- Email: [email protected]
Emergency department utilization by a jail population
YAJEM-57614; No of Pages 4 American Journal of Emergency Medicine xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Emergency department utilization by a jail population Patrick J. Maher, MD a, Adeyinka A. Adedipe, MD b, Benjamin L. Sanders, MD, MPH c, Taylor Buck d, Paul Craven, MD e, Jared Strote, MD, MS b,⁎ a
Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America Department of Emergency Medicine, University of Washington, Seattle, WA, United States of America Jail Health Services Division, Public Health Seattle & King County, United States of America d University of Notre Dame, Notre Dame, IN, United States of America e University of Washington School of Medicine, Seattle, WA, United States of America b c
a r t i c l e
i n f o
Article history: Received 18 May 2018 Received in revised form 10 June 2018 Accepted 15 June 2018 Available online xxxx Keywords: Incarcerated Emergency department Reducing unnecessary visits
a b s t r a c t Background: Incarcerated individuals represent a significant proportion of the US population and face unique healthcare challenges. Scarce articles have been published about emergency department (ED) care of these patients. We studied the ED visits from one urban jail to better describe this population. Methods: A cohort study design was used, identifying patients who were sent to the ED from a city jail in 2015. Demographics, triage information, length of stay, number of studies, billing codes, diagnoses, and disposition data were collected. These were compared to the overall ED patient population in the same year. Results: 868 ED visits by jail patients occurred, representing 1.3% of the ED census. Compared to the general population, incarcerated patients were younger (32.1 years vs. 44.0 years, p b .01), healthier based on Elixhauser comorbidity scores (0.71 vs. 0.98, p b .01), and had lower admission rates (11.29% vs. 21.54%, p b .01). An abnormal vital sign was noted in 25% of incarcerated patients. Laboratory (61% vs. 57%, p b .02) and radiologic (63% vs 45%, p b .001) testing was more frequent for inmates and length of stay was longer (271 vs. 225 min, p b .01). Conclusion: ED visits from jail were common, involving a relatively young and healthy population with a low incidence of abnormal vital signs and admission. Given the high costs associated with ED care and the medical resources available at some jails, further study should evaluate if increased jail medical capabilities could improve care and decrease costs by decreasing ED visits. © 2018 Elsevier Inc. All rights reserved.
1. Introduction The United States has a large incarcerated population, with a recent estimate of 2.1 million adults [1]. There are many obstacles to providing healthcare for this population: in addition to obvious logistical constraints, these individuals tend to have more healthcare needs. Compared to the general population, there is a higher use of tobacco, alcohol and drugs, and a greater likelihood of untreated or under treated psychiatric and chronic health conditions such as hypertension, diabetes, and blood borne viral infections [2,3,5,6]. In order to facilitate care, incarceration facilities in the US often have associations with local hospitals and emergency departments (EDs) [2-4]. Providing emergency care for these patients is also uniquely challenging. Policies often require continuous law enforcement presence, restraints, and restriction of information about follow-up. Emergency providers may feel the need for more testing than usual, as incarcerated ⁎ Corresponding author at: 1959 NE Pacific Street, Seattle, WA 98195, United States of America. E-mail address: [email protected] (J. Strote).
patients frequently have poor access to health care prior to incarceration and may not easily return to the hospital for a missed diagnosis. Conversely, physicians may perform a less thorough workup if there is suspicion of malingering, drug seeking behavior, or secondary gain [2,5,7,8]. Given these challenges, the potential impact on emergency departments (EDs) is high. Despite this, little is known about emergent care of this population. In order to better define these patients and the care they are receiving, we examined jailed patients' visits to one ED and compared them to the overall ED census at the same hospital.
2. Methods 2.1. Design and setting This study was a single site, retrospective cohort study of individuals currently incarcerated in King County Correctional Facility (KCCF), in Seattle, Washington, who were sent for evaluation at the Harborview Medical Center ED during 2015.
https://doi.org/10.1016/j.ajem.2018.06.034 0735-6757/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Maher PJ, et al, Emergency department utilization by a jail population, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.06.034
2
P.J. Maher et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx
Seattle is a medium-sized city with a population estimate of 662,400 in 2015 [9]. Harborview Medical Center is the public hospital for the city and region; during the study period, the patient census was 65,888. It serves as the only hospital for patients from KCCF who require acute medical care. The two facilities are located 0.5 miles from each other. KCCF books approximately 27,000 people per year, with a median length of stay of 72 h (mean 19 days). The population has average age of 35 and is 79% male. Medical and psychiatric physicians and nurse practitioners are available on call continuously and staff clinic hours every day. A registered nurse is always present for intake evaluation, medication administration, and monitoring. Before booking, individuals are screened and may be sent to the ED for workup or stabilizing treatment. For potentially emergent issues arising after booking, individuals are screened by registered nurses who decide ED transport using consultation with in-house providers at their discretion.
were more KCCF patients with no insurance (26%) and fewer with private insurance (4%; p b .001).
