Emergency Medical Responses at US Immigration and Customs Enforcement Detention Centers in California

Key Points Question What were the characteristics of medical emergencies at US Immigration and Customs Enforcement (ICE) detention centers in California from 2018 to 2022? Findings In this cross-sectional analysis of 3 detention centers, emergency medical services reported a median of 68 emergencies per center per year for a total of 1224 medical emergencies. The median number of monthly emergency medical services–reported emergencies across all 3 centers was 3, while that of monthly ICE-reported emergencies was 4. Meaning These findings suggest a need for an increased understanding of how medical emergencies are managed at ICE detention centers to ensure that the health care system meets the needs of detained individuals.


Introduction
2][3] Deaths in ICE facilities typically occur in young individuals (mean age, 42.7 years) with few comorbidities. 4One-half of the fatalities are due to potentially preventable causes, such as COVID-19 and suicide. 5Systematic substandard care has been identified as a factor associated with these deaths, including lack of recognition of severe illness, medical staff dismissal of concerns about individuals' health, and delays in activating external emergency care.These findings suggest that there are near misses not captured in death reviews. 6st US health systems have mechanisms to review poor outcomes.However, oversight of medical care in ICE detention centers is limited.Nationally, ICE Enforcement and Removal Operations contracts with the Nakamoto Group Inc to conduct annual facility inspections, while the Office of Detention Oversight inspects facilities every 3 years.Inspections evaluate facility compliance with Performance-Based National Detention Standards. 7p4) Moreover, facilities are not held accountable for correcting deficiencies. 7Mandated medical reviews occur for individuals who die while in ICE custody; however, no systematic reviews currently exist to monitor other outcomes. 8In California, legislators have increased oversight of ICE detention centers by passing assembly bill No. 103, which establishes attorney general oversight of detention facilities, 9 and senate bill No. 29, which prohibits local governments from expanding or entering into contracts with the federal government or private companies for immigration detention. 10e aim of this study is to expand our current understanding of medical emergencies in ICE detention centers in California.The study explores rates and characteristics of emergency medical services (EMS)-reported emergencies as well as ICE-reported medical emergencies for individuals held in detention centers in California.

Methods
This cross-sectional analysis examined medical emergency responses at ICE detention centers in California from January 1, 2018, to December 31, 2022.The study was deemed exempt by the University of California, Los Angeles institutional review board, with a waiver of informed consent given that deidentified and publicly available data were used.Data were obtained and triangulated across 3 sources, including DHS ICE-mandated reporting, California Department of Justice (CA DOJ) annual inspections, and EMS agencies.This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. 11

DHS ICE
Dates of operation, mean daily population, and number of onsite medical personnel were obtained via ICE-authorized facility list reports available on the DHS ICE website. 12,13Data not posted on DHS ICE website were extracted using an internet archive, Wayback Machine. 14Noncumulative monthly mean daily populations were calculated from ICE-reported cumulative mean daily populations.Data were available from July 1, 2018, to September 30, 2022.
Additional information was obtained via ICE Enforcement and Removal Operations facility inspections available on the DHS ICE website. 15Facility inspections included ICE self-reported medical incidents per month from January 1, 2019, to December 31, 2021, including detainees transported to offsite hospitals for emergency care; detainees in mental health observation; suicide watches, constant watch, and mental health observation; and suicide attempts (or self-harm).

CA DOJ
The CA DOJ reviews ICE detention centers annually.7][18] Age and sex (female, male, transgender, not reported) of individuals held in detention were available and obtained from CA DOJ 2019 and 2022 reports (eTable 1 in Supplement 1).

EMS-Reported Emergencies
California detention centers that exclusively housed detained immigrants and were open for at least 2 years during the study period were eligible for inclusion.Five detention centers were identified:

Statistical Analysis
A Poisson model was used in which EMS-reported emergency care was the outcome and demographics, facility, and their interaction were the exposure, using an offset to control for differences in census among sites based on CA DOJ reports.Post hoc comparisons of sex were made at each facility.Two-sided hypothesis testing and an a priori significance level of .05 were used.Of note, individuals identified as transgender or sex not reported (9 of 3557 [0.3%]) were excluded from the analysis given small sample sizes.
Emergencies reported by EMS were analyzed descriptively to assess vital signs, the primary symptom, EMS provider (emergency medical technician or paramedic) impression, and treatment provided.Data were reviewed for abnormal vital signs (defined as heart rate <60 or Ն100 beats per minute, systolic blood pressure <90 or Ն180 mm Hg, respiratory rate <12 or Ն24 breaths per minute, or oxygen saturation <90%). 19Extreme vital signs were reviewed.If incongruent with the clinical context, the vital sign was replaced with the patient's median vital sign value for that measurement.
If no other vital signs were available, data were noted as missing.Sixteen of 1224 (1.3%) patients were found to have at least 1 incongruent vital sign that was modified as described.
Primary symptoms and EMS provider impressions were reviewed.Similar entries were pooled (ie, chest wall pain and cardiac chest pain were both called chest pain).EMS provider impressions were stratified by sex to describe and compare the most frequent emergencies by sex, and the 10 most frequent impressions were reported.The total number of monthly psychiatric-related EMS-reported emergencies were compared with ICE-reported mental health observations, suicide watches, and suicide attempts by detention center.Medications and procedures were reviewed and duplicates merged.
Emergencies reported by EMS were analyzed to assess the absolute number per month per center.The number of emergencies was divided by the facility census to calculate the EMS-reported emergencies per 1000 population per month. 12Complete population data were restricted to July The monthly rate of EMS-reported emergencies increased at Otay Mesa Detention Center from March to September 2020, with a peak of 52 emergencies per 1000 detained immigrants in August 2020 (Figure 1B).Imperial Regional Detention Facility showed an increase in emergencies from July to September 2020, with a peak of 12 emergencies per 1000 detained immigrants in September 2020 (Figure 1B).Adelanto ICE Processing Center showed an intermittent increase in the rate of EMS-reported emergencies in the springs of 2021 and 2022, with a peak of 77 emergencies per 1000 detained immigrants in May 2022 (Figure 1B).
From January 2019 to December 2021, there were 742 EMS-reported emergencies, compared with 1481 ICE-reported medical emergencies.The median number of monthly EMS-reported emergencies across all 3 centers was 3 (IQR, 0-9), while the median number of monthly ICE-reported emergencies was 4 (IQR, 1-15).The number of ICE-reported medical emergencies was higher across all 3 detention centers from January 2019 through July 2020 (Figure 1C).c The EMS data included 3 individuals whose sex was reported as other and 2 individuals with unknown sex.These individuals were excluded from the analysis given the small sample size.
d Based on Poisson model regression of EMS-reported emergencies for female vs women with population demographics as offset (eTables 2 and 3 in Supplement 1).
e Detention population age based on 2022 CA DOJ report.eTable 1 in Supplement 1 provides the full data range by center.Data on median age and total population age were NA.
f Age not reported for 1 individual.

Discussion
The findings of this study expand our understanding of medical emergencies that occur in ICE detention facilities.5][6] We found that EMS-reported medical emergencies were disproportionately for females at the Otay Mesa Detention Center, with 12% of all EMS-reported emergencies for female patients due to pregnancy concerns.The findings are particularly salient given the recent ICE directive 11032.4,effective July 1, 2021, that mandated that "ICE should not detain, arrest, or take into custody for an administrative violation of the immigration laws individuals known to be pregnant, postpartum, or nursing" and that officials should ensure "expeditious release, where legally authorized, of individuals known to be pregnant, postpartum, or nursing already detained in ICE custody." 20Seven EMS-reported emergencies for pregnancy-related concerns occurred after July 1, 2021, indicating that Otay Mesa continued to house pregnant individuals despite ICE directives.It is unclear whether this higher rate of emergency activations at Otay Mesa represents higher rates of illness vs higher rates of monitoring and use of emergency services for females in detainment.p26) Historically, women in ICE detention have experienced medical maltreatment, including unnecessary gynecologic procedures 21 and reports of sexual assault. 22e findings also show a low percentage of EMS-reported emergencies for mental health crises.
On average, the number of EMS-reported responses for psychiatric emergencies were 0.52 per month.In comparison, the average number of ICE-reported mental health observations were 7.13 per month, while the number of suicide attempts was 0.53 per month.The data might be interpreted as appropriate management of psychiatric crises in-house by medical staff at detention centers, with activation only when an individual has attempted suicide.However, the CA DOJ reports highlighted severe deficiencies in staffing of mental health professionals, delays in access to mental health care, dangerous use of solitary confinement, and lack of appropriate prevention of suicide harms in all 3 detention centers. 16,17Suicide accounted for 14.5% of deaths in ICE detention centers from 2011 to 2018 4 and 25.7% from 2018 to 2020. 5 According to 1 review of deaths from 2010 to 2020, the rate of suicide in ICE detention centers increased by 11-fold in 2020 compared with the prior 10-year Abbreviation: NA, not available.aCalifornia Department of Justice (CA DOJ) reports and EMS agencies did not clarify how sex vs gender was obtained; we have assumed this variable to be representative of sex.b Detention population sex based on mean of 2019 and 2022 CA DOJ report.eTable 1 in Supplement 1 provides the full data range by center.The CA DOJ reports mentioned 4 individuals who identified as transgender.These individuals were excluded from the analysis given the small sample size.