Prehospital Care for Persons Experiencing Homelessness: A Cross-Sectional Survey of the Challenges, Experiences, and Perspectives of Operational EMS Agency Medical Directors.

OBJECTIVE: Persons experiencing homelessness (PEH) are among the most vulnerable populations and experience significant health disparities. Nationally, PEH utilize Emergency Medical Services (EMS) at disproportionately higher rates than their housed peers. Developing optimal strategies to care for PEH has become critically important. However, limited data exists on best practices, challenges, and experiences of providing care to PEH. The objective of this study was to describe the experiences, challenges and perspectives of operational EMS agency medical directors in Los Angeles (LA) County as they confront the homelessness crisis. METHODS: We performed a cross-sectional survey of 9-1-1 operational EMS agency medical directors in LA County, which has one of the largest populations of PEH nationally. Twenty-nine 9-1-1 operational EMS agencies operate in LA County. The link to an anonymous, web-based survey examining documentation, training, resources, operational impact, and care challenges was emailed to medical directors with three reminders during the study period (4/19/2023-9/15/2023). RESULTS: Three quarters (75.9%; 22/29) of operational EMS agencies responded to the survey, with all questions answered in 69% (20/29) of surveys. Of these, 68.2% (15/22) of agencies document housing status and 75% (15/20) agreed or strongly agreed that homelessness presents operational challenges. No operational EMS agency reported adequate EMS clinician training on homelessness. Operational EMS agencies most commonly utilized domestic violence resources (43%, 9/21), social services (38%, 8/21), and law enforcement (38%, 8/21) services to assist PEH. Referrals were limited by accessibility (86%, 18/21), time (52%, 11/21), lack of awareness (52% 11/21) and lack of mandates (52%, 11/21). All operational EMS agencies agreed or strongly agreed that mental health and substance use disorders are major issues for PEH. The most common daily challenges reported were mental health (55%, 11/20), substance use (55%, 11/20), and patient resistance (35%, 7/20). CONCLUSION: In LA County, EMS agencies experience important operational and clinical challenges in caring for PEH, with limited resources, minimal training, and high rates of substance use disorders and mental health comorbidities. Further prehospital research is essential to standardize documentation of housing status, to identify areas for intervention, increase linkage to services, and define best practices.

Characteristics and Outcomes of 360 Consecutive COVID-19 Patients Discharged From the Emergency Department With Supplemental Oxygen.

STUDY OBJECTIVE: To describe characteristics and outcomes of coronavirus disease (COVID-19) patients with new supplemental oxygen requirements discharged from a large public urban emergency department (ED) with supplemental oxygen. METHODS: This observational case series describes the characteristics and outcomes of 360 consecutive COVID-19 patients with new supplemental oxygen requirements discharged from a large urban public ED between April 2020 and March 2021 with supplemental oxygen. Primary outcomes included 30-day survival and 30-day survival without unscheduled inpatient admission. Demographic and clinical data were collected through a structured chart review. RESULTS: Among 360 patients with COVID-19 discharged from the ED with supplemental oxygen, 30-day survival was 97.5% (95% confidence interval (CI) 95.3 to 98.9%; n=351), and 30-day survival without unscheduled admission was 81.1% (95% CI 76.7 to 85.0%; n=292). A sensitivity analysis incorporating worst-case-scenario for 12 patients without complete follow-up 30 days after index visit yields 30-day survival of 95.5% (95% CI 92.5 to 97.2%; n=343), and 30-day survival without unscheduled admission of 78.9% (95% CI 74.3 to 83.0%; n=284). Among study patients, 32.2% (n=116) had a nadir ED oxygen saturation of <90%, among these 30-day survival was 97.4% (95% CI 92.6 to 99.4%; n=113), and 30-day survival without unscheduled admission was 76.7% (95% CI 68.8 to 84.1%; n=89). CONCLUSION: COVID-19 patients with new supplemental oxygen requirements discharged from the ED had survival comparable to COVID-19 ED patients with mild exertional hypoxia treated with supplemental oxygen in other settings, and this held true when the analysis was restricted to patients with nadir ED index visit oxygen saturations <90%. Discharge of select COVID-19 patients with supplemental oxygen from the ED may provide a viable alternative to hospitalization, particularly when inpatient capacity is limited.

Exposure to and Use of Electronic Cigarettes: Does Language Matter?