3.2. Initial presentation (Table 2) ESI scores for incarcerated patients included more level 3s (78%) and less of all others, compared to the general population (p b .0001). This population also had less pre-existing illness as indicated by Elixhauser comorbidity scores (0.7 vs. 1.0; p b .0001). Vital signs in the KCCF group tended to be within normal limits (75% of all presentations) and a majority of the abnormalities were mild hypothermia (11%). Pain scores were higher in the incarcerated population (6.8 vs. 5.7, p b .0001).
2.2. Patients and samples
3.3. ED evaluation and treatment (Table 3)
The names of patients sent from KCCF for ED care during the study period were obtained from jail records electronically. Those sent from pre-booking were excluded so that only current inmates were included. KCCF records were then matched to ED encounters and medical records obtained. Variables recorded included age, gender, insurance status, triage vital signs and pain scores, emergency severity index (ESI) scores, Elixhauser comorbidity scores, ED arrival-to-departure time, number of laboratory and radiology studies ordered, category of final diagnoses, CPT billing codes, 72-hour recidivism rate, and disposition. For comparison, we obtained available data for the same variables from the entire ED population over the study year; comparative data were not available for vital signs and 72-hour recidivism rates.
A higher percentage of incarcerated patients underwent radiologic (63%; p b .01) and laboratory testing (45%; p b .02) compared to the general population; the number of studies per patient was low for both. CTs were performed on 24% of incarcerated patients, including 15% who received a head CT. The most common ED procedures for incarcerated patients were incision and drainage (6% of visits), laceration repair (6%) and fracture reduction (1%). All other billable procedures occurred for b1% of visits. ED visit time was longer for incarcerated patients with a median time difference of 46 min (p b .01). Billing Evaluation and Management CPT codes for incarcerated patients tended to be high, with 73% a level 4 or 5, significantly more than the general population (p b .001).
2.3. Statistical analysis Statistical analysis was performed using Stata 14 (StataCorp; College Station, TX). Chi-square test was used for categorical data points; Student's t-test was used for continuous data points; and Wilcoxon test was used for non-parametrically distributed variables. The study was approved by the Institutional Review Board of the University of Washington and by the KCCF Research Administrative Review Committee. 3. Results Of the 966 visit records obtained from KCCF, 65 were excluded due to lack of ED visit information and 33 were excluded as duplicates. The remaining 868 visits represent 1.3% of the total ED visits during the study period. 3.1. Demographics and insurance (Table 1) Incarcerated patients were younger and more predominantly male compared to the total ED population (p b .001). Most (70%) KCCF patients were on Medicare or Medicaid; compared to all patients, there Table 1 Characteristics of study populations. Population characteristics
Average age (years) Male (%) Insurance Medicaid/Medicare None Private
Jail patients (n = 868)
All patients (n = 65,888)
p value
32 77 (%) 70 26 4
44 65 (%) 71 11 18
b.01 b.01
b.01 b.01
Demographics of the jail population and overall ED population during the same period.
Table 2 Initial ED presentation. Initial presentation
ESI 1 2 3 4 5 Mean Elixhauser score Mean pain score Heart rate ≥120 bpm ≤50 bpm Normal Systolic blood pressure ≥180 mm Hg ≤90 mm Hg Normal Temperature ≥38 ≤36 Normal Respiratory rate ≥24 ≤10 Normal Oxygen saturation ≤92% Normal Any abnormal vital sign No Yes
Jail patients
All patients
(%) b1 14 78 8 b1 0.7 6.8 (%) 5 2 93 (%) 2 1 96 (%) 2 11 87 (%) 2 b1 97 (%) 3 97 (%) 75 25
(%) 2 17 60 19 3 0.9 5.7
p value b.01
b.01 b.01
Characteristics of the initial presentation of patients to the emergency department. Vital sign data were not available for the overall emergency department population. ESI – emergency severity index.
