|Year : 2014 | Volume
| Issue : 9 | Page : 460-465
The preliminary experience in the emergency department of a newly opened penitentiary institution hospital in Turkey
Bora Koc1, Firat Tutal1, Mehmet Urumdas2, Yalcin Ozkurt2, Tugcan Erus3, Alpaslan Yavuz4, Ozgur Kemik5
1 Department of Surgery, Silivri Penitentiary Institution Hospital, Silivri, Istanbul, Turkey
2 Department of Cardiology, Silivri Penitentiary Institution Hospital, Silivri, Istanbul, Turkey
3 Department of Internal Disease, Silivri Penitentiary Institution Hospital, Silivri, Istanbul, Turkey
4 Departments of Radiology, Faculty of Medical, Yuzuncu Yil University, Van, Turkey
5 Department of Surgery, Faculty of Medical, Yuzuncu Yil University, Van, Turkey
|Date of Web Publication||24-Sep-2014|
Source of Support: None, Conflict of Interest: None
Background: Emergency cases become a widespread problem in prisons across Turkey. The opening of a new prison hospital in January 2012 within the catchment of Silivri Penitentiary Institution gave a unique opportunity to treat the inmates quickly. Aims: The study was to conduct an extensive review for documentation of prisoners' healthcare problems leading to emergency admission following the first year after the opening of Penitentiary Institution Hospital and point to decrease redundant hospital transfers of this individual cohort. Materials and Methods: A cross-sectional study was carried out where 12,325 visits to the Silivri Penitentiary Institution Hospital for emergency visits from the period of 1 st January 2012 to the 31 st December 2012 were identified from electronic medical records. After obtaining consent from the local IRB, data including details of the type, cause and nature of the complaints of the illnesses were processed. Results: In the 12-month period, there were 12,325 visits to the emergency department, of which 4328 for surgical conditions (35.1%), 2684 for medical disorders (21.8%), 1867 for sports injuries (15.2%), 1327 for Ear Nose Throat (ENT) problems (10.8%), 827 for psychiatric disorders (6.70%), 396 for violence injury (3.2%), 169 for self harm (1.4%), and 727 for miscellaneous (5.8%). The most common cause of emergency visits was sports injuries, followed by non-specific abdominal pain and ENT problems. Eighteen prisoners re-attended 243 times, ranging from 8 visits to a maximum of 56 visits. Conclusion: Inmates in prison have a wide range of complaints, and sometimes these complaints do not suggest an illness. Prison population exhibited substantially higher prevalence rates of diseases than the civilian population. We conclude that this new healthcare system in prisons will prevent redundant hospital transfers and guarantee detainees have access to the same health care that is offered to non-detained population.
Keywords: Emergency department, Inmates, Prison hospital
|How to cite this article:|
Koc B, Tutal F, Urumdas M, Ozkurt Y, Erus T, Yavuz A, Kemik O. The preliminary experience in the emergency department of a newly opened penitentiary institution hospital in Turkey. North Am J Med Sci 2014;6:460-5
|How to cite this URL:|
Koc B, Tutal F, Urumdas M, Ozkurt Y, Erus T, Yavuz A, Kemik O. The preliminary experience in the emergency department of a newly opened penitentiary institution hospital in Turkey. North Am J Med Sci [serial online] 2014 [cited 2020 Apr 10];6:460-5. Available from: http://www.najms.org/text.asp?2014/6/9/460/141642
| Introduction|| |
The healthcare of detainees is very important from human rights perspective and a public health priority. According to the United Nations (UN) resolution of 1990, all prisoners have the right to adequate healthcare.  However, in many countries, the healthcare service in prisons could not be granted as same as the normal population. The inadequate state of health in prisons is still cause for international concern. , Management of these patients presents a number of problems to transfer to hospital and diagnosis and treatment can disturb the normal routine of the civil hospital. In addition, this practice presented numerous logistical problems to the prison governance including safety transfer and requiring multiple escorts to transport the prisoners.
