A safe haven for the injured? Urban trauma care at the intersection of healthcare, law enforcement, and race

"You Have to Be a Doctor First": Trauma Surgeons' Perspectives on Police Interactions in the Hospital

BACKGROUND

Police activity in emergency medical settings has been shown to complicate the care of patients and impact patient-provider relationships. Recent scholarship has called for clear hospital policy outlining the terms of police access to patients and the role of clinicians. Despite regular contact between trauma surgeons and police, research on the impact of police activity on trauma care has been limited.

METHODS

Semi-structured interviews were conducted with attending trauma surgeons and general surgery residents (N = 13) at 3 urban hospitals about their interactions with police in clinical settings. Participants were recruited using snowball sampling. Interviews were audio-recorded, transcribed, and analyzed for recurrent themes using an iterative grounded theory process.

RESULTS

Participants reported routine contact with police that required active negotiation of the scope of clinical and police authority in the hospital. These negotiations were shaped by prior experiences, perceptions of police, officer behavior, and institutional culture. Surgeons felt compelled to advocate for patients, but reported intimidation in moments of conflict. Participants noted uncertainty around the legal dimensions of their relationship to police and a lack of universal guidance on appropriate responses.

DISCUSSION

This data points to the need for improvements in both policy and workflow to regulate and reduce the burden of these interactions and protect clinicians' priorities from being subordinated to those of police. Further research is needed to understand how police presence impacts patient outcomes, and to guide best practices for regulating and mitigating potential negative impact.

History of Racial Discrimination by Police Contributes to Worse Physical and Emotional Quality of Life in Black Americans After Traumatic Injury

BACKGROUND

Black Americans are more likely than their White counterparts to experience traumatic injury and worse functional outcomes. Unfair police treatment has been identified as one specific form of racial discrimination potentially driving these deleterious outcomes. The aim of the investigation was to better understand the relationship between experiences of discrimination by police and trauma-specific quality of life outcomes, including PTSD symptom severity, in Black Americans following traumatic injury.

METHOD

Traumatically injured Black American adults (N = 53) presenting to a level 1 trauma center completed a measure of police and law enforcement discrimination at baseline, and quality of life and PTSD were assessed 6 months later.

RESULTS

Stepwise regressions results showed more frequent discrimination by police and law enforcement significantly predicted lower emotional and physical well-being 6 months after injury. Further, more frequent police discrimination resulted in more severe PTSD symptoms by 6 months after injury.

CONCLUSIONS

Findings underscore that following an injury not specifically related to discrimination by police, patients' historical, negative police experiences contributed to worse physical and emotional recovery in the present. These findings, in unison with prior investigations, reveal the need to consider patients' history of negative police experiences as a social determinant of health in their recovery.

"We Come From Different Worlds": The Collision of Caring and Carceral Institutions

The purpose of this study was to give voice to the lived experiences of nurses and law enforcement officers whose professional responsibilities converge in the acute care setting, while gaining insight into the perspectives and interpretations of their experiences. Using interpretative phenomenological analysis, this quality study contributes to a growing body of literature exploring the influence of law enforcement in the hospital. Overwhelmingly, participants in this study expressed a contentious dynamic, fueled by arguments, struggles for power, and a feeling of coming from "different worlds." The influence of socially and spatially constructed territories was critical points of contention.

Training Among Noncustodial Health Care Workers Caring for Patients Experiencing Incarceration: A Preliminary Investigation

People experiencing incarceration in the United States receive much of their health care outside of custodial settings. Optimizing care in this setting requires further understanding of the training and experiences of noncustodial health care workers. We conducted a cross-sectional, exploratory survey of health care workers at a single academic institution to assess their training and experiences related to caring for this patient population. Of 333 respondents, 94.1% had cared for patients experiencing incarceration but only 22.5% had received any formal training, with 94.6% somewhat or very interested in further training. Common challenges included lack of privacy, difficulty obtaining patient history or completing an examination, and patient distress. Health care workers frequently experience challenges and report strong interest in further training to address knowledge gaps, and further detailed investigation is needed.

Assault Injury and Community Violence

Community violence happens between unrelated individuals, who may or may not know each other, generally outside the home, and often results in assaultive injuries. Community violence interventions can prevent assaultive injuries and assist victims of community violence. Trauma-informed care is foundational to the success of community violence intervention. Place-based environmental interventions can decrease community violence on the population level, and further research and developments are needed in this area. Substance use is a significant barrier to intervention program involvement and greater research and program development is needed to support substance use treatment of those impacted by community violence.

Police Violence in Health Care Settings in US Media Coverage

Importance

Hospitals do not collect or share data tracking their policing and security activities despite their reliance on police and security personnel, including armed officers. Thus, little is known about how hospital security is associated with patient and staff safety.

Objective

To examine the harms exerted by health care-affiliated police and security personnel.

Design, Setting, and Participants

For this qualitative study, data were collected using a systematic Media Cloud search for US news media coverage from January 2011 to May 2022. A total of 18 987 articles on policing and hospitals were screened and a content and thematic analysis of articles that met the search criteria was conducted, which involved incidents that revealed harm to patients, patients' families, and staff. Data were analyzed from October 2022 to April 2023.

