ACEP COVID-19 Field Guide

Authors: Nicholas J. Dreyer, MD; and Aisha T. Terry, MD, MPH, FACEP

Overview

With nearly 2.2 million people residing within US jails and prisons as of 2016, the US leads the world in the number of incarcerated individuals.¹ These data are concerning for many reasons but most urgently for that of public health and safety amid the current COVID-19 pandemic. The confining nature of such detention facilities paired with specific characteristics of the detainees poses a significant challenge in the realm of infection prevention and control. Compared to the general population, people in prison have greater underlying disease burdens (ie, HCV, HIV, and tuberculosis), have worse overall health statuses, and face conditions unfavorable to attaining proper medical care.² For these reasons, an already vulnerable patient population becomes even more so in times of widespread communicable disease outbreak, such as the one we now face. Furthermore, this increased risk to health safety is shared not only among incarcerated persons, but also with those who work at, interact with, and live nearby the affected detention facilities — through close interplay with these groups of people. 

As of mid-April 2020, the Federal Bureau of Prisons (BOP) has reported confirmed COVID-19 cases at 40 detention facilities and 9 residential re-entry centers.³ The infection of over 350 federal inmates and nearly 200 BOP employees, causing 10 inmate deaths, has quickly gained attention. To combat this spreading threat, the BOP recently enacted an emergency response plan with guidance and directives from the WHO and CDC that aims to mitigate and control the spread of COVID-19. Mechanisms set in place to achieve this include suspending social visits, limiting legal counsel visits, reducing facility transfers, maximizing social distancing, and implementing various screening efforts. Some detention centers quarantine all new arrestees in separate housing units for a designated number of days or until they show symptoms, in an effort to limit exposure of other inmates and staff to COVID-19. However, given the congregate nature of the prison system, conventional strategies for reduction of viral transmission through social distancing and isolation are far less likely to be effective, given the limited space, lack of resources, and overwhelming population at these facilities. Thus, it is paramount to limit the virus from entering such correctional facilities as much as possible. 

Testing 

In light of the unique challenges that detention facilities face with regard to the threat of viral spread, emergency medicine clinicians play an important role in the realm of prevention. As the BOP ramps up its efforts to manage the impact COVID-19 has on its population, emergency departments should prioritize the testing of those in custody whose final destination has limited or no capability to isolate, quarantine, and monitor appropriately. In these patients, it is prudent to perform COVID-19 testing with a rapid turn-around time prior to discharge and transfer to limit the introduction of this viral pathogen to such a highly vulnerable population. By obtaining infection status, more efficient use of already limited space and resources can be made in the receiving detention facilities. While the availability of testing modalities may vary among institutions, it is advisable to use tests with the greatest sensitivity and fastest turn-around time to screen patients who are of low suspicion to rule out COVID-19 prior to transfer. For patients with moderate to high suspicion of COVID-19, modalities with longer turn-around times may be employed, but under the advice that patients are to be placed in quarantine until testing results are available. In theory, depending on the availability of testing kits, this will help prevent introduction of the virus into the accepting facility while making efficient use of limited resources. However, given the relatively low volume of patients seen in the emergency department who are incarcerated or otherwise under police custody, every effort should be made to obtain a result prior to their discharge or transfer. 

Facility transfer 

The current COVID-19 pandemic presents a new challenge in the transfer of incarcerated or soon-to-be incarcerated patients. While their rights should never be violated, certain precautions must be taken to limit the spread of this highly communicable pathogen. In the setting of patient transfer from the referring detention facility to the hospital or emergency department, predetermined protocols should continue to be followed but with added emphasis on effective communication regarding the reason for transfer, current medical complaints, and clinical condition. Clear communication between all parties involved in the transfer and medical care of patients is key to preventing unnecessary pathogen exposure and its potential propagation. Furthermore, the referring facility should be informed of the potential need for patient quarantine on return and that such arrangements should be made prior to patient discharge from the local medical facility. Due to the lack of space and resources of many detention facilities, timely updates on patient status and potential disposition should be relayed to the referring facility to free up resources if patient discharge and return is unlikely. Although contingent on testing availability, COVID-19 status of all incarcerated patients prior to transfer out of a detention facility should be obtained, if possible. 

Prior to discharge, the COVID-19 status of the patient should be known by both parties involved in the patient transfer and care, and appropriate precautions should be taken, if required. If isolation is necessary, these arrangements should be made by the detention facility prior to discharge of the patient. In the event that testing kits are unavailable at the accepting emergency department and the COVID-19 status is still unknown, the following guidelines set forth by the BOP should be followed on return: Asymptomatic inmates with exposure risk factors should be quarantined; symptomatic inmates with exposure risk factors should be isolated and tested for COVID-19 per local health authority protocols.⁴ 

References

1. Kaeble D, Cowhig M. Correctional Populations in the United States, 2016. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 2018 Apr.
2. Maruschak LM, Berzofsky M, Unangst J. Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-2012. Washington, DC: U.S. Department of Justice, Bureau of Justice Statistics; 2015 Feb.
3. COVID-19 coronavirus. Federal Bureau of Prisons, U.S. Department of Justice website. 
4. Federal Bureau of Prisons COVID-19 action plan. Federal Bureau of Prisons, U.S. Department of Justice website. 2020 Mar 13.