Prison populations have risen significantly during the last years, worldwide. Most prisoners were unemployed or did not have an insurance, which correlates with increased morbidity and mortality.  In literature, it is shown that 65-81% of all prisoners suffer from one or more health problems.  Prisoners are known to be a high-risk group for medical and psychiatric illnesses, infectious diseases, and physical diseases. ,, Detainees are generally young population, but the number of prisoners older than 60 years is increasing.  Due to this aging population, it is expected to suffer from at least one chronic disease. Additionally, in consequence of lower sociocultural situation, prisoners' health problems are unrecognized and treated too late.
Opening of a new prison in 2008 within the Silivri District, with more than 10,000 detainees who live in prison require emergency and routine care service. Prior to 2012 January, all patients in Silivri Penitentiary Institutions were referred to the Silivri Government Hospital located 15 km away from the catchment area of the prison. Since the opening of a new prison hospital within the campus, the management of the prisoners could be completed in the secure ground. The efficacy of this system included the appropriate use of outward patient transfers, enhancement of healthcare for inmates, increased prisoners and staff, public safety, and the retrenchment of prisoner healthcare costs incurred by Ministry of Justice.
The aim of this study was to give an overview of prisoners' healthcare problems leading to emergency department admission during the first year and point to decrease redundant hospital transfers of this target group after the opening of Penitentiary Institution Hospital.
| Materials and Methods|| |
In total, 12,325 visits, which referred to the Silivri Penitentiary Institution Hospital Emergency Department between 1 st January 2012 and 31 st December 2012, were identified retrospectively. This retrospective observational study was approved by the institutional review board at the relevant institution. Records of all prisoners attending were collected and analyzed from the hospital computerized database and reviews of emergency medical charts. The records of the patients were manually surveyed by a hand search and the digital automation software of the institution was used as the source. With the search mode in software, the term "by Emergency" was used as the label for "Application Type" to constitute the cases that were referred to "emergency". Two internal specialists and two emergency medicine specialist surgeons analyzed all medical records. Records of patients with psychiatric disorders were discussed with a consultant psychiatrist. The patients were divided into following seven main groups:
- Violence injury,
- Sports injury,
- Surgical conditions,
- Medical disorders,
- Ear Nose and Throat (ENT) problems,
- Psychiatric disorders, according to appeal complaints.
Medical and surgical references were sub-divided into the most frequently complaints, which were managed in the emergency department. If the headache and abdominal pain complaints of the patient did not point to a specific disease after physical examination and alleviated with a simple painkiller, the complaint is defined as non-specific headache and non-specific abdominal pain. Details such as the type, cause, and nature of the injury at the clinic were gathered from the clinical notes.
No nursing data were consulted. Data was entered and analyzed into SPSS version 15.0 and independent samples t-test and Pearson's Chi-square test were employed. Statistical significance was based on a P value below 0.05.
| Results|| |
The total number of emergency visits to prison hospital in year 2012 was 12,325. The age of the studied population ranged between 18 and 79, with a mean age of 41 (Standard Deviation, SD = 12.5). In consequence of the specialist male gender of Silivri Penitentiary Institution, all visits were applied by male prisoners. The 18-49 age group accounted for 72.6% of the total emergency visits due to injuries and surgical conditions, while elderly patients aged >49 years due to medical disorders (P < 0.001). Presentations were as a result of 4,328 for surgical conditions (35.1%), 2684 for medical disorders (21.8%), 1867 for sports injuries (15.2%), 1327 for ENT problems (10.8%), 827 for psychiatric disorders (6.70%), 396 for violence injury (3.2%), 169 for self-harm (1.4%), and 727 for miscellaneous (5.8%) [Figure 1]. The clinical conditions including medical and surgical disorders are showed in [Figure 2] and [Figure 3], respectively. Presentation complaint according to age distribution is shown in [Figure 4].
|Figure 1: Distribution of causes of emergency referrals in prison hospital|
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In total, 563 patients, 221 for sports injury, 123 for non-specific abdominal pain, 102 for angina, 40 for drug overdose, 34 for psychiatric disorders, 25 for hyperglycemia, and 18 for acute appendicitis, were referred to the Silivri Government Hospital for further evaluation. Due to the acute myocardial infarct, two prisoners died in a period of one year.
