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The Broader Consequences of Prehospital Transport by Police for Penetrating Trauma Sara F Jacoby ‍ ‍ ,1 Charles C Branas,2 Daniel N Holena,3 Elinore J Kaufman ‍ ‍ 3

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The Broader Consequences of Prehospital Transport by Police for Penetrating Trauma Sara F Jacoby ‍ ‍ ,1 Charles C Branas,2 Daniel N Holena,3 Elinore J Kaufman ‍ ‍ 3 Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2020-000541 on 26 November 2020. Downloaded from Open access Original research Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma Sara F Jacoby ,1 Charles C Branas,2 Daniel N Holena,3 Elinore J Kaufman 3 ► Additional material is ABSTRACT by emergency medical services (EMS).7 This is likely published online only. To view, Background Time to definitive hemorrhage control because, unlike EMS, bystanders are not delayed please visit the journal online by the need for notification, dispatch, and travel. (http:// dx. doi. org/ 10. 1136/ is a primary driver of survival after penetrating injury. tsaco- 2020- 000541). For these injuries, mortality outcomes after prehospital Police on patrol are often first to arrive at the scene transport by police and emergency medical service of an injury. Direct hospital transport by police 1Department of Family and (EMS) providers are comparable. In this study we identify has demonstrated its potential to improve survival Community Health, University of patient and geographic predictors of police transport outcomes after penetrating injuries.8–10 However, Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA relative to EMS transport and describe perceptions of little is known about the broader impact of police 2Department of Epidemiology, police transport elicited from key stakeholders. transport on patients, police officers, and trauma Columbia University Mailman Methods This mixed methods study was conducted in centers.11 School of Public Health, New Philadelphia, Pennsylvania, which has the highest rate Philadelphia, Pennsylvania, was the first US York, New York, USA 3Division of Trauma, Surgical of police transport nationally. Patient data were drawn municipality to codify a ‘scoop and run’ policy 12 13 Critical Care and Emergency from Pennsylvania’s trauma registry and geographic data in 1987. This policy authorizes non- medical Medicine, University of from the US Census and American Community Survey. police personnel to transport patients to the nearest Pennsylvania Perelman School For all 7500 adults who presented to Philadelphia trauma center without waiting for EMS in cases of Medicine, Philadelphia, trauma centers with penetrating injuries, 2006–2015, we of ‘a serious penetrating wound, eg, gunshot, stab Pennsylvania, USA compared how individual and geospatial characteristics wound, and similar injuries of the head, neck, 14 Correspondence to predicted the odds of police versus EMS transport. chest, abdomen’. By 2015, over 50% of patients Dr Sara F Jacoby; sfjacoby@ Concurrently, we conducted qualitative interviews with with penetrating injuries arrived to one of the city’s nursing. upenn. edu patients, police officers and trauma clinicians to describe eight trauma centers in a police vehicle.8 15 Philadel- their perceptions of police transport in practice. phia has the highest police transport rate for any US copyright. Received 24 June 2020 Results Patients who were Black (OR 1.50; 1.20–1.88) city,16 17 followed by Sacramento and Detroit,18 and Revised 28 September 2020 Accepted 25 October 2020 and Hispanic (OR 1.38; 1.05–1.82), injured by a more than 60% of all US police hospital transports firearm (OR 1.58; 1.19–2.10) and at night (OR 1.48; occur in Philadelphia. Other cities are beginning to 1.30–1.69) and who presented with decreased levels adopt police transport policies to meet the emer- of consciousness (OR 1.18; 1.02–1.37) had higher gency medical needs of their residents.16 odds of police transport. Neighborhood characteristics Police transport upends many of the usual expecta- predicting police transport included: percent of Black tions for prehospital patient care and understanding population (OR 1.18; 1.05–1.32), vacant housing (OR its full effects can inform trauma systems seeking 1.40; 1.20–1.64) and fire stations (OR 1.32; 1.20–1.44). new strategies to reduce the impact of penetrating All stakeholders perceived speed as police transport’s injuries. In Philadelphia, for example, patients with primary advantage. For patients, disadvantages penetrating injuries are predominately young Black included pain and insecurity while in transport. Police men who may be at higher risk for mortality after http://tsaco.bmj.com/ identified occupational health risks. Clinicians identified trauma and postacute morbidities like depression occupational safety risks and the potential for police and post- traumatic stress disorder.19–22 Qualitative transport to complicate the workflow. evidence has