OBJECTIVES: To determine whether patients who are English proficient become aware of e-cigarettes through different marketing tactics and have dissimilar patterns of use than patients who are non-English speaking. DESIGN: This was a cross-sectional study surveying adult English- and Spanish-speaking patients. ANOVA and chi-squared tests were used to examine differences between groups. SETTING: A large public, safety-net hospital in Los Angeles County, California. RESULTS: Respondents (N=1899) were predominately Hispanic (78%), foreign-born (68%), and reported Spanish as a primary language (64%). Native English speakers reported the highest use of e-cigarettes (26%), followed by non-native (13%) and non-English speakers (2%) (P<.001). In terms of marketing, native and non-native English speakers were more likely to have friends and family as sources of e-cigarette information (P<.001). Native speakers were more likely to see advertisements for e-cigarettes on storefronts (P=.004) and on billboards (P<.001). Non-English speakers were most likely to learn about e-cigarettes on the news (P<.001) and in advertisements on the television and radio (P=.002). Differences in reasons for use were not significant between the three groups. CONCLUSIONS: Native and non-native English speakers become aware of e-cigarettes through different mechanisms and use e-cigarettes at a significantly higher rate than non-English speakers. These results highlight an opportunity for public health programs to concentrate on specific channels of communication that introduce patient populations to e-cigarettes to slow the spread of e-cigarette usage.

Trial to examine text message-based mHealth in emergency department patients with diabetes (TExT-MED): a randomized controlled trial.

STUDY OBJECTIVE: Increasingly, low-income inner-city patients with diabetes utilize emergency departments (EDs) for acute and chronic care. We seek to determine whether a scalable, low-cost, unidirectional, text message-based mobile health intervention (TExT-MED) improves clinical outcomes, increases healthy behaviors, and decreases ED utilization in a safety net population. METHODS: We conducted an randomized controlled trial of 128 adult patients with poorly controlled diabetes (glycosylated hemoglobin [Hb A1C] level ≥8%) in an urban, public ED. The TExT-MED group received 2 daily text messages for 6 months in English or Spanish. The primary outcome was change in Hb A1C level. Secondary outcomes included changes in medication adherence, self-efficacy, performance of self-care tasks, quality of life, diabetes-specific knowledge, ED utilization, and patient satisfaction. RESULTS: Hb A1C level decreased by 1.05% in the TExT-MED group compared with 0.60% in the controls (Δ0.45; 95% confidence interval [CI] -0.27 to 1.17) at 6 months. Secondary outcomes favored the TExT-MED group, with the most sizable change observed in self-reported medication adherence (as measured by the Morisky Medication Adherence Scale, an 8-point validated scale with higher scores representing better adherence), which improved from 4.5 to 5.4 in the TExT-MED group compared with a net decrease of -0.1 in the controls (Δ1.1 [95% CI 0.1 to 2.1]). Effects were larger among Spanish speakers for both medication adherence (1.1 versus -0.3; Δ1.4; 95% CI 0.2 to 2.7) and Hb A1C (-1.2% versus -0.4%) in the TExT-MED group. The proportion of patients who used emergency services trended lower in the TExT-MED group (35.9% versus 51.6%; Δ15.7%; 95% CI 9.4% to 22%). Overall, 93.6% of respondents enjoyed TExT-MED and 100% would recommend it to family/friends. CONCLUSION: The TExT-MED program did not result in a statistically significant improvement in Hb A1C. However, trends toward improvement in the primary outcome of Hb A1C and other secondary outcomes, including quality of life, were observed, the most pronounced being improved medication adherence. TExT-MED also decreased ED utilization. These findings were magnified in the Spanish-speaking subgroup. Technologies such as TExT-MED represent highly scalable, low-cost, and widely accessible solutions for safety-net ED populations.

Perceptions of successful cues to action and opportunities to augment behavioral triggers in diabetes self-management: qualitative analysis of a mobile intervention for low-income Latinos with diabetes.