Please cite this article as: Maher PJ, et al, Emergency department utilization by a jail population, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.06.034
P.J. Maher et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx Table 3 ED evaluation. ED evaluation
Radiology % receiving a test Median number of tests IQR Laboratory % receiving a test Median number of tests IQR Median bed to depart time E&M CPT billing code 99281 99282 99283 99284 99285
Jail patients
All patients
p value
63 1 0–2
45 1 1–3
b.001
61 4 0–8 271 min (%) 0.1 5 22 40 33
57 2 1–4 225 min (%) 1.2 11 22 27 39
b.02
b.01 b.0001
Extent and complexity of evaluation and length of stay.in the ED. E&M = Evaluation and Management; CPT = current procedural terminology; IQR = interquartile range.
3.4. Diagnosis, disposition and recidivism The most common final diagnosis categories were trauma (24%), infection (16%), cardiac (13%), gastrointestinal (12%), toxicologic (7%), and neurologic (6%); all others comprised b5% each. The admission rate for incarcerated patients was 11%, significantly lower than the rate for all visits (22%; p b .001). More patients in the incarcerated group had multiple visits to the ED during the year compared to the general population (11.64% vs. 7.78% (p b .001)). Returns within 72 h by jail patients were rare, however (b1%).
4. Discussion The large number of incarcerated individuals in the United States represents a substantial healthcare burden but the ED care received by these individuals is not well studied. In our retrospective analysis of one system, ED use was common and, despite the higher disease burden in the incarcerated population generally [2,3,5,6], involved relatively young and healthy patients with a low incidence of abnormal vital signs, low admission rates, and frequent visits for traumatic injury. The admission rate in particular – similar to national rates overall [10] but double the rate for the hospital in this study – raises the question of whether some visits could be avoided. Such concerns about jail transports have been voiced previously [2]; given available onsite nursing and physician care and triage, highly targeted use of EDs is theoretically feasible. Notably, the one other study of an incarcerated population presenting to an ED had an admission rate 3.5 times higher (39.8%) [11]. If certain visits may be unnecessary, our study points to some possible ways to identify them. 8% of patients were triaged with an ESI score of 4 or 5, representing cases much less likely to need emergent care. Similarly, more than a quarter of patients were billed at a low Evaluation and Management CPT-code. A subset did not need radiologic or laboratory study, which might identify patients not needing ED-level resources. Almost 13% of patients received a laceration repair or abscess drainage. And, finally, there were relatively high recidivism rates, also seen in the prior study of a similar population [11]. If unnecessary ED visits are occurring and could be identified and avoided, many benefits could be realized. ED over-crowding has become a major problem; in our study, the length of ED stays was significantly longer, even though the admission rate was significantly lower. The cause of this is unclear and may reflect more extensive evaluations. It may also be attributable to the requirement by the jail that an ED note
3
be completed prior to discharge. More generally, there is potential to create benefits to the system overall; ED care when compared to primary care often involves increased laboratory and radiologic testing and is associated with increased costs [12]. Estimating financial costs to the healthcare system is difficult to evaluate. The hospital in this study is contracted to provide free emergency care to jail patients, so no billing records are generated. Based on the large number of high Evaluation and Management CPT codes, the costs of visits likely represent the potential for a large financial burden in a system that does not have a similar relationship. This is validated by reports of rapidly increasing large costs for ED visits from jails. Estimates for the ED care of inmates in Texas was almost $43 million in 2016, 60% more than 5 years earlier [13]. One recent study looking at costs from a single county jail estimated a $4 million/year savings with a 20% decrease in ED visits [3]. When costs are borne by the jail system, there may be a disincentive to send patients to the ED; in contrast, in our system, ED care is essentially free, taking financial concern out of the triage question. Although it is likely that in-jail acute care for certain conditions would be less expensive than transport to and care received within the ED, the diversity of different populations and systems makes global assessments difficult. Further study will be necessary to identify best practices. The one prior similar study demonstrated a considerably higher hospitalization rate but involved a different population – most importantly, patients were equally distributed from both a jail and a prison, with likely different medical capabilities and patient populations than the jail described here [11]. In contrast to jails which tend to have more limited infirmaries, shorter periods of incarceration, more acutely ill patients, and less stable populations, prisons frequently have more extensive medical capabilities and can provide continued care over time [14]. Similarities between these two studies, however, could be informative. In both populations, traumatic injuries were common, accounting for nearly a quarter of visits, while