Prisoners

Aka: Prisoners, Prison Inmate, Incarcerated Patient, Jailed Patient, Healthcare of the Incarcerated Patient

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II. Epidemiology

  1. U.S. Adult Incarceration rate: 870 per 100,000
  2. Jailed population is roughly 720,000 total at one time (nearly 11 million jail admissions/year)
  3. Highest rates of incarceration are for black persons (Relative Risk >5 compared with white persons)
  4. Most Incarcerated Patients come from poor, segregated communities with high unemployment
  5. Most U.S. inmates are young males of minority race or ethnicity, and lower socioeconomic status
    1. Females account for 7% of U.S. inmates
    2. Over age 55 years account for 11% of U.S. inmates
    3. Veterans account for 10% of U.S. inmates
    4. Homelessness rates prior to incarceration are as high as 12-16% in U.S.

III. Evaluation: Guidelines for Accredited Prisons, Jails and Detention Centers

  1. Accreditation Organizations (most facilities are NOT accredited)
    1. National Commission on Correctional Health Care
    2. American Correctional Association
  2. Intake Screening
    1. Fit for confinement screening (Intake health screening) of all inmates on arrival
      1. Performed early in incarceration period by health professional or trained corrections officer
      2. Structured history and limited examination
      3. Failed evaluation (unfit for confinement) results in transfer for Emergency Department evaluation
    2. Intake health assessment
      1. Medical, dental and mental health history and physical exam
      2. Performed by medical provider within 7-14 days of incarceration
      3. Specific high risk screening (e.g. Tuberculosis) may take place at this time
    3. Mental health (refer for formal mental health evaluation and management as indicated)
      1. Continue neuropsychiatric medications
      2. Obtain mental health records of patients with pre-existing mental health conditions
      3. Screening tools
        1. Correctional Mental Health Screen
        2. Brief Jail Mental Health Screen
      4. Substance Withdrawal protocols are available at many larger facilities
        1. Alcohol Withdrawal, Opioid Withdrawal and Benzodiazepine Withdrawal protocols
    4. Reproductive health evaluation in women
      1. Pregnancy screening
      2. Gonorrhea and Chlamydia DNA Probes
  3. Ongoing healthcare
    1. Onsite Clinics (prisons and large jails)
      1. Acute and chronic medical problems addressed
    2. Medical or Psychiatric Infirmary (some prisons and large jails)
      1. Subacute unit for ill patients requiring frequent nursing care or unable to perform ADLs

IV. Labs: Screening

  1. STD Screening
    1. HIV Infection
    2. Hepatitis C
    3. Syphilis
    4. Gonorrhea and Chlamydia DNA Probes (esp. in female inmates)
  2. Other screening
    1. Latent Tuberculosis

V. Precautions

  1. Lab blood draws
    1. Patient must consent to blood draw or officer must have a warrant to obtain blood (fourth amendment rights)
      1. Exception: Immediate health and safety of patient
    2. Medical staff may refuse to draw blood despite warrant, if they believe there is a threat to their safety (Violence)
  2. Evaluation of acute medical conditions
    1. Malingering is common, but start with a reasonable evaluation for presenting concerns
    2. Expect Alcohol Withdrawal after 12-48 hours of incarceration
    3. Thoroughly evaluate acute medical conditions (e.g. Chest Pain, Abdominal Pain, Unknown Ingestions)
    4. Thoroughly evaluate Trauma patients and have a low threshold for imaging (e.g. Head CT, neck CT) when indicated
      1. Inmates are frequently vague about assaults that occur in prison
  3. Privacy in interviewing the patient
    1. Ask officers to allow for sensitive patient interview questions that allow for privacy (without risking safety)
  4. Ensure continuation of important chronic medications
    1. Insulin in Diabetes Mellitus
    2. Antiepileptics in Seizure Disorder
    3. Antipsychotics in Schizophrenia

VI. Associated Conditions

  1. Communicable Disease
    1. HIV Infection: 1297 per 100,000 persons (RR >4 compared with general population)
    2. Tuberculosis Relative Risk: 8 (50% were born outside the United States)
  2. Psychiatric Illness (present in up to 60% of inmates)
    1. Associated with higher rates of assault, solitary confinement, self harm and repeat offenses
    2. See Intake Screening as above
    3. Substance Abuse (and risk for withdrawal on incarceration; see above)
      1. Alcohol Use Disorder
      2. Opioid Use Disorder
      3. Stimulant Use Disorder
    4. Schizophrenia
    5. Bipolar Disorder
    6. Posttraumatic Stress Disorder
  3. Chronic medical conditions
    1. Continue chronic medical condition management including medication
    2. Type 2 Diabetes Mellitus
    3. Hypertension
    4. Obesity
  4. Female inmate conditions
    1. Higher rates of chronic medical and psychiatric illness and Substance Abuse than male inmates
    2. Higher rates of Gonorrhea and Chlamydia (esp. juvenile inmates)
    3. Higher rates of Cervical Cancer
    4. Pregnancy in 6-10% of incarcerated women (often unintended)
    5. Longterm inmates
      1. Contraception
      2. Preconception Counseling
      3. Pap Smear Intervals per USPTF schedules (higher rates of Cervical Cancer)
      4. Mammogram per USPTF schedules for longstanding Prison Inmates

VII. Prevention

  1. STD Prevention Education
    1. Condom distribution to Prisoners (recommended by WHO)
  2. Substance Abuse education
    1. Consider referral to Opioid Addiction Management program on discharge
  3. Discharge Planning
    1. Serious health conditions are referred to community facilities (e.g. Transitions Clinic Network)
    2. Adequate supply of chronic medications to allow for follow-up
    3. Within 2 weeks of incarceration discharge, mortality is very high (Relative Risk: 12)
      1. Drug Overdose related death (Relative Risk: 129)
      2. Suicide Attempts
      3. Chronic Medical Condition decompensation and noncompliance

VIII. Resources

  1. American College of Correctional Physicians
    1. https://accpmed.org/
  2. CDC Correctional Health
    1. https://www.cdc.gov/correctionalhealth/
  3. Federal Bureau of Prisons Health Management
    1. https://www.bop.gov/resources/health_care_mngmt.jsp
  4. National Commission on Correctional Health Care
    1. https://www.ncchc.org/

IX. References

  1. Swadron and Eiting in Herbert (2019) EM:Rap 19(3):13-15
  2. Davis (2018) Am Fam Physician 98(10): 577-83 [PubMed]
  3. Kane (2023) Am Fam Physician 108(3): 295-300 [PubMed]

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