BACKGROUND: The increasing prevalence of diabetes and the associated cost of managing this complicated disease have a significant impact on public health outcomes and health expenditures, especially among resource-poor Latino patients. Mobile health (mHealth) may be the solution to reaching this group and improving their health. OBJECTIVE: In this qualitative study, we examined nuances of motivation, intention, and triggers to action effected by TExT-MED (Trial to Examine Text Messaging for Emergency Department patient with Diabetes), an mHealth intervention tailored to low-income, urban Latinos with diabetes. TExT-MED is a fully-automated, text message-based program designed to increase knowledge, self-efficacy, and subsequent disease management and glycemic control. METHODS: We conducted 5 focus group interviews with 24 people who participated in TExT-MED. We employed a modified grounded theory analytic approach-an iterative process of coding and immersion in the data used to recognize the patterns and links between concepts voiced by the participants. We coded data to identify themes of participant experiences, motivations, and responses to the program. We organized themes into a theory of TExT-MED's action. RESULTS: Participants enjoyed their experience with TExT-MED and believed it improved their diabetes management. Through analysis of the transcripts, we identified that the strengths of the program were messages that cued specific behaviors such as medication reminders and challenge messages. Our analysis also revealed that increasing personalization of message delivery and content could augment these cues. CONCLUSIONS: This in-depth qualitative analysis of TExT-MED shows that low-income Latino patients will accept text messages as a behavioral intervention. This mHealth intervention acts as a behavioral trigger rather than an education platform. Personalization is an opportunity to enhance these cues to action and further research should be conducted on the ideal forms of personalization.

Social support via Internet communication technology for diabetes self-management: a scoping review.

Background: The global prevalence of diabetes has been increasing over the past 30 years, leading to a rise in complications; diabetes is the leading cause of amputations, blindness, and kidney failure in developed countries. Diabetes self-management is challenging due to the complex lifestyle changes required. Social support from family and friends plays a crucial role in overcoming barriers to healthy behavior choices. Integrating Internet and communication technologies with social support interventions has the potential to improve diabetes self-management. Methods: A scoping review was conducted by searching PubMed, Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Association for Computing Machinery (ACM) Digital Library databases for studies combining diabetes, Internet and communication technologies, and social support interventions. Inclusion criteria focused on adult patients with diabetes and primarily Internet and communication technologies-based strategies to initiate and enhance social support. Data abstraction included study population, design, outcomes, social support domains emphasized, support relationship intervention strategy, and Internet and communication technologies modality. Results: The review identified 39 articles and 33 unique studies representing 27 unique interventions utilizing peer web forums, interactive voice recordings, messaging-based interventions (including Short Message Service and instant messaging), and email as Internet and communication technologies modalities. Various outcomes were reported, including improvements in perception of social support, psychosocial well-being, behavior changes, and clinical outcomes. Existing support relationships may be more effective in promoting behavior change and clinical outcomes compared to developing new relationships. Studies that explicitly measured patients' perception of support consistently showed improvements in psycho-social, behavioral, and clinical outcomes. Conclusions: This scoping review highlights the pivotal role of social support in diabetes self-management. By integrating Internet and communication technologies into interventions, diverse modalities such as web forums and text messaging have shown promise in enhancing patients' perception of support and improving psychosocial well-being, behavior changes, and clinical outcomes. The emphasis on leveraging existing support relationships, rather than establishing new ones, underscores the effectiveness of personalized, patient-centered approaches. These findings provide essential insights for healthcare strategies, emphasizing the need to harness technology and existing social networks to empower individuals in managing diabetes effectively.

Deaths in Immigration and Customs Enforcement (ICE) detention: A Fiscal Year (FY) 2021-2023 update.

Background: This study describes the deaths of individuals in Immigration and Customs Enforcement (ICE) detention between FY2021-2023, updating a report from FY2018-2020, which identified an increased death rate amidst the COVID-19 pandemic. Methods: Data was extracted from death reports published online by ICE. Causes of deaths were recorded, and death rates per 100,000 admissions were calculated using population statistics reported by ICE. Reports of individuals released from ICE custody just prior to death were also identified and described. Results: There were 12 deaths reported from FY2021-2023, compared to 38 deaths from FY2018-2020. The death rate per 100,000 admissions in ICE detention was 3.251 in FY2021, 0.939 in FY2022, and 1.457 in FY2023, compared with a pandemic-era high of 10.833 in FY2020. Suicide caused 1 of 12 (8.3%) deaths in FY2021-2023 compared with 9 of 38 (23.7%) deaths in FY2018-2020. COVID-19 was contributory in 3 of 11 (25%) medical deaths in FY2021-2023, compared with 8 of 11 (72.7%) in the COVID-era months of FY2020 (p = 0.030). Overall, 4 of 11 (36.3%) medical deaths in FY2021-2023 resulted from cardiac arrest in detention facilities, compared with 6 of 29 (20.3%) in FY2018-2020. Three deaths of hospitalized individuals released from ICE custody with grave prognoses were identified. Conclusions: The death rate among individuals in ICE custody decreased in FY2021-2023, which may be explained in part by the release of vulnerable individuals following recent federal legal determinations (e.g., Fraihat v. ICE). Identification of medically complex individuals released from ICE custody just prior to death and not reported by ICE indicates that reported deaths underestimate total deaths associated with ICE detention. Attentive monitoring of mortality outcomes following release from ICE custody is warranted.