Eighteen prisoners re-visited the emergency department a total of 243 times, ranging from 8 visits to a maximum of 56 visits. Ten of these inmates were known to have a history of drug abuse and duplicated for crisis of drug abuse. The other six prisoners came for medical disorders-four for hypertension crisis and two for angina pectoris. The prisoner with most revisits was a 32-year-old male, who was a drug abuser, and visited the emergency department 56 times within 2 months for different self-harms. The other frequent visitor was a 24-year-old male who swallowed nails or screws and attended with non-specific abdominal pain 18 times within only one month.
In terms of the 1867 sports injuries, the lower extremities of the body were mostly affected (43.3%), followed by the upper extremities (56.7%). While 221 (11.8%) of these sports injuries were referred to Silivri Government Hospital for further evaluation, the remaining prisoners were treated and returned to the prison for the recovery period. Seventeen of 221 patients were operated and discharged.
In total, 827 admissions for psychiatric problems were recorded in the study period. Of these, 386 were for depression (46%), 176 for auto-aggression (22%), 122 for psychosocial crisis (14.75%), 116 for drug abuse (14%) and 27 for Psychosis (3.25%). From the psychosis group, admissions for the psychiatric problems were treated in the institution. Of the patients presenting with auto-aggression, 96% (n = 169) were caused self-harm and 4% (n = 7) were auto-aggressive but not suicidal. The entire substance abuse group presented with withdrawal symptoms.
| Discussion|| |
Silivri Penitentiary Institution, located 12 km from Silivri Centrum and 70 km from Istanbul, is the largest remand prison in Turkey housing 10,000-12,000 detainees. The penitentiary institution was built in a 938024-m 2 area, which included 8 type L high-security prison and one minimum security prison camp built in 2008. All nine prisons have practitioner doctors and dentists who service the detainees during "working hours" (09.00-17.00). Prior to 2012, all emergency or control healthcare that occurred in these institutions were referred to Silivri Government Hospital.
Due to the characteristics of prisoners and the prison environment's predisposition to violence, treatment of the prisoners near the civil population causes huge problems to both prisoners and civil population. Generally, inmates have exhibited violent unpredictable behavior during the course of their emergency treatments. This has resulted in threats and physical altercations with staff, an apprehensive working environment, and escape attempts.  Because of these conditions, the new prison hospital was built in 2012 within the Silivri Penitentiary Institution. Medical facilities at the prison hospital consist of a 30-bedded hospital staffed by nurses and a staff doctor for 24 hours. Specialist doctors, including specialists in surgery, orthopedics, internal medicine, neurology, and cardiology, are present 40 hours for per week with a 24-hour on-call cover (working hours 09.00-17.00). Routine dental treatment and radiological evaluation could be provided only during normal working hours. An emergency treatment room is present for minor procedures, such as suturing or following hypertensive and hyperglycemia attacks. In case of life-threatening injury or illness, the inmates are transferred directly to the central hospital by an ambulance.
Owing to increased incarceration worldwide, prison populations have risen significantly during the last decade.  Approximately more than 100,000 detainees live in prisons in Turkey. Prisoner health is more diverse and complex than the normal population, because they are more preoccupied with their health than the general population.  Poorer physical, mental, and social health, including drug, alcohol, and tobacco dependency and breakdowns in family relationships add to this preoccupation, and detainee emergency visits reach peak numbers. ,,, In 2001, Marshall et al. reported that prisoners need healthcare three times more than the demographically equivalent population in the community.  No published study has thus far identified the detainee emergency visits in Turkey. In our paper, 12,325 emergency visits, which occurred within one year in this institution, are more than the demographic equivalent of town hospital emergency department. We considered that a large group of prisoners that presented to emergency department did not require immediate treatment and hospital admission. The main reason for these huge visits number is repeat attendances by prisoner manipulative behavior. In our study, we state inappropriate repeat referrals in 18 prisoners with 243 visits. Most of these prisoners were well-known to the prison medical service for their manipulative behavior.
