US Emergency Department Encounters for Law Enforcement-Associated Injury, 2006-2012

Relationship between Civilian Injuries Caused during Contact with Law Enforcement and Community-Level Sociodemographic Characteristics

Civilian injuries caused during contact with law enforcement personnel erode community trust in policing, impact individual well-being, and exacerbate existing health inequities. We assessed the relationship between ZIP code-level rates of civilian injuries caused during legal interventions and community-level sociodemographic characteristics using Illinois hospital data from 2016 to 2022. We developed multivariable Poisson regression models to examine whether legal intervention injury rates differed by race-ethnicity and community economic disadvantage across three geographic regions of Illinois representing different levels of urbanization. Over the study period, 4976 civilian injuries were treated in Illinois hospitals (rate of 5.6 per 100,000 residents). Compared to non-Hispanic white residents, non-Hispanic Black residents demonstrated 5.5-10.5 times higher injury rates across the three geographic regions, and Hispanic-Latino residents demonstrated higher rates in Chicago and suburban Cook County, but lower rates in the rest of the state. In most regions, models showed that as the percent of minority residents in a ZIP code increased, injury rates among non-Hispanic Black and Hispanic-Latino residents decreased. As community economic disadvantage increased at the ZIP code level, civilian injury rates increased. Communities with the highest injury rates involving non-Hispanic white residents were significantly more economically unequal and disadvantaged. While the injury rates were consistently and substantially higher among non-Hispanic Black residents throughout the state, the findings illustrate that the association between overall civilian injuries caused during contact with law enforcement and community sociodemographic characteristics varied across regions. Data on local law enforcement agency policies and procedures are needed to better identify appropriate interventions.

Costs for Long-Term Health Care After a Police Shooting in Ontario, Canada

Importance

Police shootings can cause serious acute injury, and knowledge of subsequent health outcomes may inform interventions to improve care.

Objective

To analyze long-term health care costs among survivors of police shootings compared with those surviving nonfirearm police enforcement injuries using a retrospective design.

Design, Setting, and Participants

This population-based cohort analysis identified adults (age ≥16 years) who were injured by police and required emergency medical care between April 1, 2002, and March 31, 2022, in Ontario, Canada.

Exposure

Police shootings compared with other mechanisms of injury involving police.

Main Outcomes and Measures

Long-term health care costs determined using a validated costing algorithm. Secondary outcomes included short-term mortality, acute care treatments, and rates of subsequent disability.

Results

Over the study, 13 545 adults were injured from police enforcement (mean [SD] age, 35 [12] years; 11 637 males [86%]). A total of 13 520 individuals survived acute injury, and 8755 had long-term financial data available (88 surviving firearm injury, 8667 surviving nonfirearm injury). Patients surviving firearm injury had 3 times greater health care costs per year (CAD$16 223 vs CAD$5412; mean increase, CAD$9967; 95% CI, 6697-13 237; US $11 982 vs US $3997; mean increase, US $7361; 95% CI, 4946-9776; P < .001). Greater costs after a firearm injury were not explained by baseline costs and primarily reflected increased psychiatric care. Other characteristics associated with increased long-term health care costs included prior mental illness and a substance use diagnosis.

Conclusions and Relevance

In this longitudinal cohort study of long-term health care costs, patients surviving a police shooting had substantial health care costs compared with those injured from other forms of police enforcement. Costs primarily reflected psychiatric care and suggest the need to prioritize early recognition and prevention.

Immediate Medical Care Rendered by US Law Enforcement Officers after Officer-Involved Shootings - An Open-Access Public Domain Video Analysis

BACKGROUND

After officer-involved shootings (OIS), rapid delivery of emergency medical care is critical but may be delayed due to scene safety concerns. The purpose of this study was to describe medical care rendered by law enforcement officers (LEOs) after lethal force incidents.

METHODS

Retrospective analysis of open-source video footage of OIS occurring from February 15, 2013 through December 31, 2020. Frequency and nature of care provided, time until LEO and Emergency Medical Services (EMS) care, and mortality outcomes were evaluated. The study was deemed exempt by the Mayo Clinic Institutional Review Board.

RESULTS

Three hundred forty-two (342) videos were included in the final analysis; LEOs rendered care in 172 (50.3%) incidents. Average elapsed time from time-of-injury (TOI) to LEO-provided care was 155.8 (SD = 198.8) seconds. Hemorrhage control was the most common intervention performed. An average of 214.2 seconds elapsed between LEO care and EMS arrival. No mortality difference was identified between LEO versus EMS care (P = .1631). Subjects with truncal wounds were more likely to die than those with extremity wounds (P < .00001).