Implementation and Evaluation of an Automated Text Message-Based Diabetes Prevention Program for Adults With Pre-diabetes.

BACKGROUND: Despite the efficacy of diabetes prevention programs, only an estimated 5% of people with pre-diabetes actually participate. Mobile health (mHealth) holds promise to engage patients with pre-diabetes into lifestyle modification programs by decreasing the referral burden, centralizing remote enrollment, removing the physical requirement of a brick-and-mortar location, lowering operating costs through automation, and reducing time and transportation barriers. METHODS: Non-randomized implementation study enrolling patients with pre-diabetes from a large health care organization. Patients were exposed to a text message-based program combining live human coaching guidance and support with automated scheduled, interactive, data-driven, and on-demand messages. The primary analysis examined predicted weight outcomes at 6 and 12 months. Secondary outcomes included predicted changes in HbA1c and minutes of exercise at 6 and 12 months. RESULTS: Of the 163 participants included in the primary analysis, participants had a mean predicted weight loss of 5.5% at six months (P < .001) and of 4.3% at 12 months (P < .001). We observed a decrease in predicted HbA1c from 6.1 at baseline to 5.8 at 6 and 12 months (P < .001). Activity minutes were statistically similar from a baseline of 155.5 minutes to 146.0 minutes (P = .567) and 142.1 minutes (P = .522) at 6 and 12 months, respectively, for the overall cohort. CONCLUSIONS: In this real-world implementation of the myAgileLife Diabetes Prevention Program among patients with pre-diabetes, we observed significant decreases in weight and HbA1c at 6 and 12 months. mHealth may represent an effective and easily scalable potential solution to deliver impactful diabetes prevention curricula to large numbers of patients.

Medical Mismanagement in Southern US Immigration and Customs Enforcement Detention Facilities: A Thematic Analysis of Secondary Medical Records.

Detention facilities in the southern US hold a large percentage of individuals detained in the US and have amassed numerous reports of medical mismanagement. The purpose of this study was to evaluate expert declarations of individuals residing in these facilities to assess the appropriateness of medical care provided. We analyzed 38 medical expert declarations from individuals in detention from 2020 to 2021. A thematic analysis was conducted to explore the management of medical conditions. Major themes include inadequate workup, management and treatment of medical conditions, psychiatric conditions, and medical symptoms. Subthemes identified include incorrect workup, failure to refer to a specialist, incorrect medications and/or treatments, missed or incorrect diagnoses, and exacerbation of chronic conditions. This study supports growing evidence of medical mismanagement and neglect of individuals while in immigration detention. Enhanced oversight and accountability around medical care in these facilities is critical to ensure the quality of medical care delivered meets the standard of care.

Does Housing Status Matter in Emergency Medical Services Administration of Naloxone? A Prehospital Cross-sectional Study.

