Emergency Department Visits by Incarcerated Adults for Nonfatal Injuries — United States, 2010–2019

Avital Wulz, MPH, MSW1; Gabrielle Miller, PhD1; Livia Navon, MS1; Jill Daugherty, PhD1 (

Summary

What is already known about this topic?

Incarcerated adults experience disproportionate negative health outcomes compared with the general adult population, including unintentional and violence-related injuries.

What is added by this report?

The proportion of nonfatal injury-related emergency department (ED) visits by incarcerated adults resulting from assault or self-harm was five times as high as those among nonincarcerated adults. Among incarcerated adults, men and persons aged What are the implications for public health practice?

Tailoring injury prevention efforts for incarcerated adults with age- and sex-specific strategies might reduce injuries and ED visits in this population.

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During 2010–2019, U.S. correctional authorities held 1.4–1.6 million persons in state and federal prisons annually, and 10.3–12.9 million persons were admitted to local jails each year (1,2). Incarcerated persons experience a disproportionate burden of negative health outcomes, including unintentional and violence-related injuries (3,4). No national studies on injury-related emergency department (ED) visits by incarcerated persons have been conducted, but a previous study demonstrated a high rate of such visits among a Seattle, Washington jail population (5). To examine nonfatal injury-related ED visits among incarcerated adults, CDC analyzed 2010–2019 National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP) data. During 2010–2019, an estimated 733,547 ED visits by incarcerated adults occurred in the United States. The proportion of ED visits resulting from assault* and self-harm among incarcerated adults was five times as high as those among nonincarcerated adults. Among incarcerated adults, men and adult persons aged NEISS-AIP collects data on patients treated in EDs for nonfatal injuries from a nationally representative, stratified probability sample of hospitals.† Data are weighted by the inverse probability of selection to provide annual national estimates. A visit by an incarcerated person was defined as an ED visit by a person aged ≥18 years who was transported to an ED from a jail or prison for an injury.§ A visit by a nonincarcerated person was defined as an ED visit by any other persons aged ≥18 years. Data include a narrative summarizing the circumstances of each visit written by a trained data abstractor. Specific terms within narratives were used to identify visits by incarcerated persons.¶ An iterative process was used to improve identification of visits by incarcerated persons through manual review of a sample of narratives by two authors to ensure that selected visits met the case definition and to identify additional terms.

The weighted number of ED visits among incarcerated and nonincarcerated adults were calculated using SAS-callable SUDAAN (version 11.0.1; RTI International). Visits were stratified by patient sex, age group, injury intent, mechanism of injury,** and disposition,†† and the proportion of visits with these characteristics was calculated separately for incarcerated and nonincarcerated adults. Ratio of proportions (RPs) with 95% CIs were calculated to compare ED visits by incarcerated and nonincarcerated adults. Rao-Scott chi-square tests were used to calculate p-values, and p-values §§

During 2010–2019, an estimated 733,547 ED visits by incarcerated adults and 211,497,918 by nonincarcerated adults occurred in the United States (

Reasons for ED visits by incarcerated adults also differed by sex (

Discussion

During the study period, an estimated 750,000 ED visits by incarcerated adults and >200 million by nonincarcerated adults occurred. The proportion of ED visits for assault and self-harm was five times as high among incarcerated adults than among nonincarcerated adults. A higher proportion of ED visits by incarcerated adults resulted from being struck by or against an object, compared with ED visits by nonincarcerated adults. Among incarcerated adults with injury-related ED visits, there were differences in injury mechanisms by age group and by sex. This study is the first to present national estimates of nonfatal injury-related ED visits by incarcerated adults in the United States.

A majority of ED visits among incarcerated adults were made by men and persons aged ≤45 years, likely reflecting the makeup of the incarcerated population (1,2). However, because older adults are the fastest growing segment of prison populations (6,7), it is notable that a higher proportion of ED visits for unintentional injuries, including falls, and a higher proportion of ED visits resulting in hospitalization occurred among incarcerated adults aged ≥65 years than occurred among younger incarcerated adults. A higher proportion of ED visits among incarcerated women were related to poisoning and falls, and a lower proportion were related to assault than were those by incarcerated men. These findings illustrate the importance of age- and sex-specific injury prevention strategies for incarcerated adults.

Approximately 50,000 assaults occurring within public correctional facilities are reported annually (7). Persons aged ≥18 years detained in jails were twice as likely to die by suicide in 2019 compared with persons in the overall U.S. adult population (8). The higher proportion of assault- and self-harm–related ED visits among incarcerated persons, particularly among younger adults and men, points to the need for the development and implementation of violence and suicide prevention strategies that consider the intersectional factors related to incarceration.