Main Outcomes and Measures

Incident year, incident location (hospital name, city, state), survivor and victim characteristics (race and ethnicity, presence of mental illness), and a narrative description of the incident focusing on outcomes of harm exerted by police and security personnel in the health care setting.

Results

A total of 48 unique stories across 25 US states were included. The median (range) year published was 2017 (2009-2022). Harms reported to have been perpetuated by health care-affiliated police and security personnel were identified within 5 domains from 48 unique incidents: (1) patients shot by police or security personnel (17 patients); (2) patients subject to excessive use of force (17 patients); (3) patients arrested (7 patients); (4) patients subject to sexual assault (2 patients); and (5) hospital personnel or those considered collateral damage shot, injured, or arrested (5 individuals). Most survivors and victims were Black, although the race and/or ethnicity of involved individuals was not routinely reported across the news stories. Mental illness was the most documented medical condition among patients injured or killed by health care-affiliated police and security personnel.

Conclusions and Relevance

This qualitative study of US news media found that police and security personnel in hospitals were reported to have perpetuated harm via excessive force, sexual assaults, injuring patients and health care workers, and fatal shootings. Compounded by a lack of transparency and accountability mechanisms, this may represent an underrecognized manifestation of structural racism at the organizational level. Policy suggestions include introducing accountability measures, deescalation techniques, and removing arms from hospital security personnel to reduce harm and fulfill health care's healing mission.

Patient Experiences of Acute and Postacute Care After Trauma

INTRODUCTION

Traumatic injury can transform a healthy, independent individual into a patient with complex health needs. Little is known about how injured patients understand their health and healthcare needs during postacute recovery, limiting our ability to optimize care. This multiple-methods study explored injured patients' experiences of care up to 30 days after discharge.

METHODS

Injured adults admitted to an urban, Level I trauma center August 1, 2019-November 30, 2020 were sampled purposively to balance blunt and penetrating injuries. Patient experience and health status were assessed at baseline and 30 days postdischarge using the Quality of Trauma Care Patient-Reported Experience Measure. Fifteen qualitative interviews were conducted with a purposive subset and analyzed using qualitative content analysis.

RESULTS

Of 67 participants (76% male, 73% Black, 51% penetrating, median age 34 years), 37 completed follow-up surveys. Quality of acute care was rated 9-10/10 by 81% of the sample for acute and 65% for postacute care (P = 0.09). Thirty percent described fair or poor mental health, but only mental health concerns were addressed for only 2/3. Pain control was inadequate in 31% at baseline and for 46% at follow-up (P = 0.09). Qualitative analysis revealed general satisfaction with acute care but challenges in recovery with unmet needs for communication and care coordination.

CONCLUSIONS

Trauma patients appreciated the quality of their acute care experiences but identified opportunities for improvement in prognostic communication, pain management, and mental health support. Unmet mental and physical care needs persist at least 1 month after hospital discharge and reinforce the need for interventions that optimize postacute trauma care.

Engagement With Mental Health Services Among Survivors of Firearm Injury

Importance

Despite the prevalence of posttraumatic stress symptoms after firearm injury, little is known about how firearm injury survivors connect with mental health services.

Objective

To determine facilitators and barriers to mental health care engagement among firearm injury survivors.

Design, Setting, and Participants

A qualitative study of 1-on-1, semistructured interviews conducted within a community setting in Indianapolis, Indiana, between June 2021 and January 2022. Participants were recruited via community partners and snowball sampling. Participants who survived an intentional firearm injury, were shot within Indianapolis, were aged 13 years or older, and were English speaking were eligible. Participants were asked to discuss their lives after firearm injury, the emotional consequences of their injury, and their utilization patterns of mental health services. Data were analyzed from August 2022 to June 2023.

Main Outcomes and Measures

Survivors' lived experience after firearm injury, sources of emotional support, mental health utilization, and their desired engagement with mental health care after firearm injury.

Results

A total of 18 participants (17 were Black [94%], 16 were male [89%], and 14 were aged between 13 and 24 years [77%]) who survived a firearm injury were interviewed. Survivors described family members, friends, and informal networks as their main source of emotional support. Barriers to mental health care utilization were perceived as a lack of benefit to services, distrust in practitioners, and fear of stigma. Credible messengers served as facilitators to mental health care. Survivors also described the emotional impact their shooting had on their families, particularly mothers, partners, and children.

Conclusions and Relevance

In this study of survivors of firearm injury, findings illustrated the consequences of stigma and fear when seeking mental health care, inadequate trusted resources, and the need for awareness of and access to mental health resources for family members and communities most impacted by firearm injury. Future studies should evaluate whether community capacity building, digital health delivery, and trauma-informed public health campaigns could overcome these barriers to mitigate the emotional trauma of firearm injuries to reduce health disparities and prevent future firearm violence.

"So There. I Won.": The Struggle for Power Between Caring and Carceral Institutions

OBJECTIVE

The objectives of this study were to give voice to the lived experiences of nurses and law enforcement officers (LEOs) who interact with one another in acute hospital settings and to interpret and understand their unique perspectives and experiences.