Introduction: Persons experiencing homelessness (PEH) use emergency medical services (EMS) at disproportionately high rates relative to housed individuals due to several factors including disparate access to healthcare. Limited access to care is compounded by higher rates of substance use in PEH. Despite growing attention to the opioid epidemic and housing crisis, differences in EMS naloxone administration by housing status has not been systematically examined. Our objective in this study was to describe EMS administration of naloxone by housing status in the City of Los Angeles. Methods: This was a 12-month retrospective, cross-sectional analysis of electronic patient care reports (ePCRs) for all 9-1-1 EMS incidents attended by the Los Angeles Fire Department (LAFD), the sole EMS provider agency for the City of Los Angeles during the study period, January-December 2018. During this time, the City had a population of 3,949,776 with an estimated 31,825 (0.8%) PEH. We included in the study individuals to whom LAFD personnel had administered naloxone. Housing status is a mandatory field on ePCRs. The primary study outcome was the incidence of EMS naloxone administration by housing status. We used descriptive statistics and logistic regression models to examine patterns by key covariates. Results: There were 345,190 EMS incidents during the study period. Naloxone was administered during 2,428 incidents. Of those incidents 608 (25%) involved PEH, and 1,820 (75%) involved housed individuals. Naloxone administration occurred at a rate of 19 per 1,000 PEH, roughly 44 times the rate of housed individuals. A logistic regression model showed that PEH remained 2.38 times more likely to receive naloxone than their housed counterparts, after adjusting for gender, age, and respiratory depression (odds ratio 2.38, 95% confidence interval 2.15-2.64). The most common provider impressions recorded by the EMS responders who administered naloxone were the same for both groups: overdose; altered level of consciousness; and cardiac arrest. Persons experiencing homelessness who received naloxone were more likely to be male (82% vs 67%) and younger (41.4 vs 46.2 years) than housed individuals. Conclusion: In the City of Los Angeles, PEH are more likely to receive EMS-administered naloxone than their housed peers even after adjusting for other factors. Future research is needed to understand outcomes and improve care pathways for patients confronting homelessness and opioid use.

2022 consensus conference on diversity, equity, and inclusion: Developing an emergency medicine research agenda for addressing racism through health care research.

Racism in emergency medicine (EM) health care research is pervasive but often underrecognized. To understand the current state of research on racism in EM health care research, we developed a consensus working group on this topic, which concluded a year of work with a consensus-building session as part of the overall Society for Academic Emergency Medicine (SAEM) consensus conference on diversity, equity, and inclusion: "Developing a Research Agenda for Addressing Racism in Emergency Medicine," held on May 10, 2022. In this article, we report the development, details of preconference methods and preliminary results, and the final consensus of the Healthcare Research Working Group. Preconference work based on literature review and expert opinion identified 13 potential priority research questions that were refined through an iterative process to a list of 10. During the conference, the subgroup used consensus methodology and a "consensus dollar" (contingent valuation) approach to prioritize research questions. The subgroup identified three research gaps: remedies for racial bias and systematic racism, biases and heuristics in clinical care, and racism in study design, and we derived a list of six high-priority research questions for our specialty.

Training Leaders in Trauma Resuscitation: Teacher and Learner Perspectives on Ideal Methods.

INTRODUCTION: Effective leadership improves patient care during medical and trauma resuscitations. While dedicated training programs can improve leadership in trauma resuscitation, we have a limited understanding of the optimal training methods. Our objective was to explore learners' and teachers' perceptions of effective methods of leadership training for trauma resuscitation. METHODS: We performed a qualitative exploration of learner and teacher perceptions of leadership training methods using a modified grounded theory approach. We interviewed 28 participants, including attending physicians, residents, fellows, and nurses who regularly participated in trauma team activations. We then analyzed transcripts in an iterative manner to form codes, identify themes, and explore relationships between themes. RESULTS: Based on interviewees' perceptions, we identified seven methods used to train leadership in trauma resuscitation: reflection; feedback; hands-on learning; role modeling; simulation; group reflection; and didactic. We also identified three major themes in perceived best practices in training leaders in trauma resuscitation: formal vs informal curriculum; training techniques for novice vs more senior learner; and interprofessional training. Participants felt that informal training methods were the most important part of training, and that a significant part of a training program for leaders in trauma resuscitation should use informal methods. Learners who were earlier in their training preferred more supervision and guidance, while learners who were more advanced in their training preferred a greater degree of autonomy. Finally, participants believed leadership training for trauma resuscitation should be multidisciplinary and interprofessional. CONCLUSION: We identified several important themes for training leaders in trauma resuscitation, including using a variety of different training methods, adapting the methods used based on the learner's level of training, and incorporating opportunities for multidisciplinary and interprofessional training. More research is needed to determine the optimal balance of informal and formal training, how to standardize and increase consistency in informal training, and the optimal way to incorporate multidisciplinary and interprofessional learning into a leadership in trauma resuscitation training program.

Technological Proficiencies, Engagement, and Practical Considerations for mHealth Programs at an Urban Safety-Net Hospital Emergency Departments: Data Analysis.