psychiatric visits were rare. This likely reflects better protocols and in-house care for psychiatric disease at jails and prisons – which could potentially serve as a model for medical and traumatic conditions. The comparable and sizeable recidivism rates may suggest that there a population for whom review of prior ED evaluations could be used to avoid repeat visits for similar issues. Further studies would ideally compare different systems' ED use and outcomes, identifying costs and benefits for increased in-house capabilities that decrease ED visits. Certain feasible improvements have already been identified. Telemedicine is increasingly being used to allow for advanced or specialized practitioner evaluation without the costs associated with transfer to the ED [15-17]; and even phone consultation availability may lead to reductions in transport [2]. On-site care for minor injuries, along with wound-care, laceration repair, and abscess management are fast, simple, and safe procedures that rarely require ED-level care. One recent study describes an on-site jail urgent care program staffed by emergency physicians leading to a 20% decrease in ED visits [3]. As emergency physicians, we have a unique responsibility to vulnerable populations, including those in custody of law enforcement [5]. Because EDs are not the best setting to manage many conditions, and unnecessary visits can impact both the patient and the entire ED in negative ways, emergency physicians should work closely with jails and prisons to identify practices to provide the best care possible in the best setting possible. 4.1. Limitations This was a study at a single emergency department and single jail facility and is likely not generalizable. Beyond the unique jail population, our system does not charge for emergency care likely impacting both jail and ED provider practices. Records obtained in this study from the jail included several duplicate and unmatched records removed from analysis that may have
Please cite this article as: Maher PJ, et al, Emergency department utilization by a jail population, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.06.034
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P.J. Maher et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx
biased results. We think a significant impact is unlikely however: the unmatched records likely represented transfers to the hospital to units other than the ED or initial requests for an ED visit that did not occur; similarly, the duplicate records appear to have been administrative errors where two jail records were recorded for a single ED visit. 4.2. Conclusions In our study of a single jail system, we found ED use was common, involving a relatively young and healthy population with a low incidence of abnormal vital signs and admission. Given the high costs associated with ED care and the medical resources available at some jails, further study should evaluate whether increased jail medical capabilities could improve care and cost by decreasing ED visits. Acknowledgment The authors have no financial conflict of interest with the subject matter of this work. This work was presented at the 2018 ACEP Research Forum. There was no funding or financial support. References [1] Kaeble D, Glaze L. Correctional populations in the United States, 2015. Justice do. Bureau of Justice Statistics; 2016. [2] Chan TC, Vilke GM, Smith S, Sparrow W, Dunford JV. Impact of an after-hours on-call emergency physician on ambulance transports from a county jail. Prehosp Emerg Care 2003;7:327–31.
[3] Eiting E, Korn CS, Wilkes E, Ault G, Henderson SO. Reduction in jail emergency department visits and closure after implementation of on-site urgent care. J Correct Health Care 2017;23:88–92. [4] Reeves R, Brewer A, Debilio L, Kosseff C, Dickert J. Benefits of a department of corrections partnership with a health sciences university: New Jersey's experience. J Correct Health Care 2014;20:145–53. [5] Comnmittee APH. Clinical & practice management: recognizing the needs of incarcerated patients in the emergency department ACEP; 2006. [6] Lessenger JE. Prisoners in the emergency department. Ann Emerg Med 1985;14: 179–83. [7] Baker EF, Moskop JC, Geiderman JM, et al. Law enforcement and emergency medicine: an ethical analysis. Ann Emerg Med 2016;68:599–607. [8] Shalit M, Lewin MR. Medical care of prisoners in the USA. Lancet 2004;364(Suppl. 1):s34–5. [9] State of Washington Office of financial management April 1 official population estimates. Olympia, WA: OFM; 2017. [10] National Center for Health Statistics. Emergency department visits; 2015. [11] Koester L, Brenner JM, Goulette A, Wojcik SM, Grant W. Inmate health care provided in an emergency department. J Correct Health Care 2017;23:157–61. [12] Drummond AJ. No room at the inn: overcrowding in Ontario's emergency departments. CJEM 2002;4:91–7. [13] Counties TAo. The cost of county government: 2016 unfunded mandates survey. Austin, Tx: Texas Association of Counties; 2017. [14] How does jail medicine differ from prison medicine? CorrectionsOne.com; 2015. [15] Ellis DG, Mayrose J, Jehle DV, Moscati RM, Pierluisi GJ. A telemedicine model for emergency care in a short-term correctional facility. Telemed J E Health 2001;7: 87–92. [16] Ellis DG, Mayrose J, Phelan M. Consultation times in emergency telemedicine using realtime videoconferencing. J Telemed Telecare 2006;12:303–5. [17] Fox KC, Somes GW, Waters TM. Timeliness and access to healthcare services via telemedicine for adolescents in state correctional facilities. J Adolesc Health 2007;41: 161–7.