METHODS

This qualitative study employed interpretative phenomenological analysis in the interviews of registered nurses and LEOs. The analysis and discussion was underpinned by biopolitical theories of power and control, including Georgio Agamben, Michel Foucault, and Erving Goffman.

RESULTS

There is a paucity of literature on nurse and law enforcement interactions in the hospital setting. Nurses and law enforcement exerted power and authority through several means. Overwhelmingly, participants described a contentious dynamic between nurses and LEOs in the hospital, wrought with argument, stress, and a feeling of coming from "different worlds."

CONCLUSION

The results provide alarming examples of deformed caring practices and assert the necessity for continued unearthing and discussion of how nurses can, and should, navigate law enforcement interaction. The tangible interference of care is of particular importance and consideration for nurses. Inequity in care and unfavorable outcomes for already marginalized and vulnerable populations are of grave concern. Additional research is needed on the specific ways this struggle for power between institutions and their political actors impairs caring practices and the emotional and psychological sequelae of these interactions.

How do current police practices impact trauma care in the prehospital setting? A scoping review

Objective

In the United States, police are often important co-responders to 911 calls with emergency medical services for medical emergencies. To date, there remains a lack of a comprehensive understanding of the mechanisms by which police response modifies time to in-hospital medical care for traumatically injured patients. Further, it remains unclear if differentials exist within or between communities. A scoping review was performed to identify studies evaluating prehospital transport of traumatically injured patients and the role or impact of police involvement.

Methods

PubMed, SCOPUS, and Criminal Justice Abstracts databases were utilized to identify articles. English-language, US-based, peer-reviewed articles published on or prior to March 30, 2022 were eligible for inclusion.

Results

Of 19,437 articles initially identified, 70 articles were selected for full review and 17 for final inclusion. Key findings included (1) current law enforcement practices involving scene clearance introduce the potential for delayed patient transport but to date there is little research quantifying delays; (2) police transport protocols may decrease transport times; and (3) there are no studies examining the potential impact of scene clearance practices at the patient or community level.

Conclusions

Our results highlight that police are often the first on scene when responding to traumatic injuries and have an active role via scene clearance or, in some systems, patient transport. Despite the significant potential for impact on patient well-being, there remains a paucity of data examining and driving current practices.

Interactions With Police in the Emergency Care of Children: Ethical and Legal Considerations

OBJECTIVES

Emergency medicine providers may interface with law enforcement personnel (LEP) on behalf of their pediatric patients for a variety of reasons, from reporting child abuse to caring for children who are in police custody. Given the unique nature of caring for minors who may not have legal or medical autonomy, interactions with LEP can raise ethical concerns for emergency providers, specifically with regard to legal representation, developmental immaturity, and the civil rights of children and their parents/guardians.

METHODS

We review 4 patient scenarios, based on real cases experienced by the authors, to demonstrate the legal and ethical issues that may arise when LEP are involved in the emergency care of a child. These scenarios discuss parental/guardian visitation for children in police custody in the emergency department (ED), the practice of making arrests on hospital grounds, and police interviews of children in the ED.

RESULTS

Using the ethical principles of autonomy, beneficence, and justice, we offer recommendations for emergency providers on how to advocate for their pediatric patients in LEP custody within the constraints and protections of the law. We also suggest best practices for hospital systems to develop policies surrounding LEP activity in the ED.

CONCLUSIONS

These nuanced situations require careful advocacy for the child and a collaborative approach between medical providers and LEP to balance the child's well-being with public safety. We offer recommendations here, and we maintain that clear, widely adopted best practices for the care of minors in LEP custody are long overdue.

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.

Law enforcement in the trauma bay: a survey of members of the American Academy for the Surgery of Trauma

Background

Trauma patients frequently come into contact with law enforcement officers (LEOs) during the course of their medical care, but little is known about how LEO presence affects processes of care. We surveyed members of the American Association for the Surgery of Trauma (AAST) to assess their perspectives on frequency, circumstances, and implications of LEO presence in trauma bays nationwide.

Methods

Survey items addressed respondents' experience with the frequency and context of LEO presence and their perspectives on the impact of LEO presence for patients, clinical care, and public safety. Respondent demographics, professional characteristics, and practice setting were collected. The survey was distributed electronically to AAST members in September and October of 2020. Responses were compared by participant age, gender, race, ethnicity, urban versus rural location using χ2 tests.

Results

Of 234 respondents, 189 (80.7%) were attending surgeons, 169 (72.2%) identified as white, and 144 (61.5%) as male. 187 respondents (79.9%) observed LEO presence at least weekly. Respondents found LEO presence was most helpful for public safety, followed by clinical care, and then for patients. Older respondents rated LEO presence as helpful more often than younger respondents regarding the impact on patients, clinical care, and public safety (p<0.001 across all domains). When determining LEO access, respondents assessed severity of the patient's condition, the safety of emergency department staff, the safety of LEOs, and a patient's potential role as a threat to public safety.

Conclusions

Respondents described a wide range of perspectives on the impact and consequence of LEO in the trauma bay, with little policy to guide interactions. The overlap of law enforcement and healthcare in the trauma bay deserves attention from institutional and professional policymakers to preserve patient safety and autonomy and patient-centered care.