BACKGROUND: Safety-net emergency departments often serve as the primary entry point for medical care for low income predominantly minority patient populations. Herein, we sought to provide insight into the feasibility, technological proficiencies, engagement characteristics, and practical considerations for a mHealth intervention at a safety-net emergency department. OBJECTIVE: We aimed to analyze patient technological proficiency to understand the feasibility of and draw practical considerations for mobile phone technology (mHealth) solutions for patients with chronic disease served by safety-net emergency departments. METHODS: We analyzed data from a previous diabetes randomized clinical mHealth trial for a diabetes social support intervention. Patients from a safety-net emergency department with preexisting diabetes who used SMS text messages, owned a mobile phone, and with hemoglobin A1c levels >8.5% were enrolled. A text message-based mHealth program to improve disease self-management was provided to all patients. Supporters of patients were randomized to receive a mailed copy or mHealth-based curriculum designed to improve diabetes support. Among enrolled patients, we surveyed mobile technological capacity and frequency of use. We performed latent class analysis to identify classes of patients by level of technological proficiency and compared demographic characteristics between the latent classes to identify demographic subgroups that may require more training or tailoring of the mHealth approach. Study engagement between classes was assessed by comparing the mean number of text messages exchanged, loss to follow-up, and early termination. RESULTS: Of 1876 patients who were approached, 44.2% (n=829) of patients had a stable mobile phone and were able to use text messages. Among them 166 met the trial inclusion and enrolled, 90% (149/166) of the cohort were ethnically diverse. Significant variance was found in technology capacity and frequency of use. Our latent class analysis classified 75% (124/166) of patients as highly technologically proficient and 25% (42/166) patients as minimally technologically proficient. Age (P<.001) and level of education (P<.001) were associated with class membership. Highly technologically proficient patients were younger and had higher levels of education (45.74 years old; high school or more: 90%) than minimally technologically proficient patients (53.64 years old; high school or more: 18%). Highly technologically proficient participants exchanged a mean of 40 text messages with the system coordinators compared to a mean of 10 text messages by minimally technologically proficient patients (P<.001). CONCLUSIONS: This study found that nearly half of the patients screened at the safety-net emergency department were equipped for an SMS text message-based mHealth intervention. In the small sample of patients who were enrolled, the majority were classified as highly technologically proficient. These highly proficient patients had greater study engagement. mHealth use in emergency departments may be an opportunity to improve health of ethnically diverse populations by pairing sophisticated chronic disease self-management program with SMS text message-based and traditional in-person interventions to reach patients through the method that is most familiar and comfortable. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1016/j.cct.2019.03.003.

Correction: Deaths in Immigration and Customs Enforcement (ICE) detention: FY2018-2020.

[This corrects the article DOI: 10.3934/publichealth.2021006.].

Deaths in Immigration and Customs Enforcement (ICE) detention: FY2018-2020.

BACKGROUND: Many civil liberties organizations have raised concerns that substandard medical care in United States Immigration and Customs Enforcement (ICE) detention facilities have led to preventable deaths. The 2018 Department of Homeland Security Appropriations Bill required ICE to make public all reports regarding in-custody deaths within 90 days beginning in Fiscal Year (FY) 2018. Accordingly, ICE has released death reports following each in-custody death since April of 2018. This study describes characteristics of deaths among individuals in ICE detention following the FY2018 mandate. METHODS: Data was extracted from death reports published by ICE following the FY2018 mandate. Causes of death were categorized as suicide or medical, and medical deaths as COVID-19-related or not. Characteristics were compared between medical and suicide deaths, and among medical deaths between COVID-19-related and non-COVID-19-related deaths. Additionally, death rates per person-year and per 100,000 admissions were calculated for FY2018, 2019, and 2020 using methods from prior work evaluating deaths among detained immigrants in the United States. RESULTS: Since April 2018, 35 individuals have died in ICE detention. The death rate per 100,000 admissions in ICE detention was 2.303 in FY2018, 1.499 in FY2019, and 10.833 in FY2020. Suicide by hanging was identified as the cause of death in 9 (25.7%), and medical causes in the remaining 26 (74.3%). Among 26 deaths attributable to medical causes, 8 (30.8%) were attributed to COVID-19, representing 72.7% of 11 deaths occurring since April 2020. CONCLUSIONS: The death rate among individuals in ICE detention is increasing amidst the COVID-19 pandemic. Potentially preventable causes of death including COVID-19 and suicide contribute to at least half of recent deaths. Findings suggest that individuals detained by ICE may benefit from improved psychiatric care and prevention measures to combat suicide, as well as increased infection control efforts to reduce mortality associated with COVID-19.