illustrated how some injured Black Conclusions Police transport may improve prompt men associate police transport and their interac- access to trauma care but should be implemented tions with law enforcement prior to reaching a with consideration of the equity of access and broad trauma center with additional pain and feelings stakeholder perspectives in efforts to improve outcomes, of dehumanization.23 24 Police transport may also on September 30, 2021 by guest. Protected safety, and efficiency. pose underappreciated hazards to officers who Level of evidence Epidemiological study, level III. provide injury first response with minimal medical training and equipment. Lastly, no studies have assessed variations in police transport and access to trauma care across a municipality or the effect on BACKGROUND trauma care processes at a receiving center. To our © Author(s) (or their Hemorrhage control is a primary determinant of knowledge, no study has evaluated police transport employer(s)) 2020. Re- use 1–3 permitted under CC BY-NC . No survival after penetrating trauma. Accordingly, beyond hospital survival and length of stay. commercial re-use . See rights a key goal of trauma system improvement is to In this study, we examine the practice, context, and permissions. Published minimize prehospital time.4–6 In urban areas near and social perception of police transport in Phila- by BMJ. trauma centers, at- scene prehospital interventions delphia, as a case study of the municipality with the To cite: Jacoby SF, may delay transport with little benefit. This is longest and most prevalent use of police transport Branas CC, Holena DN, et al. supported by evidence demonstrating that patients as a prehospital strategy. To do so, we combined a Trauma Surg Acute Care Open transported in private vehicles have better survival quantitative analysis of retrospective trauma registry 2020;5:e000541. outcomes when compared with those transported data with a prospective exploratory qualitative Jacoby SF, et al. Trauma Surg Acute Care Open 2020;5:e000541. doi:10.1136/tsaco-2020-000541 1 Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2020-000541 on 26 November 2020. Downloaded from Open access analysis to achieve two distinct but complementary aims. The and injury intentionality were derived from external cause- of- quantitative arm of this study aimed to identify the influence injury codes. of geography, neighborhood sociodemography and crime inci- We evaluated neighborhood crime characteristics including dence on prehospital transportation for victims of penetrating rates of aggravated assault, robbery with a gun, homicide, and injuries over 10 years in Philadelphia. We hypothesized that narcotic arrests. We evaluated neighborhood sociodemographic the distribution of police versus EMS transport would differ characteristics including racial and ethnic make-up, percent of by neighborhoods of the city and would be associated with the adult population with less than a high school education, percent sociodemographic features and crime incidence of those neigh- of vacant housing units, percent of living in poverty, percent of borhoods.4 In the qualitative arm of this study we used qualita- unemployed, and percent of receiving public assistance. We also tive interviews to develop an in- depth description the perceived included number of police and fire stations in each neighbor- advantages and disadvantages of ‘scoop and run’ as it is inter- hood. EMS in Philadelphia is part of the city’s Fire Department preted by injured people, police, and trauma clinicians working and ground EMS deploys from fire stations. After evaluating in the city’s trauma center emergency departments (EDs).25 26 variables for collinearity, final models included number of fire This approach allows us to identify the perceived trade- offs of stations, aggravated assault rate, narcotic arrest rate, percent police transport in practice that we might not have expected a of the population that was Black, percent of housing units that priori and serves to generate hypotheses for future testing. were vacant, and percent of living in poverty. STUDY DESIGN Analysis We used a concurrent (QUANT- QUAL) mixed methods We used bivariable and multivariable analyses to compare police- approach.27 Multivariate regression and geospatial modeling transported to EMS- transported patients. Categorical variables of trauma registry data permitted us to examine individual and were compared using χ2 tests and continuous variables were geographic characteristics that predict police transport relative compared using the Kruskal- Wallis test. We used multivariable to EMS. Qualitative interviews and content analysis of interview logistic regression to identify significant predictors of police data offered a complementary perspective on police transport transport. Candidate predictors were included in the final model from the point of view of
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