Level of evidence

IV, survey study.

Addressing the educational gap in the role of law enforcement personnel in the resuscitation bay

BACKGROUND

Health care workers are often uncertain of the role of law enforcement personnel in the resuscitation bay. A cross-sectional, quality improvement project was designed with an educational intervention to address the knowledge gaps.

METHODS

There were 2 sessions for trauma surgery and emergency medicine faculty, residents, and staff. The first was a formal presentation by hospital risk management and security focused on answering questions generated by real-life scenarios. After reviewing feedback from the first session, the second session was designed as a panel discussion led by attending physicians who reviewed various clinical scenarios. A pre/postsurvey was administered, including potential clinical scenarios with multiple-choice answers and open feedback.

RESULTS

There were 64 presurvey and 31 postsurvey respondents from the first session (48.4%). Significantly more questions were answered correctly from pre to postsurvey (5.5 vs 6.7/16 questions; U = 798.0, P = .048). Of the 14 (45.2%) respondents who provided open-ended feedback, 50% indicated confusion, and 21.4% expressed strong, negative emotions. In the second session, there were 39 presurvey and 18 postsurvey respondents (46.2%). Again, significantly more questions were answered correctly after the second session (2.2 vs 4.5/7 questions; U = 115.0, P ≤ .001). Feedback highlighted that the panel format was considered more helpful than the formal didactic of the first session.

CONCLUSION

Confusion about the role of law enforcement personnel in the clinical environment can be partially addressed using multidisciplinary joint conferences that should be led by clinicians to ensure real-life clinical applicability. Further education and law enforcement personnel role clarification for health care workers are critical to protect patient rights.

Law Enforcement and Patient Privacy Among Survivors of Violence: A Nationwide Mixed-Methods Study

INTRODUCTION

During the emergent treatment of violently injured patients, law enforcement (LE) officers and health care providers frequently interact. Both have duties to protect patient health, rights, and public health, however, the balance of these duties may feel at odds. The purpose of this study is to assess hospital-based violence intervention program (HVIP) representatives' experiences with LE officers among survivors of violence and the impact of hospital policies on interactions with LE officers.

MATERIALS AND METHODS

A nationwide survey was distributed to the 35 HVIPs that form the Health Alliance for Violence Intervention. Data regarding respondent affiliation, programs, and perceptions of hospital policies outlining LE activity were collected. Follow-up video interviews were open coded and qualitatively analyzed using grounded theory.

RESULTS

Respondents from 32 HVIPs completed the survey (91%), and 22 interviews (63%) were conducted. Common themes from interviews were: police-patient interactions; racism, bias, and victims' treatment as suspects; and training and education. Only 39% of respondents knew that policies existed and were familiar with them. Most representatives believed their hospitals' existing policies were inadequate, ineffective, or biased. Programs that reported good working relationships with LE officers offered insight on how their programs maintain these partnerships and work with LE officers towards a common goal.

CONCLUSIONS

Unclear or inadequate policies relating to LE activity may jeopardize the health and privacy of violently injured patients. Primary areas identified for improvement include clarifying and revising hospital policies, education of staff and LE officers, and improved communication between health care providers and LE officers to better protect patient rights.

Beyond Recidivism: Hospital-Based Violence Intervention and Early Health and Social Outcomes

BACKGROUND

Hospital-based violence intervention programs (HVIPs) are aimed at decreasing recurrent injury and improving the social determinants of health. We hypothesized that the HVIP intervention should be evaluated by how well it can address the immediate health and social needs of patients after injury. Our study sought to describe the experience of our nascent HVIP.

STUDY DESIGN

Case management records of patients treated by the HVIP of a level 1 trauma center from July 1, 2017 to October 1, 2020 were reviewed. Inclusion criteria were as follows: age between 18 and 60 with injury mechanisms that resulted from intentional violence. Patient-stated goals and social worker designation of patient services provided were analyzed. A subset of HVIP patients who completed the three planned study visit surveys at discharge and 1 and 3 months were compared with a cohort of violently injured patients to whom HVIP services were not available. Participants in both groups were asked to complete a battery of validated surveys to assess social outcomes and post-traumatic stress disorder (PTSD). Repeated-measures ANOVA was used to compare the two groups.

RESULTS

Two hundred and ninety-five patients met the inclusion criteria. One hundred and forty-six patients (49%) achieved their stated goals within 6 months of hospital discharge. Sixteen patients who achieved their stated goals disengaged from the program. Engagement in the HVIP resulted in significantly less PTSD at the time of hospital discharge. HVIP patients also experienced higher positive affect at hospital discharge, as described in the Positive and Negative Affect Schedule. HVIP participants were significantly more likely to achieve early positive health outcomes, such as completion of victim of crime compensation and return to school.

CONCLUSIONS

Our HVIP successfully achieved patient-stated short-term health and social goals in nearly half of all enrollees, indicating that HVIP patients are more likely to improve their social determinants of health than non-HVIP patients. Short-term health and social outcomes were improved in HVIP patients compared with non-HVIP patients, indicating increased engagement with the healthcare system. We suggest that these outcomes should replace recidivism as a metric for the efficacy of HVIP programs.