CONCLUSIONS

It was found that LEOs rendered medical care in one-half of all OIS incidents, initiating care on average 3.5 minutes prior to EMS arrival. Although no significant mortality difference was noted for LEO versus EMS care, this finding must be interpreted cautiously, as specific interventions, such as extremity hemorrhage control, may have impacted select patients. Future studies are needed to determine optimal LEO care for these patients.

Health Effects of Policing in Hospitals: a Narrative Review

IMPORTANCE

Law enforcement activity, in the form of outside agencies or hospital security forces, is increasingly common in American healthcare. Little is known about the potential effects of this prevalent, modifiable exposure on hospital staff and patient health. This narrative review characterizes existing evidence on the direct and indirect health effects of law enforcement activity in hospitals.

OBSERVATIONS

Law enforcement activity in hospitals can affect health outcomes through four mechanisms: (1) physical health effects related to workplace violence, restraint use, excessive force, and weapon use; (2) mental health effects involving perceptions of safety and psychological distress; (3) social effects related to the patient-provider relationship, mistrust, and bias and discrimination; and (4) legal and ethical considerations affecting overall well-being.

CONCLUSIONS AND RELEVANCE

Unchecked law enforcement activity in hospitals may risk patient physical and mental health, reduce patient trust, result in bias and discrimination, and contribute to legal and ethical rights violations. Importantly, law enforcement activity in hospitals may also contribute to staff perceptions of safety. To fill knowledge gaps on the measurable impact of law enforcement activity in the hospital on staff and patients, hospitals should collect and publicly share robust data on law enforcement activity in their facilities, create and adopt patient-centered policies to ensure safety and protect patient health and privacy, and implement evidence-based interventions that safely reduce law enforcement involvement with patients.

Manhandling injuries during legal interventions

INTRODUCTION

Data concerning injuries resulting from physical force during legal interventions are scarce. The purpose of this study was to examine manhandling injuries occurring in both civilian suspects and law enforcement officials (LEO).

METHODS

Retrospective cross-sectional study using data from the National Trauma Data Bank. All patients who sustained manhandling injuries during legal interventions were identified using ICD-10 e-codes. The study groups were injured civilian suspects and LEO. The primary outcomes were type and severity of injuries among the groups.

RESULTS

A total of 507 patients were included in the study, 426 (84.0%) civilians and 81 (16.0%) LEO. Overall, median age was 37 years (IQR: 28-48) and 90.3% were male. The median ISS was higher in civilians compared to LEO (5 [4-10] vs 4 [4-9], p = 0.023). Civilians were more likely to sustain injuries to the face (49.8% vs 35.9%, p = 0.024) and abdomen (8.3% vs 1.3%, p = 0.028). LEO were more likely to sustain tibia/fibula fractures (3.5% vs 9.9%, p = 0.019). The mortality was 1.2% (5/426) in civilians and there were no deaths in LEO. The overall complication rates and hospital length of stay were similar between the groups.

CONCLUSION

Injury patterns and severity of injuries sustained from the use of physical force during legal interventions are different in civilians and law enforcement officials. Further research and more comprehensive data are warranted to better understand and prevent these injuries.

Association of Residential Racial and Ethnic Segregation With Legal Intervention Injuries in California

IMPORTANCE

The continued harm of Black individuals in the US by law enforcement officers calls for reform of both law enforcement officers and structural racism embedded in communities.

OBJECTIVE

To examine the association between county characteristics and racial and ethnic disparities in legal intervention injuries.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, cross-sectional study was conducted among 27 671 patients presenting to California hospitals from January 1, 2016, to December 31, 2019, with legal intervention injuries (defined as any injury sustained as a result of an encounter with any law enforcement officer) as identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.

MAIN OUTCOMES AND MEASURES

Legal intervention injuries were classified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision external cause of injury code Y35. Expected injury counts were calculated for each county by multiplying statewide median rates of injury per capita for each age-racial and ethnic group, and then observed to expected injury ratios were measured. The association between county injury ratio, percentage of Black individuals, and residential segregation (measured using an index of dissimilarity) was modeled, stratifying by race and ethnicity.