The findings in this report are subject to at least five limitations. First, there are differences in health care access for incarcerated persons, which might partially explain the observed differences. For example, some correctional facilities have the capacity to provide health care on-site, and therefore, a subset of injuries among incarcerated adults might not be represented in these findings. The decision to seek ED care is made by authorities rather than patients, which could affect the types of ED visits made by incarcerated persons and be biased toward more serious injuries. Second, it is unclear how the proximity of NEISS-AIP–participating hospitals to correctional facilities affects national estimates presented in this study. Third, classification of incarcerated status was based on text narratives written by NEISS-AIP data abstractors, which might have led to misclassification of incarceration status. Fourth, it was not possible to determine when the injury occurred for incarcerated cases; therefore, data include injuries that could have occurred before incarceration. Finally, data on race and ethnicity were not presented because these data in NEISS-AIP are incomplete; however, U.S. Department of Justice statistics consistently demonstrate that Black or African American men are disproportionately overrepresented in the correctional system (1,2) stemming from upstream factors, particularly structural racism (9), and are therefore likely overrepresented in these data.

Nearly one in every 100 persons in the United States is in a prison or jail (10), and this study found that characteristics of ED visits by incarcerated adults differ from those by nonincarcerated adults. These differences suggest that setting-appropriate risk-prevention strategies that account for the conditions experienced while incarcerated could help prevent injuries among incarcerated persons. Increased availability of community- and facility-level resources for comprehensive mental health services and creating protective environments could help mitigate the risk for self-harm and violence associated with incarceration. CDC has created technical packages and resources that outline evidence-based strategies for communities for preventing suicide,¶¶ interpersonal and community violence,*** overdose,††† and falls§§§; tailoring these strategies and developing interventions for the jail and prison setting with age-appropriate and sex-specific recommendations might reduce injuries and ED visits in this population.

Acknowledgments

Dana Flanders, Amy Funk Wolkin, Keming Yuan, National Center for Injury Prevention and Control, CDC.

Corresponding author: Avital R. Wulz, awulz@cdc.gov.

1Division of Injury Prevention, National Center for Injury Prevention and Control, CDC.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

• Assault was defined as assault or legal intervention.

† https://www.cpsc.gov/s3fs-public/2001d010-6b6.pdf

§ ED visits among persons brought in by law enforcement before being booked in a jail or prison (e.g., immediately after arrest) or among persons who sustained an injury during detention-associated transportation were excluded from the case definition. Only persons brought directly to the ED from either a prison or a jail were included in this analysis. Injuries could have been sustained before incarceration. Occupational injuries were removed to exclude staff members injured while working in jails or prisons and were removed from nonincarcerated cases for consistency.

¶ “Jail,” “prison,” “corrections,” “correctional,” “incarcerate,” “incarcerated,” “incarceration,” “convict,” “inmate,” “detention,” “detain,” “detainee,” “detained,” and “police cell,” were used for inclusion, and other relevant search terms such as “custody,” “custody dispute,” “cell phone,” and “cellulitis” were used to help identify cases for exclusion.

** Injuries were categorized by intent (unintentional/undetermined, assault/legal intervention, or self-harm). Injuries were also categorized by mechanism of injury (fall, cut/pierce, struck by/against an object, inhalation/suffocation, overdose/poisoning, fire/burn, or other). Other includes injuries related to motor vehicles (occupant, motorcyclist, pedal cyclist, pedestrian, and other transport, which includes traffic-related, non–traffic-related, and unknown transportation injuries), overexertion, drowning/submersion, machinery, foreign body, dog bite, other bite/sting, firearm gunshot, bb/pellet gunshot, natural/environmental, other specified, and unknown/unspecified.

†† Disposition was categorized as treated and released, transferred to another hospital or hospitalized, or other. Other includes patients who left without being seen, left against medical advice, were held for observation, or had unknown disposition.

§§ 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

¶¶ https://www.cdc.gov/violenceprevention/communicationresources/pub/technical-packages.html; https://www.cdc.gov/suicide/pdf/suicideTechnicalPackage.pdf

*** https://www.cdc.gov/violenceprevention/communityviolence/index.html; https://www.cdc.gov/violenceprevention/communityviolence/prevention.html

††† https://www.cdc.gov/drugoverdose/strategies/index.html

§§§ https://www.cdc.gov/falls/programs/community_prevention.html

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• Numbers are weighted.
  † The nonincarcerated sample was used as the referent group for this analysis.

• Statistically significant at p† Dashes indicate that values were suppressed because of one of the following criteria: small sample size (30%.

• Statistically significant at p† Dashes indicate that values were suppressed because of either small sample size (

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