-old chief medical resident at Yale-New Haven Hospital, traced his search for answers about medical restraint-use bias to the murder of George Floyd in 2020 at the hands of police in Minneapolis.

Having grown up Black in Minneapolis, Agboola described feeling connected to Floyd as two men separated only by life’s circumstances. And as the social justice movement sparked by Floyd’s death unfolded, Agboola deepened his own commitment to fight against health inequality.

The stakes were crystal clear to Agboola as he watched Black men seemingly getting restrained more often than other patients at the emergency room where he worked.

“At the end of the day, regardless of me being an ER physician, I’m a Black man and I see the world through that lens,” Agboola said recently.

The restraint-use observations led Agboola to collaborate with Wong on research of potential racial disparity, which helped lead to Wong’s study published in the Journal of American Medical Association.

Despite the breakthrough, however, Agboola still struggles with the thought that it took Floyd’s death to ignite the probe of potential racial disparity in hospital restraint use.

“It’s unfortunate that people have to die for conversations to happen,” he said.

How and why patient restraints happen

Still, a myriad of unanswered questions remains regarding how and why patients get restrained in hospitals.

For example, Wong’s 2021 study of restraints looked mainly at patients’ sex, race, and ethnicity, as well as health-insurance status. But it did not probe potential causes of disparity, or improper use of restraints.

Still, the study found Black patients with Medicaid or Medicare coverage faced a higher risk of restraint than other patients, noting about 2,040, or 29%, of the nearly 7,100 overall restraint incidents involved Black or African American patients. Homelessness was a factor in 164 cases. The same data points are not available in the New York records analyzed for this story.

Agboola also described a complex web of factors linked to the restraint-use cases he observed or ordered himself. While drugs, alcohol and mental-health issues contributed to some cases, others were just an angry or confused person, he said.

“In many of these situations you could calm this person down, and the big issue is it might take some time,” he added.

One of the first things Agboola said he does to de-escalate the situation: “Limit security and police presence to only as needed, especially when treating patients who have historically had biased interactions with law enforcement.”

Indeed, Agboola attributes some potential bias in restraint use to how the patient arrives at the hospital.

“Some people might come handcuffed by police, and that patient is viewed inherently with a degree of criminality,” he said.

Police transfers to hospitals, however, span from potentially dangerous criminals to non-violent mental-health episodes and the homeless.

But the medical workers receiving the person typically get limited details beyond the person was agitated and needed to be handcuffed, Agboola said, which often results in a restraint order in the hospital.

One factor in overcoming potential implicit bias connected to restraint use, he added, is the ongoing push to improve the diversity of doctors and nurses in American medicine.

“I can imagine being on the other side of it and humanizing this patient,” Agboola said, adding “there’s a lot of data that signifies a diverse medical staff is the best medical staff.”

What we know (and don’t know) about hospital restraint use

The push for improved oversight of restraints in health care, in many ways, stemmed from a Hartford Courant expose in 1998, which spotlighted how authorities failed to track restraint-related deaths nationally.

Lawmakers promptly pushed to improve restraint-use safety and reporting but failed to pass legislation. Federal regulators, however, enacted some of the policies, including a requirement in 1999 that hospitals begin reporting details for all deaths related to restraints and seclusion.

But hospitals nationally failed to report to federal officials on 44 of 104 documented deaths related to restraint and seclusion between 1999 and 2004, a federal Office of Inspector General review found in 2006.

Despite that history, the Centers for Medicare and Medicaid Services recently declined to provide updated statistics on the death reports. A public-records request for the reports, which include details about the type of restraints and drugs used to subdue patients, is pending with the federal agency.

Yet in 2011, top national researchers analyzed 61 restraint-related deaths in hospitals and other settings across the country, revealing in part that about 75% of the patients had a psychiatric history and most were male.

About one-third of the restraint-related deaths also resulted from unlawful restraint use, according to the research affiliated with Equip for Equality, an Illinois-based legal advocacy group.

In 2016, Disability Rights New York, a government-authorized advocacy program, also released details of its investigation into restraint use at psychiatric hospitals operated by New York City.