RESULTS

A total of 27 671 patients (24 159 male patients [87.3%]; 1734 Asian and Pacific Islander [6.3%], 5049 Black [18.2%], 11 250 Hispanic [40.7%], and 9638 White [34.8%]; mean [SD] age, 34.2 [12.5] years) presented with legal intervention injuries in California from 2016 to 2019. Observed to expected injury ratios ranged from 0 to 7 for Black residents and from 0 to 5 for White residents. High observed to expected injury ratios for Black residents (408 observed vs 60 expected; ratio = 7) were clustered around San Francisco Bay Area counties and corresponded with a higher proportion of Black residents. High observed to expected injury ratios for White residents (57 observed vs 11 expected; ratio = 5) clustered around rural northern California counties and corresponded with higher mean percentage of residents with income below the federal poverty level and fewer urban areas.

CONCLUSIONS AND RELEVANCE

This study suggests that residential segregation may be associated with increased legal intervention injury rates for Black residents of California counties with a large percentage of Black residents. Reform efforts to address racial and ethnic disparities in these injuries should carefully consider and address the legacy of discriminatory policies that has led to segregated communities in California and the United States.

Compounding Trauma: the Intersections of Racism, Law Enforcement, and Injury

Purpose of Review

Traumatic injury sits at the nexus of law enforcement and structural racism. This narrative review aims to explore the major impacts of law enforcement on health, its intersections with US structural racism, and their joint impacts on traumatic injury and injury care.

Recent Findings

Many of the same forces of systemic disadvantage that put Black people, other people of color, and other marginalized groups at risk for violent injury also expose these same individuals and communities to intensive policing. Recent evidence speaks to the broad impact of police exposure and police violence on individual and community physical and mental health. Moreover, injured patients who are exposed to law enforcement during their care are at risk for erosion of trust in and relationships with their healthcare providers. To optimize the role of law enforcement agencies in injury prevention, collaboration across sectors and with communities is essential.

Summary

A broad approach to the prevention of injury and violence must incorporate an understanding of the intersecting impacts of law enforcement and structural racism on health and traumatic injury. Clinicians who seek to provide trauma-informed injury care should incorporate an understanding of the role of law enforcement in individual and community health.

Firearm injuries during legal interventions Nationwide analysis

INTRODUCTION

There is limited literature on firearm injuries during legal interventions. The purpose of this study was to examine the epidemiology, injury characteristics, and outcomes of both civilians and law enforcement officials (LEOs) who sustained firearm injuries over the course of legal action.

METHODS

Retrospective observational study using data from the National Trauma Data Bank (2015-2017) was performed. All patients who were injured by firearms during legal interventions were identified using the International Classification of Disease, Tenth Revision, external cause of injury codes. The study groups were injured civilian suspects and police officers. Demographics, injury characteristics, and outcomes were analyzed and compared between the groups. Primary outcomes were the clinical and injury characteristics among the victims.

RESULTS

A total of 1,411 patients were included in the study, of which 1,091 (77.3%) were civilians, 289 officers (20.5%), and 31 bystanders (2.2%). Overall, 95.2% of patients were male. Compared with LEOs, civilians were younger (31 vs. 34 years, p = 0.007) and more severely injured (median Injury Severity Score, 13 vs. 10 [p = 0.005]; Injury Severity Score >15, 44.4% vs. 37.1% [p = 0.025]). Civilians were more likely to sustain severe (Abbreviated Injury Scale, ≥3) intra-abdominal injuries (26.8% vs. 16.1%, p < 0.001) and spinal fractures (13.0% vs. 6.9%, p = 0.004). In-hospital mortality and overall complication rate were similar between the groups (mortality: civilians, 24.7% vs. LEOs, 27.3% [p = 0.360]; overall complications: civilians, 10.3% vs. LEOs, 8.4% [p = 0.338]).

CONCLUSION

Firearm injuries during legal interventions are associated with significant injury burden and a higher mortality than the reported mortality in gunshot wounds among civilians. The mortality and overall complication rate were similar between civilian suspects and law enforcement officials.

LEVEL OF EVIDENCE

Epidemiologic, level IV.

Injury patterns and demographics due to legal intervention seen in US emergency departments

BACKGROUND

Injury and deaths inflicted by law enforcement are a topic of significant discussion in the US. The purpose of this study was to analyze injuries due to law enforcement activity that presented to emergency departments (ED) across the entire US and correlate the injury patterns with patient demographics.

METHODS

The National Electronic Injury Surveillance System (NEISS) All Injury Program (AIP) data was used for the years 2005 through 2015. Injuries due to legal/law enforcement activity were identified. Statistical analyses were performed with SUDAAN 11.0.01™. A p < 0.05 was considered statistically significant.