Please cite this article as: Maher PJ, et al, Emergency department utilization by a jail population, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.06.034
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Emergency department utilization by a jail population Patrick J. Maher, MD a, Adeyinka A. Adedipe, MD b, Benjamin L. Sanders, MD, MPH c, Taylor Buck d, Paul Craven, MD e, Jared Strote, MD, MS b,⁎ a
Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America Department of Emergency Medicine, University of Washington, Seattle, WA, United States of America Jail Health Services Division, Public Health Seattle & King County, United States of America d University of Notre Dame, Notre Dame, IN, United States of America e University of Washington School of Medicine, Seattle, WA, United States of America b c
a r t i c l e
i n f o
Article history: Received 18 May 2018 Received in revised form 10 June 2018 Accepted 15 June 2018 Available online xxxx Keywords: Incarcerated Emergency department Reducing unnecessary visits
a b s t r a c t Background: Incarcerated individuals represent a significant proportion of the US population and face unique healthcare challenges. Scarce articles have been published about emergency department (ED) care of these patients. We studied the ED visits from one urban jail to better describe this population. Methods: A cohort study design was used, identifying patients who were sent to the ED from a city jail in 2015. Demographics, triage information, length of stay, number of studies, billing codes, diagnoses, and disposition data were collected. These were compared to the overall ED patient population in the same year. Results: 868 ED visits by jail patients occurred, representing 1.3% of the ED census. Compared to the general population, incarcerated patients were younger (32.1 years vs. 44.0 years, p b .01), healthier based on Elixhauser comorbidity scores (0.71 vs. 0.98, p b .01), and had lower admission rates (11.29% vs. 21.54%, p b .01). An abnormal vital sign was noted in 25% of incarcerated patients. Laboratory (61% vs. 57%, p b .02) and radiologic (63% vs 45%, p b .001) testing was more frequent for inmates and length of stay was longer (271 vs. 225 min, p b .01). Conclusion: ED visits from jail were common, involving a relatively young and healthy population with a low incidence of abnormal vital signs and admission. Given the high costs associated with ED care and the medical resources available at some jails, further study should evaluate if increased jail medical capabilities could improve care and decrease costs by decreasing ED visits. © 2018 Elsevier Inc. All rights reserved.
1. Introduction The United States has a large incarcerated population, with a recent estimate of 2.1 million adults [1]. There are many obstacles to providing healthcare for this population: in addition to obvious logistical constraints, these individuals tend to have more healthcare needs. Compared to the general population, there is a higher use of tobacco, alcohol and drugs, and a greater likelihood of untreated or under treated psychiatric and chronic health conditions such as hypertension, diabetes, and blood borne viral infections [2,3,5,6]. In order to facilitate care, incarceration facilities in the US often have associations with local hospitals and emergency departments (EDs) [2-4]. Providing emergency care for these patients is also uniquely challenging. Policies often require continuous law enforcement presence, restraints, and restriction of information about follow-up. Emergency providers may feel the need for more testing than usual, as incarcerated ⁎ Corresponding author at: 1959 NE Pacific Street, Seattle, WA 98195, United States of America. E-mail address: [email protected] (J. Strote).
patients frequently have poor access to health care prior to incarceration and may not easily return to the hospital for a missed diagnosis. Conversely, physicians may perform a less thorough workup if there is suspicion of malingering, drug seeking behavior, or secondary gain [2,5,7,8]. Given these challenges, the potential impact on emergency departments (EDs) is high. Despite this, little is known about emergent care of this population. In order to better define these patients and the care they are receiving, we examined jailed patients' visits to one ED and compared them to the overall ED census at the same hospital.
2. Methods 2.1. Design and setting This study was a single site, retrospective cohort study of individuals currently incarcerated in King County Correctional Facility (KCCF), in Seattle, Washington, who were sent for evaluation at the Harborview Medical Center ED during 2015.
https://doi.org/10.1016/j.ajem.2018.06.034 0735-6757/© 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Maher PJ, et al, Emergency department utilization by a jail population, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.06.034
2
P.J. Maher et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx
Seattle is a medium-sized city with a population estimate of 662,400 in 2015 [9]. Harborview Medical Center is the public hospital for the city and region; during the study period, the patient census was 65,888. It serves as the only hospital for patients from KCCF who require acute medical care. The two facilities are located 0.5 miles from each other. KCCF books approximately 27,000 people per year, with a median length of stay of 72 h (mean 19 days). The population has average age of 35 and is 79% male. Medical and psychiatric physicians and nurse practitioners are available on call continuously and staff clinic hours every day. A registered nurse is always present for intake evaluation, medication administration, and monitoring. Before booking, individuals are screened and may be sent to the ED for workup or stabilizing treatment. For potentially emergent issues arising after booking, individuals are screened by registered nurses who decide ED transport using consultation with in-house providers at their discretion.
were more KCCF patients with no insurance (26%) and fewer with private insurance (4%; p b .001).