The probe found in part that Bellevue Hospital in Manhattan restrained patients at more than twice the rate of several other psychiatric hospitals, prompting sweeping reforms at Bellevue.

Further, Bellevue has higher rates of uninsured and Medicaid patients from communities of color than other hospitals in Manhattan, underscoring concerns about disparity in restraint use.

Since the 2016 report, Disability Rights New York has received additional complaints about improper restraint use at several other psychiatric hospitals statewide as part of its ongoing monitoring of the issue, according to Alison Lynch, a staff attorney who co-authored the Bellevue report.

The lack of publicly reported details of restraint cases, however, hinders the advocacy program’s push to address concerns about everything from racial disparity in restrained patients to overuse of chemical restraints, Lynch said.

“If there was some type of database we could pull from that we could use to track trends in real-time – rather than wait for the buildup in complaints – that would potentially alleviate some of these systemic problems,” she added.

Staggs, the restraint-use oversight expert, elaborated on the repercussions of keeping many details of restraint incidents in the shadows, calling it uniquely troubling for psychiatric units.

“These are people who tend to be out of sight, out of mind,” he said, “and if no one’s paying attention, historically, we’ve known that those conditions have been very dangerous.”

Further, some of the same problems in psychiatric units likely apply to many patients getting restrained in emergency rooms and other hospital wards, though it is unclear because hospitals closely guard information about the incidents.

“It all reflects a societal failure to appreciate the importance and the need for behavioral health care and mental health care,” Staggs said.

How hospital restraint use training is evolving

Despite the safety gaps surrounding hospital restraint use, some progress has been made in recent years around training workers to deploy it as a last resort.

For example, the Joint Commission, the nation’s largest standards-setting and accrediting body in health care, last year moved to require hospitals to provide hospital workers with de-escalation training annually.

David Farrell, CEO of Welle, a de-escalation training company, described the development as a message that the commission is serious about equipping workers with the tools to identify and resolve patient aggression before restraints are needed.

“Health systems are looking for training for many, many more staff associates than they were five to 10 years ago,” Farrell said, adding some details of the Joint Commission policy shift remain unclear.

Previously, the federal government required that hospital workers received an initial restraint-use competency training program with “periodic” follow-up at the hospital’s discretion. The broad list of competency topics included de-escalation.

In response to questions about the issue, the Joint Commission noted in a statement that its restraint standards have historically aligned with federal regulations. It added the recent reforms to de-escalation training “are focused on reduction in work place violence not specifically to restraints.”

Mary Farrell, Welle’s clinical director, suggested the growing public attention on patient aggression during the pandemic is fueling regulatory change, despite the fact workplace violence has historically plagued hospitals.

“This is not a new phenomenon, and it was really never out in the public eye because nurses took it as part of their job,” she said.

Federal legislation also aims to require the Occupation Safety and Health Administration to implement a variety of measures to prevent workplace violence specifically in health care and social services, including potentially improving employer reporting requirements.

The state Department of Health acknowledged it does not collect data on the number of patients restrained at hospitals, but the agency noted it has cited 12 hospitals for the most severe “immediate jeopardy” violations related to restraints since 2015.

“To ensure hospitals are held accountable for the quality of care they provide, the (Health Department) conducts unannounced surveys at hospitals in the state to investigate complaints in accordance with federal and state regulations,” agency spokesman Jeffrey Hammond said in a statement.

Still, gauging the success of efforts to curb workplace violence and restraint use could be difficult until public reporting on incidents improves, Staggs said, voicing concerns about unintended consequences of reform without independent oversight.

“If you’re going to eliminate device restraints entirely, then you may inadvertently cause hospitals to rely more heavily on chemical restraints and whether that’s a good trade-off I’m not sure,” he said.

About the team

New York’s USA Today reporting teams are working on a series of wide-ranging investigations intended to shine a light on processes that are critical to public life but are often hidden. The topic areas for 2022 include government accountability and oversight, policing and public safety, health and environmental justice and consumer rights. We welcome your feedback and suggestions to help inform our reporting priorities.

Email: [email protected].

This article originally appeared on New York State Team: Thousands restrained in hospital ERs and wards with limited oversight