RESULTS

There were 939,405 ED visits for non-fatal injuries due to law enforcement. The average age was 31.9 years; 84.6% were male. The mechanism of injury was being struck in 69.7%; firearm gunshot wounds accounted for only 1.2%. The most common location of injury was the head and neck (44.0%) followed by the upper extremity (20.2%). The vast majority of the patients (94.9%) were treated and released from the ED. The seven major diagnoses were contusion/abrasion (37.8%), strain/sprain (22.7%), laceration (12.9%), fracture (7.6%), puncture (8.2%), and foreign body (2.5%). The injuries with the highest percentage of hospital admissions were foreign bodies and fractures (11.4% and 11.3% respectively. Although the number of events occurring at schools or sporting venues was 2.0%, those seen at children's hospitals demonstrated a higher percentage at 15.6%.

CONCLUSIONS

This data set provides another viewpoint of injuries inflicted by police. It can be used as baseline data for further studies, especially in the US recent sociopolitical environment calling for police reform and improvements in the education and training of police officers.

Epidemiologic Trends in Fatal and Nonfatal Firearm Injuries in the US, 2009-2017

IMPORTANCE

Firearm injury research in the US has focused on fatal injuries. The incidence and epidemiologic factors associated with nonfatal firearm injuries are less understood.

OBJECTIVE

To evaluate estimates of incidence and trends over time of fatal and nonfatal firearm injuries.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, ecologic study was conducted using data throughout the US from 2009 to 2017. Data on fatal injuries from the Centers for Disease Control and Prevention were combined with national data on emergency department visits for nonfatal firearm injury from the Nationwide Emergency Department (ED) sample. Data analysis was conducted from August 2019 to September 2020.

EXPOSURES

Firearm injuries identified with International Classification of Diseases external cause of injury codes and categorized by intent of injury, age group, and urban-rural location.

MAIN OUTCOMES AND MEASURES

Incidence, case fatality rate, and trends over time of firearm injury according to intent, age group, and urban-rural location.

RESULTS

From 2009 to 2017, there was a mean of 85 694 ED visits for nonfatal firearm injury and 34 538 deaths each year. An annual mean of 26 445 deaths (76.6%) occurred outside of the hospital. Assault was the most common overall mechanism (38.9%), followed by unintentional injuries (36.9%) and intentional self-harm (19.6%). Self-harm, which accounted for 21 128 deaths (61.2%), had the highest case fatality rate (89.4%; 95% CI, 88.5%-90.4%), followed by assault (25.9%; 95% CI, 23.7%-28.6%) and legal intervention (23.4%; 95% CI, 21.6%-25.5%). Unintentional injuries were the most common nonfatal injuries (43 729 [51.0%]) and had the lowest case fatality rate (1.2%; 95% CI, 1.1%-1.3%). Self-harm deaths, 87.8% of which occurred outside the hospital, increased in all age groups in both rural and urban areas during the study period and were most common among people aged 55 years and older. The rate of fatal assault injuries was higher in urban than in rural areas (16.6 vs 9.0 per 100 000 per year) and highest among people aged 15 to 34 years (38.6 per 100 000 per year). Rates of unintentional injury were higher in rural than in urban areas (18.5 per 100 000 vs 12.4 per 100 000).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, suicide appears to be the most common cause of firearm injury death in the US, and most people who die from suicide never reach the hospital. These findings suggest that assaults and unintentional injuries account for most nonfatal and overall firearm injuries and for most of the injuries that are treated in hospitals.

Association of Legal Intervention Injuries With Race and Ethnicity Among Patients Treated in Emergency Departments in California

IMPORTANCE

Increased public concern regarding police use of force has coincided with a dearth of available data to uncover the magnitude and trends in injuries, particularly across race or ethnicity.

OBJECTIVE

To examine trends in injury rates, severity, and disparities across black individuals, white individuals, Hispanic individuals, and Asian/Pacific Islander individuals.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective, cross-sectional study, data collected on every hospital visit in California from January 1, 2005, to September 30, 2015, were used to model trends in rates of legal intervention injuries (n = 92 386) per capita and per arrest for men aged 14 to 64 years, by race or ethnicity. The study also examined descriptive statistics on injury dispositions to assess changes in severity. Analyses were conducted between December 2017 and June 2018.