Continued Trauma: A Thematic Analysis of the Asylum-Seeking Experience Under the Migrant Protection Protocols.

Introduction: The Migrant Protection Protocols (MPP) required asylum seekers presenting to the U.S. southern border to wait in Mexico while seeking asylum. Currently, there is a lack of understanding of the MPP's potential harm to an already highly traumatized population. We sought to understand health impacts of this policy, including exposure to continued trauma. Methods: The University of Southern California (USC)'s Keck Human Rights Clinic analyzed de-identified legal declarations and forensic medical affidavits of 11 asylum seekers subjected to MPP. A deductive, thematic analysis was performed to understand the health impact and traumas experienced, and instances of each subtheme were counted by utilizing content analysis methodology. Results: Case analysis identified a total of 36 subthemes. Trauma subthemes included physical assault, psychological abuse, violence against family/friends, witnessed violence, sexual violence, and escalation. Perpetrator subthemes included gang, paramilitary, intimate partner, family, state, and unknown/other. Stress subthemes included despondency and social isolation. Security subthemes included reach of perpetrator, impunity of perpetrator, continued fear of persecution, fear of return, lack of safety, and reliance on strangers. Social determinants of health subthemes included tenuous housing, financial support, food insecurity, health care access, access to employment, and hazardous conditions. Psychological sequelae included anxiety, depressive, post-trauma, and suicidality; physical sequelae included dental, neurological, and dermatological sequelae. Conclusion: The MPP caused harm among these 11 cases evaluated. Harm resulted from continued trauma, worsening social determinants of health, and continued presence of fear and insecurity. The MPP may increase the risk of re-traumatization as well as detract from asylum seekers' ability to heal from pre-migration trauma.

Who Stayed Home Under Safer-at-Home? Impacts of COVID-19 on Volume and Patient-Mix at an Emergency Department.

INTRODUCTION: To describe the impact of COVID-19 on a large, urban emergency department (ED) in Los Angeles, California, we sought to estimate the effect of the novel coronavirus 2019 (COVID-19) and "safer-at-home" declaration on ED visits, patient demographics, and diagnosis-mix compared to prior years. METHODS: We used descriptive statistics to compare ED volume and rates of admission for patients presenting to the ED between January and early May of 2018, 2019, and 2020. RESULTS: Immediately after California's "safer-at-home" declaration, ED utilization dropped by 11,000 visits (37%) compared to the same nine weeks in prior years. The drop affected patients regardless of acuity, demographics, or diagnosis. Reductions were observed in the number of patients reporting symptoms often associated with COVID-19 and all other complaints. After the declaration, higher acuity, older, male, Black, uninsured or non-Medicaid, publicly insured, accounted for a disproportionate share of utilization. CONCLUSION: We show an abrupt, discontinuous impact of COVID-19 on ED utilization with a slow return as safer-at-home orders have lifted. It is imperative to determine how this reduction will impact patient outcomes, disease control, and the health of the community in the medium and long terms.

Characteristics of Deaths Among Individuals in US Immigration and Customs Enforcement Detention Facilities, 2011-2018.