Health Care Providers' Lived Experience Caring for Victims of Youth Violence Separated From Family During Trauma Resuscitation

BACKGROUND

Family presence during trauma resuscitation is increasingly emphasized; yet it is inconsistently applied and has not been studied in victims of youth violence from the perspective of the health care provider.

OBJECTIVE

The purpose of this study is to explore the lived experience of health care providers involved in the care of children who are separated from their family during trauma resuscitation for injuries sustained from youth violence.

METHODS

A qualitative, transcendental phenomenological study was conducted to examine health care providers' experiences. Data were collected from March 2021 to April 2021 using open-ended, semistructured interviews conducted via Zoom or telephone. Data were transcribed and analyzed following the transcendental phenomenological reduction approach.

RESULTS

Seven health care providers were interviewed. Ages of the participants ranged from 31 to 60 years (mean: 52.1 years). Years of practice ranged from 9.5 to 36 years (mean: 26 years). The participants' professions included surgeon, registered nurse, violence interventionalist, and social worker. From the data collected, 6 major themes emerged: current landscape, decision making, safety and security, law enforcement presence, characteristics of families of victims of youth violence, and staff reflections.

CONCLUSIONS

This study demonstrates the value of incorporating health care providers' experiences to inform the barriers, facilitators, and nuances of implementing family presence during trauma resuscitation for pediatric victims of violence.

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.

Trends in Hospital Care for Intentional Assault Gunshot Wounds Among Residents of Cook County, Illinois, 2018-2020

Objectives. To examine gun violence with respect to hospital visits for treatment of intentional assault gunshot wounds (IGWs). Methods. IGW-coded visits among residents of Cook County, Illinois, were matched to census zip code tabulation areas (ZCTAs) to map changes in IGW visit frequencies between 2018 and 2020. Patient characteristics were compared across years, and Poisson regression models for the likelihood of an inpatient admission or in-hospital death were estimated. Results. Over the study period, Cook County residents made 7122 IGW-coded hospital visits to 89 Illinois hospitals, resulting in $342 million in charges and 24 894 hospital days. The number of visits almost doubled between 2018 and 2020, from 1553 to 3031; 6 ZCTAs had increases of more than 60 visits. Approximately one third of patients with a visit were admitted, and 6.5% died. Conclusions. Hospital statistics do not include the full toll of nonfatal gun injuries or the costs of related community-level trauma. The health care system remains crucial in implementing epidemiological approaches to violence prevention. Addressing the national spike in shootings will require large investments in community economic development and a professional public safety workforce. (Am J Public Health. 2022;112(5):795-802. https://doi.org/10.2105/AJPH.2022.306747).

The Impact of Intentionality of Injury and Substance Use History on Receipt of Discharge Opioid Medication in a Cohort of Seriously Injured Black Men

Black patients are less likely than white patients to receive pain treatment, especially opioids, for both acute and chronic pain. Black men are at higher risk than other populations of being "assumed criminal" regardless of any involvement in criminal activity. Additionally, certain injury and patient characteristics such as intentionality of injury and substance use history may lead providers to suspect criminal involvement and impact pain treatment decisions. The purpose of this study was to describe factors that predict receipt of opioid prescription at hospital discharge. We conducted a secondary analysis of data from a cohort of 623 seriously injured Black men treated at trauma centers in Philadelphia between 2013 and 2017. Regression models were used to examine relationships between discharge opioid prescriptions, injury intent, and substance use history. Controlling for age, injury severity, pain score, length of hospital stay (LOS), insurance type, and year of study, receipt of opioids was not impacted by injury intent. However, patients who self-reported substance overuse were less likely to receive opioids than those who did not. Patients with higher injury severity, pain scores, and longer LOS were more likely to receive opioids. Of patients who received opioids, patients with higher pain scores and longer LOS received higher dosages than those with lower scores and shorter LOS. While previous research highlights stigmatization experienced by intentionally injured patients, injury intent did not impact receipt of discharge opioid prescriptions in this study. Future research should continue to explore the effect of injury intent on patients' experiences in the healthcare system.

Addressing the inappropriate use of force by police in the United States and beyond: A behavioral and social science perspective

Recent high-profile incidents involving the deadly application of force in the United States sparked worldwide protests and renewed scrutiny of police practices as well as scrutiny of relations between police officers and minoritized communities. In this report, we consider the inappropriate use of force by police from the perspective of behavioral and social science inquiry related to aggression, violence, and intergroup relations. We examine the inappropriate use of force by police in the context of research on modern policing as well as critical race theory and offer five recommendations suggested by contemporary theory and research. Our recommendations are aimed at policymakers, law enforcement administrators, and scholars and are as follows: (1) Implement public policies that can reduce inappropriate use of force directly and through the reduction of broader burdens on the routine activities of police officers. (2) For officers frequently engaged in use-of-force incidents, ensure that best practice, evidence-based treatments are available and required. (3) Improve and increase the quality and delivery of noncoercive conflict resolution training for all officers, along with police administrative policies and supervision that support alternatives to the use of force, both while scaling back the militarization of police departments. (4) Continue the development and evaluation of multicomponent interventions for police departments, but ensure they incorporate evidence-based, field-tested components. (5) Expand research in the behavioral and social sciences aimed at understanding and managing use-of-force by police and reducing its disproportionate impact on minoritized communities, and expand funding for these lines of inquiry.

