Structural and Clinical Factors Associated with Physical Restraint Use in a Pediatric Emergency Department.

Objectives: To examine how structural factors, such as child protective services (CPS) involvement, prehospital interactions with police or emergency medical services (EMS), and clinical factors, such as autism diagnosis, contribute to physical restraint use among pediatric patients presenting to the emergency department (ED) for behavioral health concerns. Methods: In this retrospective cohort study, we reviewed pediatric ED encounters from January 1, 2021, to October 31, 2023, at a tertiary care children's hospital. Multivariable logistic regression was used to assess associations among autism diagnosis, CPS involvement, and arrival mode (police/EMS) and physical restraint use, adjusted for demographic variables. Results: Among 6288 behavioral health encounters, physical restraints were used in 124 (1.97%; 95% CI, 1.69, 2.58) encounters. Children arriving by police or EMS were 3 times more likely to be restrained than those arriving by car or walk-in (adjusted odds ratio, aOR = 3.07, 95% CI, 2.01-4.69). Children with CPS involvement were almost twice as likely to be restrained (aOR = 1.91; 95% CI, 1.26-2.88). Children diagnosed with autism were 7 times more likely to be restrained (aOR = 7.25, 95% CI, 3.61-14.55). Black children were more likely to be restrained than White children (aOR = 1.78, 95% CI, 1.12-2.84). Conclusion: CPS involvement, transport by police or EMS, autism diagnosis, and Black race were independently associated with increased physical restraint use in pediatric ED patients. These findings emphasize the role of both structural and child-level factors in contributing to physical restraint in emergency behavioral health care, highlighting the need for a multifactorial approach to reduce restraint use.