MAIN OUTCOMES AND MEASURES

All visits with an external cause of injury code of E970 to E977 were classified as legal intervention injuries. This range of codes includes injuries inflicted by the police or other law-enforcing agents in the course of arresting or attempting to arrest lawbreakers, suppressing disturbances, maintaining order, and other legal action.

RESULTS

The study identified a total of 92 386 hospital visits that were the result of legal intervention among males aged 14 to 64 years. Black individuals were at the highest risk of legal intervention injury per capita in 2005 (for black vs white individuals, rate ratio, 2.90; 95% CI, 2.74-3.06), and remained so across the study period. Although rates among Asian/Pacific Islander individuals remained stable, rates in all other groups increased from 2005 to 2009 and then declined from 2009 to 2015, nearly returning to 2005 levels. During the period of increasing rates, the black to white disparity widened by 3% annually (rate ratio, 1.03; 95% CI, 1.01-1.05), then narrowed as rates declined. In contrast, rates of injury per arrest have increased over the past decade, although rates were broadly similar across race or ethnicity. The proportion of injuries involving firearms (ie, shootings by police) declined from 7.0% in 2005 and 2006 to 3.7% in 2014 and 2015.

CONCLUSIONS AND RELEVANCE

States with central repositories for hospital visits offer data sources to illuminate the public health problem of legal intervention injuries, and warrant greater attention to ensure consistent coding for complete capture.

Risk of Police-Involved Death by Race/Ethnicity and Place, United States, 2012-2018

OBJECTIVES

To estimate the risk of mortality from police homicide by race/ethnicity and place in the United States.

METHODS

We used novel data on police-involved fatalities and Bayesian models to estimate mortality risk for Black, Latino, and White men for all US counties by Census division and metropolitan area type.

RESULTS

Police kill, on average, 2.8 men per day. Police were responsible for about 8% of all homicides with adult male victims between 2012 and 2018. Black men's mortality risk is between 1.9 and 2.4 deaths per 100 000 per year, Latino risk is between 0.8 and 1.2, and White risk is between 0.6 and 0.7.

CONCLUSIONS

Police homicide risk is higher than suggested by official data. Black and Latino men are at higher risk for death than are White men, and these disparities vary markedly across place. Public Health Implications. Homicide reduction efforts should consider interventions to reduce the use of lethal force by police. Efforts to address unequal police violence should target places with high mortality risk.

Injuries sustained during contact with law enforcement: An analysis from US trauma centers

BACKGROUND

Injuries sustained by civilians from interaction with police are a polarizing contemporary sociopolitical issue. Few comprehensive studies have been published using national hospital-based data. The aim of this study was to examine the epidemiology of these injuries to better understand this mechanism of injury.

METHODS

Patients entered into the National Trauma Data Bank (NTDB) (January 2007 to December 2012) with E-codes E970.0 to E976.0 (International Classification of Diseases, Ninth Revision, Clinical Modification), identifying injuries associated with law enforcement in the course of legal action, were enrolled. Patients' demographics, injury characteristics, procedures, and outcomes were collected and analyzed. Patients injured by other civilians (E960.0-E968.0) were used for comparison.

RESULTS

Of 4,146,428 patients in the NTDB, 7,203 (0.17%) were injured during interaction with police. The numbers of patients in consecutive study years were 858, 1,103, 1,148, 1,274, 1,316, and 1,504. The incidence of these injuries was stable over time (0.17-0.18%) (p = 0.129). Patients had a median age of 31 years (range, 0-108), and 94.3% were male. Median injury severity score was 9 (interquartile range [IQR], 4-17). The most common mechanism of injury was gunshot wound (44%).Patients were white, 43%; black, 30%; Hispanic, 17%; Asian, 1%; and Other, 9%. As a proportion of the total race-specific NTDB trauma population, there was an average of 1.13 white patients, 2.71 Hispanic patients, and 3.83 black patients per 1,000. Mechanism, injury severity score, and outcomes did not vary by race. Compared to patients injured by civilians, patients injured by police are more likely to be white (43% vs 25%, p < 0.001) and injured by gunshot wounds (44% vs 32%, p < 0.001).

CONCLUSIONS

Based on data from trauma centers across the United States, the rate of injuries sustained during interactions with police has been stable over time. Gunshot wounds are the most common mechanism of injury. Proportionally, black patients are the most frequently injured race. When compared to patients injured by civilians, however, patients injured by police are more likely to be white. This study provides a step toward a better understanding of police-associated injuries.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.