Identifying nonfatal firearm assault incidents through linking police data and clinical records: Cohort study in Indianapolis, Indiana, 2007-2016

Nonfatal firearm assault incidents are more prevalent than gun homicides, however, little is understood about nonfatal firearm assault incidents due to a lack of accurate data in the United States. This is a descriptive study of all nonfatal firearm assault incidents identified through police and clinical records from 2007 to 2016 in Indianapolis, Indiana. Records were linked at the incident level to demonstrate the overlap and non-overlap of nonfatal firearm assault incidents in police and clinical records and describe differences in demographic characteristics of the victims. Incidents were matched within a 24-h time window of the recorded date of the police incident. Data were analyzed in fall 2020. There were 3797 nonfatal firearm assault incidents identified in police reports and 3131 clinical encounters with an ICD 9/10 diagnosis-based nonfatal firearm-related injury. 62% (n = 2366) of nonfatal firearm assault incidents matched within 24 h to a clinical encounter, 81% (n = 1905) had a firearm related ICD code: 40% (n = 947) were coded as a firearm-related assault, 32% (n = 754) were coded as a firearm-related accident; and 8.6% (n = 198) were coded as undetermined, self-inflicted or law enforcement firearm-related. The other 20% (n = 461) did not have an ICD firearm related diagnosis code. Results indicate most nonfatal firearm assault incidents overlap between police and clinical records systems, however, discrepancies between the systems exist. These findings also demonstrate an undercounting of nonfatal firearm assault incidents when relying on clinical data systems alone and more efforts are needed to link administrative police and clinical data in the study of nonfatal firearm assaults.

Policed Patients: How the Presence of Law Enforcement in the Emergency Department Impacts Medical Care

STUDY OBJECTIVE

We sought to examine how physicians understand the role of law enforcement in the emergency department (ED) and to identify how the presence of law enforcement officers may impact the delivery of emergency medical care.

METHODS

In this qualitative study, we conducted semistructured interviews with 20 emergency physicians practicing in county EDs across 3 health care systems in Northern California between November 2017 and September 2018. Participants were recruited using snowball sampling and included 10 board-certified physicians and 10 resident physicians. We analyzed the interview content using grounded theory, where concepts from interview data were coded, grouped by theme, and compared over consecutive interviews to identify recurrent themes.

RESULTS

Participants reported interacting frequently with law enforcement officers while treating patients. Most participants characterized their experiences with law enforcement as "mixed" or "variable." Positive interactions with officers, who were described as helpful and collegial, contrasted with instances in which respondents felt police presence led to interruptions in treatment, breaches in health privacy, and potentially diminished patient trust. Participants reported that, at times, the authority of officers in the ED felt unclear and ill-defined, leading to contentious interactions between officers and health care personnel.

CONCLUSION

Lack of clear definition of the role of law enforcement officers in the ED may lead to contentious interactions with emergency physicians. Further research on the medical impacts of police presence in health care settings and on best practices for mitigating negative impacts is needed.

Barriers to recruitment, retention and intervention delivery in a randomized trial among patients with firearm injuries

BACKGROUND

We discuss barriers to recruitment, retention, and intervention delivery in a randomized controlled trial (RCT) of patients presenting with firearm injuries to a Level 1 trauma center. The intervention was adapted from the Critical Time Intervention and included a six-month period of support in the community after hospital discharge to address recovery goals. This study was one of the first RCTs of a hospital- and community-based intervention provided solely among patients with firearm injuries.

MAIN TEXT

Barriers to recruitment included limited staffing, coupled with wide variability in length of stay and admission times, which made it difficult to predict the best time to recruit. At the same time, more acutely affected patients needed more time to stabilize in order to determine whether eligibility criteria were met. Barriers to retention included insufficient patient resources for stable housing, communication and transportation, as well as limited time for patients to meet with study staff to respond to follow-up surveys. These barriers similarly affected intervention delivery as patients who were recruited, but had fewer resources to help with recovery, had lower intervention engagement. These barriers fall within the broader context of system avoidance (e.g., avoiding institutions that keep formal records). Since the patient sample was racially diverse with the majority of patients having prior criminal justice system involvement, this may have precluded active participation from some patients, especially those from communities that have been subject to long and sustained history of trauma and racism. We discuss approaches to overcoming these barriers and the importance of such efforts to further implement and evaluate hospital-based violence intervention programs in the future.

CONCLUSION

Developing strategies to overcome barriers to data collection and ongoing participant contact are essential to gathering robust information to understand how well violence prevention programs work and providing the best care possible for people recovering from injuries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02630225 . Registered 12/15/2015.

"The cops didn't make it any better": Perspectives on police and guns among survivors of gun violence

BACKGROUND

Survivors of gun violence in the United States (US) are twenty times more likely to be re-injured with a firearm and three times more likely to be arrested under a violence or a weapons-related charge. The mechanisms for these outcomes are multifactorial and remain largely understudied. We aimed to examine perspectives on both the police and guns among survivors of guns violence.