Importance: Concerns have been raised that substandard medical care has contributed to deaths in US Immigration and Customs Enforcement (ICE) detention facilities. After each in-custody death, ICE produces detainee death reviews, which describe the circumstances of the death and determine whether ICE Performance-Based National Detention Standards (PBNDS) were violated. Objective: To describe factors associated with deaths in ICE detention facilities. Design, Setting, and Participants: This case series used data extracted from detainee death reviews of deaths among individuals detained in ICE facilities for whom these reviews were available from January 2011 to December 2018. Exposures: All individuals were in the custody of ICE at the time of death. Main Outcomes and Measures: Data including demographic information, medical histories, recorded medical data, and reported violations of PBNDS were systematically extracted and summarized. Results: Among 71 individuals who died in an ICE detention facility during the study period, detainee death reviews were available for 55 (77.5%). Most were male (47 [85.5%]), and the mean (SD) age at death was 42.7 (11.5) years. Individuals resided in the US for a mean (SD) of 15.8 (13.2) years before detention and were in ICE custody for a median of 39 days (interquartile range, 9-76 days) before death. Most had low burdens of preexisting disease, with 18 (32.7%) having a Charlson Comorbidity Index score of 0 and 15 (27.3%) having a score of 1 or 2. A total of 47 deaths (85.5%) were attributed to medical causes and 8 (14.5%) to suicide. Markedly abnormal vital signs were documented in the death reviews before 29 of 47 deaths from medical causes (61.7%), and 21 of these 29 deaths (72.4%) were preceded by abnormal vital signs during 2 or more encounters with ICE personnel before death or terminal hospital transfer. Overall, 43 detainee death reviews (78.2%) identified PBNDS violations related to medical care, with a mean (SD) of 3.2 (3.0) deficiencies per detainee death review. Conclusions and Relevance: In this case series, deaths in ICE detention facilities from 2011 to 2018 occurred primarily among young men with low burdens of preexisting disease. Markedly abnormal vital signs preceded death or hospital transfer for most nonsuicide deaths. The PBNDS were violated in most detainee death reviews. These results suggest that additional oversight and external evaluation of practices related to medical and psychiatric care within ICE facilities are needed.

Mapping factors associated with deaths in immigration detention in the United States, 2011-2018: A thematic analysis.

Background: Climate change, poverty, and violence increasingly drive migration to the United States. United States Immigration and Customs Enforcement (ICE) detain some individuals while awaiting determination of immigration status or potential deportation. Over the last two decades, more than 200 individuals died in ICE detention. In this study, we aim to identify systemic issues related to deaths of individuals in ICE detention to potentially mitigate further harm. Methods: The ICE Office of Detention Oversight conducts investigations after each death in detention, producing a report called a "Detainee Death Review". To identify systemic issues in these deaths, we used thematic analysis to review 55 Detainee Death Reviews available between 2011 and 2018. Findings: We identified 3 major themes of pervasive issues-Detainee Not Patient, System Over Patient, and Grossly Substandard Care- and 11 subthemes. Subthemes of culture of shortcuts, delays in care, and poor care delivered were present in the vast majority of cases. Subthemes bias and discrimination, language injustice, falsification of and inconsistencies between records and reports, willful indifference, security over health, communication breakdown, inadequate resources, failure of protective mechanisms, missing/ignoring red flags, and failure of emergency response were also prominent. Interpretation: This study identified underlying systems issues within the medical care provided in ICE detention. While there are issues with language services, discrimination, and inadequate response to medical emergencies, the greatest issue is the lack of independent, external review. Greater transparency is required, so that adherence to basic standards of care for individuals in ICE detention can be better evaluated. Funding: Haas Jr. Fund and the University of Southern California's Equity Research Institute.

Telehealth in emergency medicine: A consensus conference to map the intersection of telehealth and emergency medicine.

INTRODUCTION: Telehealth has the potential to significantly change the specialty of emergency medicine (EM) and has rapidly expanded in EM during the COVID pandemic; however, it is unclear how EM should intersect with telehealth. The field lacks a unified research agenda with priorities for scientific questions on telehealth in EM. METHODS: Through the 2020 Society for Academic Emergency Medicine's annual consensus conference, experts in EM and telehealth created a research agenda for the topic. The multiyear process used a modified Delphi technique to develop research questions related to telehealth in EM. Research questions were excluded from the final research agenda if they did not meet a threshold of at least 80% of votes indicating "important" or "very important." RESULTS: Round 1 of voting included 94 research questions, expanded to 103 questions in round 2 and refined to 36 questions for the final vote. Consensus occurred with a final set of 24 important research questions spanning five breakout group topics. Each breakout group domain was represented in the final set of questions. Examples of the questions include: "Among underserved populations, what are mechanisms by which disparities in emergency care delivery may be exacerbated or ameliorated by telehealth" (health care access) and "In what situations should the quality and safety of telehealth be compared to in-person care and in what situations should it be compared to no care" (quality and safety). CONCLUSION: The primary finding from the process was the breadth of gaps in the evidence for telehealth in EM and telehealth in general. Our consensus process identified priority research questions for the use of and evaluation of telehealth in EM to fill the current knowledge gaps. Support should be provided to answer the research questions to guide the evidenced-based development of telehealth in EM.