3.2. Initial presentation (Table 2) ESI scores for incarcerated patients included more level 3s (78%) and less of all others, compared to the general population (p b .0001). This population also had less pre-existing illness as indicated by Elixhauser comorbidity scores (0.7 vs. 1.0; p b .0001). Vital signs in the KCCF group tended to be within normal limits (75% of all presentations) and a majority of the abnormalities were mild hypothermia (11%). Pain scores were higher in the incarcerated population (6.8 vs. 5.7, p b .0001).
2.2. Patients and samples
3.3. ED evaluation and treatment (Table 3)
The names of patients sent from KCCF for ED care during the study period were obtained from jail records electronically. Those sent from pre-booking were excluded so that only current inmates were included. KCCF records were then matched to ED encounters and medical records obtained. Variables recorded included age, gender, insurance status, triage vital signs and pain scores, emergency severity index (ESI) scores, Elixhauser comorbidity scores, ED arrival-to-departure time, number of laboratory and radiology studies ordered, category of final diagnoses, CPT billing codes, 72-hour recidivism rate, and disposition. For comparison, we obtained available data for the same variables from the entire ED population over the study year; comparative data were not available for vital signs and 72-hour recidivism rates.
A higher percentage of incarcerated patients underwent radiologic (63%; p b .01) and laboratory testing (45%; p b .02) compared to the general population; the number of studies per patient was low for both. CTs were performed on 24% of incarcerated patients, including 15% who received a head CT. The most common ED procedures for incarcerated patients were incision and drainage (6% of visits), laceration repair (6%) and fracture reduction (1%). All other billable procedures occurred for b1% of visits. ED visit time was longer for incarcerated patients with a median time difference of 46 min (p b .01). Billing Evaluation and Management CPT codes for incarcerated patients tended to be high, with 73% a level 4 or 5, significantly more than the general population (p b .001).
2.3. Statistical analysis Statistical analysis was performed using Stata 14 (StataCorp; College Station, TX). Chi-square test was used for categorical data points; Student's t-test was used for continuous data points; and Wilcoxon test was used for non-parametrically distributed variables. The study was approved by the Institutional Review Board of the University of Washington and by the KCCF Research Administrative Review Committee. 3. Results Of the 966 visit records obtained from KCCF, 65 were excluded due to lack of ED visit information and 33 were excluded as duplicates. The remaining 868 visits represent 1.3% of the total ED visits during the study period. 3.1. Demographics and insurance (Table 1) Incarcerated patients were younger and more predominantly male compared to the total ED population (p b .001). Most (70%) KCCF patients were on Medicare or Medicaid; compared to all patients, there Table 1 Characteristics of study populations. Population characteristics
Average age (years) Male (%) Insurance Medicaid/Medicare None Private
Jail patients (n = 868)
All patients (n = 65,888)
p value
32 77 (%) 70 26 4
44 65 (%) 71 11 18
b.01 b.01
b.01 b.01
Demographics of the jail population and overall ED population during the same period.
Table 2 Initial ED presentation. Initial presentation
ESI 1 2 3 4 5 Mean Elixhauser score Mean pain score Heart rate ≥120 bpm ≤50 bpm Normal Systolic blood pressure ≥180 mm Hg ≤90 mm Hg Normal Temperature ≥38 ≤36 Normal Respiratory rate ≥24 ≤10 Normal Oxygen saturation ≤92% Normal Any abnormal vital sign No Yes
Jail patients
All patients
(%) b1 14 78 8 b1 0.7 6.8 (%) 5 2 93 (%) 2 1 96 (%) 2 11 87 (%) 2 b1 97 (%) 3 97 (%) 75 25
(%) 2 17 60 19 3 0.9 5.7
p value b.01
b.01 b.01
Characteristics of the initial presentation of patients to the emergency department. Vital sign data were not available for the overall emergency department population. ESI – emergency severity index.