METHODS

We conducted a secondary analysis of qualitative data from a study that examined the post-hospitalization recovery experience of survivors of firearm violence. Using a conceptual framework derived from sociology literature and a coding team made up of researchers, community members and former police officers, we used directed content analysis to construct themes.

RESULTS

The data set included interviews with 20 survivors of gun violence that were all Black males, aged 20-51 years. The recurring themes around the police included: (1) Legal cynicism: "I don't like police, none of them"; (2) Interactions with the police in a medical setting: "The cops didn't make it any better" and (3) Ambivalence around police presence within the community: "That's their job to protect me, too." Themes related to guns in the community encompassed: (1) The availability of guns: "Getting a gun is about as easy as buying a pair of sneakers"; (2) Symbolic meaning: "Guns give them courage"; (3) Social meaning: "I just let them know: I have a gun, too." and (4) Strategic meaning: "It's just for protection."

CONCLUSIONS

Survivors of gun violence describe distrust for the police and an ecology of guns that confers symbolic, social and strategic meaning to owning a gun. Interventions to decrease gun violence should address the cultural value of a gun as well as focus on improving police relations with the community.

Negative illness feedbacks: High-frisk policing reduces civilian reliance on ED services

OBJECTIVE

This paper demonstrates that localized and chronic stop-question-and-frisk (SQF) practices are associated with community members' utilization of emergency department (ED) resources. To explain this relationship, we explore the empirical applicability of a legal epidemiological framework, or the study of legal institutional influences on the distribution of disease and injury.

DATA AND STUDY DESIGN

Analyses are derived from merging data from the Philadelphia Vehicle and Pedestrians Investigation, the National Historical Geographic Information System, and the Southeastern Philadelphia Community Health database to zip code identifiers common to all datasets. Weighted multilevel negative binomial regressions measure the influence that local SQF practices have on ED use for this population. Analytic methods incorporate patient demographic covariates including household size, health insurance status, and having a doctor as a usual source of care.

PRINCIPAL FINDINGS

Findings reveal that both tract-level frisking and poor health are linked to more frequent use of hospital EDs, per respondent report. Despite their health care needs, however, reporting poor/fair health status is associated with a substantial decrease in the rate of emergency department visits as neighborhood frisk concentration increases (IRR = 0.923; 95% CI: 0.891, 0.957). Moreover, more sickly people in high-frisk neighborhoods live in tracts that have greater racial disparities in frisking-a pattern that accounts for the moderating role of neighborhood frisking in sick people's usage of the emergency room.

CONCLUSIONS

Findings indicating the robust association reported above interrogate the chronic incompatibility of local health and human service system aims. The study also provides an interdisciplinary theoretical lens through which stakeholders can make sense of these challenges and their implications.

Association of Police Transport With Survival Among Patients With Penetrating Trauma in Philadelphia, Pennsylvania

IMPORTANCE

Police in Philadelphia, Pennsylvania, routinely transport patients with penetrating trauma to nearby trauma centers. During the past decade, this practice has gained increased acceptance, but outcomes resulting from police transport of these patients have not been recently evaluated.

OBJECTIVE

To assess mortality among patients with penetrating trauma who are transported to trauma centers by police vs by emergency medical services (EMS).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used the Pennsylvania Trauma Outcomes Study registry and included 3313 adult patients with penetrating trauma from January 1, 2014, to December 31, 2018. Outcomes were compared between patients transported by police (n = 1970) and patients transported by EMS (n = 1343) to adult level I and II trauma centers in Philadelphia.

EXPOSURES

Police vs EMS transport.

MAIN OUTCOMES AND MEASURES

The primary end point was 24-hour mortality. Secondary end points included death at multiple other time points. After whole-cohort regression analysis, coarsened exact matching was used to control for confounding differences between groups. Matching criteria included patient age, injury mechanism and location, Injury Severity Score (ISS), presenting systolic blood pressure, and Glasgow Coma Scale score. Subgroup analysis was performed among patients with low, moderate, or high ISS.

RESULTS

Of the 3313 patients (median age, 29 years [interquartile range, 23-40 years]) in the study, 3013 (90.9%) were men. During the course of the study, the number of police transports increased significantly (from 328 patients in 2014 to 489 patients in 2018; P = .04), while EMS transport remained unchanged (from 246 patients in 2014 to 281 patients in 2018; P = .44). On unadjusted analysis, compared with patients transported by EMS, patients transported by police were younger (median age, 27 years [interquartile range, 22-36 years] vs 32 years [interquartile range, 24-46 years]), more often injured by a firearm (1741 of 1970 [88.4%] vs 681 of 1343 [50.7%]), and had a higher median ISS (14 [interquartile range, 9-26] vs 10 [interquartile range, 5-17]). Patients transported by police had higher mortality at 24 hours than those transported by EMS (560 of 1970 [28.4%] vs 246 of 1343 [18.3%]; odds ratio, 1.86; 95% CI, 1.57-2.21; P < .001) and at all other time points. After coarsened exact matching (870 patients in each transport cohort), there was no difference in mortality at 24 hours (210 [24.1%] vs 212 [24.4%]; odds ratio, 0.95; 95% CI, 0.59-1.52; P = .91) or at any other time point. On subgroup analysis, patients with severe injuries transported by police were less likely to be dead on arrival compared with matched patients transported by EMS (64 of 194 [33.0%] vs 79 of 194 [40.7%]; odds ratio, 0.48; 95% CI, 0.24-0.94; P = .03).

CONCLUSIONS AND RELEVANCE

For patients with penetrating trauma in an urban setting, 24-hour mortality was not different for those transported by police vs EMS to a trauma center. Timely transport to definitive trauma care should be emphasized over medical capability in the prehospital management of patients with penetrating trauma.

Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma

Background

Time to definitive hemorrhage control is a primary driver of survival after penetrating injury. For these injuries, mortality outcomes after prehospital transport by police and emergency medical service (EMS) providers are comparable. In this study we identify patient and geographic predictors of police transport relative to EMS transport and describe perceptions of police transport elicited from key stakeholders.

Methods

This mixed methods study was conducted in Philadelphia, Pennsylvania, which has the highest rate of police transport nationally. Patient data were drawn from Pennsylvania’s trauma registry and geographic data from the US Census and American Community Survey. For all 7500 adults who presented to Philadelphia trauma centers with penetrating injuries, 2006–2015, we compared how individual and geospatial characteristics predicted the odds of police versus EMS transport. Concurrently, we conducted qualitative interviews with patients, police officers and trauma clinicians to describe their perceptions of police transport in practice.

Results

Patients who were Black (OR 1.50; 1.20–1.88) and Hispanic (OR 1.38; 1.05–1.82), injured by a firearm (OR 1.58; 1.19–2.10) and at night (OR 1.48; 1.30–1.69) and who presented with decreased levels of consciousness (OR 1.18; 1.02–1.37) had higher odds of police transport. Neighborhood characteristics predicting police transport included: percent of Black population (OR 1.18; 1.05–1.32), vacant housing (OR 1.40; 1.20–1.64) and fire stations (OR 1.32; 1.20–1.44). All stakeholders perceived speed as police transport’s primary advantage. For patients, disadvantages included pain and insecurity while in transport. Police identified occupational health risks. Clinicians identified occupational safety risks and the potential for police transport to complicate the workflow.

Conclusions

Police transport may improve prompt access to trauma care but should be implemented with consideration of the equity of access and broad stakeholder perspectives in efforts to improve outcomes, safety, and efficiency.

Level of evidence

Epidemiological study, level III.

Beyond Band-Aids for Bullet Holes: Firearm Violence As a Public Health Priority

OBJECTIVES

To review the public health approach to preventing and treating firearm violence.

DATA SOURCES

Peer-reviewed, published scholarship and federal data systems.

STUDY SELECTION

English-language, indexed research articles on the epidemiology, risk, prevention, and consequences of firearm violence.

DATA EXTRACTION

This narrative review includes findings related to the epidemiology and impact of firearm violence, focusing on short- and long-term outcomes. Evidence supporting interventions at the individual, agent, and environmental level to reduce firearm-related harm was examined.

DATA SYNTHESIS

Firearm violence is a major public health challenge in the Unites States. The consequences of firearm violence reach beyond the nearly 40,000 firearm-related deaths and 90,000 firearm-related injuries each year. Firearm violence, including self-harm, assault, and unintentional injury, affects the health of individuals, families, communities, and health systems. Data sources remain inadequate, however, to fully capture these impacts. Treating firearm violence as a disease and taking a public health approach to prevention and treatment is key to reducing the harms of firearm violence. Using a public health framework not only recognizes the physical and mental consequences of firearm violence but also focuses our attention on underlying causes and on innovative, multi-level interventions to reduce the harms of firearm violence.

CONCLUSIONS

The public health approach positions clinicians to change the conversation from political diatribe of pro-gun and anti-gun to systematically reducing injury and death. To achieve comparable success, we must design, test, and implement effective interventions at the environmental, policy, technological, and individual levels to prevent firearm violence. We must collect robust data on firearm violence and its consequences. And we must reckon with the conditions of inequality and disadvantage that feed violence through all means.

Racism and Health in the United States: A Policy Statement From the American College of Physicians

Racial minorities in the United States have reported experiencing widespread racism throughout all aspects of life, from housing to education to employment. Existing research has examined the role of racism, discrimination, and violence in one's interaction with the health care system and their association with poorer mental and physical health. Systemic racism that underlies the fabric of society often manifests itself in prominent institutions, such as law enforcement agencies, regardless of individual intent. Overt and covert racist laws and policies, personal implicit biases, and other factors result in Black individuals and other people of color being the subject of law enforcement violence and criminal justice system interactions at disproportionately high rates. The demonstrated association between discriminatory law enforcement practices and violence and personal and community health necessitates treating these issues as public health issues worthy of a public policy intervention. Addressing some of the sources of institutional racism and harm through transparency and accountability measures is the first of many steps required to begin correcting historical racial injustices.