Please cite this article as: Maher PJ, et al, Emergency department utilization by a jail population, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.06.034
P.J. Maher et al. / American Journal of Emergency Medicine xxx (2018) xxx–xxx Table 3 ED evaluation. ED evaluation
Radiology % receiving a test Median number of tests IQR Laboratory % receiving a test Median number of tests IQR Median bed to depart time E&M CPT billing code 99281 99282 99283 99284 99285
Jail patients
All patients
p value
63 1 0–2
45 1 1–3
b.001
61 4 0–8 271 min (%) 0.1 5 22 40 33
57 2 1–4 225 min (%) 1.2 11 22 27 39
b.02
b.01 b.0001
Extent and complexity of evaluation and length of stay.in the ED. E&M = Evaluation and Management; CPT = current procedural terminology; IQR = interquartile range.
3.4. Diagnosis, disposition and recidivism The most common final diagnosis categories were trauma (24%), infection (16%), cardiac (13%), gastrointestinal (12%), toxicologic (7%), and neurologic (6%); all others comprised b5% each. The admission rate for incarcerated patients was 11%, significantly lower than the rate for all visits (22%; p b .001). More patients in the incarcerated group had multiple visits to the ED during the year compared to the general population (11.64% vs. 7.78% (p b .001)). Returns within 72 h by jail patients were rare, however (b1%).
4. Discussion The large number of incarcerated individuals in the United States represents a substantial healthcare burden but the ED care received by these individuals is not well studied. In our retrospective analysis of one system, ED use was common and, despite the higher disease burden in the incarcerated population generally [2,3,5,6], involved relatively young and healthy patients with a low incidence of abnormal vital signs, low admission rates, and frequent visits for traumatic injury. The admission rate in particular – similar to national rates overall [10] but double the rate for the hospital in this study – raises the question of whether some visits could be avoided. Such concerns about jail transports have been voiced previously [2]; given available onsite nursing and physician care and triage, highly targeted use of EDs is theoretically feasible. Notably, the one other study of an incarcerated population presenting to an ED had an admission rate 3.5 times higher (39.8%) [11]. If certain visits may be unnecessary, our study points to some possible ways to identify them. 8% of patients were triaged with an ESI score of 4 or 5, representing cases much less likely to need emergent care. Similarly, more than a quarter of patients were billed at a low Evaluation and Management CPT-code. A subset did not need radiologic or laboratory study, which might identify patients not needing ED-level resources. Almost 13% of patients received a laceration repair or abscess drainage. And, finally, there were relatively high recidivism rates, also seen in the prior study of a similar population [11]. If unnecessary ED visits are occurring and could be identified and avoided, many benefits could be realized. ED over-crowding has become a major problem; in our study, the length of ED stays was significantly longer, even though the admission rate was significantly lower. The cause of this is unclear and may reflect more extensive evaluations. It may also be attributable to the requirement by the jail that an ED note
3
be completed prior to discharge. More generally, there is potential to create benefits to the system overall; ED care when compared to primary care often involves increased laboratory and radiologic testing and is associated with increased costs [12]. Estimating financial costs to the healthcare system is difficult to evaluate. The hospital in this study is contracted to provide free emergency care to jail patients, so no billing records are generated. Based on the large number of high Evaluation and Management CPT codes, the costs of visits likely represent the potential for a large financial burden in a system that does not have a similar relationship. This is validated by reports of rapidly increasing large costs for ED visits from jails. Estimates for the ED care of inmates in Texas was almost $43 million in 2016, 60% more than 5 years earlier [13]. One recent study looking at costs from a single county jail estimated a $4 million/year savings with a 20% decrease in ED visits [3]. When costs are borne by the jail system, there may be a disincentive to send patients to the ED; in contrast, in our system, ED care is essentially free, taking financial concern out of the triage question. Although it is likely that in-jail acute care for certain conditions would be less expensive than transport to and care received within the ED, the diversity of different populations and systems makes global assessments difficult. Further study will be necessary to identify best practices. The one prior similar study demonstrated a considerably higher hospitalization rate but involved a different population – most importantly, patients were equally distributed from both a jail and a prison, with likely different medical capabilities and patient populations than the jail described here [11]. In contrast to jails which tend to have more limited infirmaries, shorter periods of incarceration, more acutely ill patients, and less stable populations, prisons frequently have more extensive medical capabilities and can provide continued care over time [14]. Similarities between these two studies, however, could be informative. In both populations, traumatic injuries were common, accounting for nearly a quarter of visits, while psychiatric visits were rare. This likely reflects better protocols and in-house care for psychiatric disease at jails and prisons – which could potentially serve as a model for medical and traumatic conditions. The comparable and sizeable recidivism rates may suggest that there a population for whom review of prior ED evaluations could be used to avoid repeat visits for similar issues. Further studies would ideally compare different systems' ED use and outcomes, identifying costs and benefits for increased in-house capabilities that decrease ED visits. Certain feasible improvements have already been identified. Telemedicine is increasingly being used to allow for advanced or specialized practitioner evaluation without the costs associated with transfer to the ED [15-17]; and even phone consultation availability may lead to reductions in transport [2]. On-site care for minor injuries, along with wound-care, laceration repair, and abscess management are fast, simple, and safe procedures that rarely require ED-level care. One recent study describes an on-site jail urgent care program staffed by emergency physicians leading to a 20% decrease in ED visits [3]. As emergency physicians, we have a unique responsibility to vulnerable populations, including those in custody of law enforcement [5]. Because EDs are not the best setting to manage many conditions, and unnecessary visits can impact both the patient and the entire ED in negative ways, emergency physicians should work closely with jails and prisons to identify practices to provide the best care possible in the best setting possible. 4.1. Limitations This was a study at a single emergency department and single jail facility and is likely not generalizable. Beyond the unique jail population, our system does not charge for emergency care likely impacting both jail and ED provider practices. Records obtained in this study from the jail included several duplicate and unmatched records removed from analysis that may have
Please cite this article as: Maher PJ, et al, Emergency department utilization by a jail population, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.06.034
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biased results. We think a significant impact is unlikely however: the unmatched records likely represented transfers to the hospital to units other than the ED or initial requests for an ED visit that did not occur; similarly, the duplicate records appear to have been administrative errors where two jail records were recorded for a single ED visit. 4.2. Conclusions In our study of a single jail system, we found ED use was common, involving a relatively young and healthy population with a low incidence of abnormal vital signs and admission. Given the high costs associated with ED care and the medical resources available at some jails, further study should evaluate whether increased jail medical capabilities could improve care and cost by decreasing ED visits. Acknowledgment The authors have no financial conflict of interest with the subject matter of this work. This work was presented at the 2018 ACEP Research Forum. There was no funding or financial support. References [1] Kaeble D, Glaze L. Correctional populations in the United States, 2015. Justice do. Bureau of Justice Statistics; 2016. [2] Chan TC, Vilke GM, Smith S, Sparrow W, Dunford JV. Impact of an after-hours on-call emergency physician on ambulance transports from a county jail. Prehosp Emerg Care 2003;7:327–31.
[3] Eiting E, Korn CS, Wilkes E, Ault G, Henderson SO. Reduction in jail emergency department visits and closure after implementation of on-site urgent care. J Correct Health Care 2017;23:88–92. [4] Reeves R, Brewer A, Debilio L, Kosseff C, Dickert J. Benefits of a department of corrections partnership with a health sciences university: New Jersey's experience. J Correct Health Care 2014;20:145–53. [5] Comnmittee APH. Clinical & practice management: recognizing the needs of incarcerated patients in the emergency department ACEP; 2006. [6] Lessenger JE. Prisoners in the emergency department. Ann Emerg Med 1985;14: 179–83. [7] Baker EF, Moskop JC, Geiderman JM, et al. Law enforcement and emergency medicine: an ethical analysis. Ann Emerg Med 2016;68:599–607. [8] Shalit M, Lewin MR. Medical care of prisoners in the USA. Lancet 2004;364(Suppl. 1):s34–5. [9] State of Washington Office of financial management April 1 official population estimates. Olympia, WA: OFM; 2017. [10] National Center for Health Statistics. Emergency department visits; 2015. [11] Koester L, Brenner JM, Goulette A, Wojcik SM, Grant W. Inmate health care provided in an emergency department. J Correct Health Care 2017;23:157–61. [12] Drummond AJ. No room at the inn: overcrowding in Ontario's emergency departments. CJEM 2002;4:91–7. [13] Counties TAo. The cost of county government: 2016 unfunded mandates survey. Austin, Tx: Texas Association of Counties; 2017. [14] How does jail medicine differ from prison medicine? CorrectionsOne.com; 2015. [15] Ellis DG, Mayrose J, Jehle DV, Moscati RM, Pierluisi GJ. A telemedicine model for emergency care in a short-term correctional facility. Telemed J E Health 2001;7: 87–92. [16] Ellis DG, Mayrose J, Phelan M. Consultation times in emergency telemedicine using realtime videoconferencing. J Telemed Telecare 2006;12:303–5. [17] Fox KC, Somes GW, Waters TM. Timeliness and access to healthcare services via telemedicine for adolescents in state correctional facilities. J Adolesc Health 2007;41: 161–7.
Please cite this article as: Maher PJ, et al, Emergency department utilization by a jail population, American Journal of Emergency Medicine (2018), https://doi.org/10.1016/j.ajem.2018.06.034