The number of prisoners treated in the emergency centers is rising. To the best of our knowledge, this is the most comprehensive study on the impact of prisoners on emergency medicine. The most frequent reason for presentation to our emergency department was sports injuries. In a study reported by Ariel et al., 4695 injury report forms were evaluated; slips and falls comprised 27% of the injuries.  In our study, 1876 (15%) sport injuries due to slips and falls were presented to emergency service. It is nevertheless possible that many of these injuries were not sufficiently severe to lead to presentation at our emergency center. The decreased incidence of sports injuries in our study was because of self-medication by prisoners. The second most frequent reason for presentation to our emergency center was that the prisoner was suffering from non-specific abdominal pain. The high number of non-specific abdominal pain may be due to a variety of factors, some of them social and the others may be conversion of psychiatric problems.  No study has been conducted about this condition and we can only speculate its cause. The other frequent reason for presentation is psychiatric problems. The high incidence of prisoners with psychiatric diseases has been reported many times. ,, In our study, we received only 6.70% psychiatric disorders in emergency presentations. These values are lower values compared to those in literature. It may depend on the conversion of the complaints and extensive psychiatric control of the prisoners.
Managing prisoner emergency presents considerable problems for prison institution administrators as well as prisoners and health teams. The transfers of detainees to city hospitals present numerous logistical problems to the prison administration in terms of supplying escorts to transport the prisoners. Due to these transfer difficulties, prison hospitals seem more effectives than city hospitals. The most important concern is that prison medicine has the obligation to guarantee detainees access to the same reliable healthcare offered to civilians people. The recommendation from the Council of Europe to member states on the European Prison Rules suggests "where a prison service has its own hospital facilities, they shall be adequately staffed and equipped to provide the prisoners referred to them with appropriate care and treatment" (Recommendation 46.2).  Our prison hospital policy, in accordance with this suggestion, is to decrease unjustifiable transfers and provide quality healthcare. It is shown that only 563 of 12,325 emergency visits were referred to city hospital within one year, without any death. Two deaths occurred in the prison ward, not in prison hospital.
The opening of the prison hospital resulted in considerable decrease in workload. Most prisoners could be treated and sent back to the prison ward for further review. The main reason for presentation was sports injury, and a large portion of injuries was mainly a result of playing football, basketball, and volleyball. Most injuries presented at the prison hospital department were minor injuries such as falls, sports-related activities, and lacerations that could be treated in our institution. In one-year period, 1646 (88.2%) of 1867 detainees could be managed for sports injury in our institution, only 221 detainees were referred to city hospital, and 17 of them were operated. The absence of general radiography in night shifts is the cause of these transfers. The second frequent complaints during visit to emergency department were non-specific abdominal pain and none of them was transferred to city hospital. Only 123 of all 4,328 surgical patients were transferred to city hospital, and 18 of them were operated for acute appendicitis. The most frequent complaints for medical disorders were non-specific headache in emergency visits, which were treated by simple painkillers and further evaluation for these detainees was not necessary. Due to the impossibility to reach the cardiac enzymes in our institution, all 164 patients who described classic cardiac chest pain were transferred to city hospital for evaluation of cardiac enzymes. It is shown that the newly opened prison hospital minimized city hospital transfers and workload. This new prison hospital decreased the numerous logistical problems to the prison in terms of supplying escorts to transfer the prisoner.
There are several limitations to this study. Because of the retrospective study design, misinterpretations cannot be excluded. Another limitation was the lack of female group; the study population was restricted to males due to the prevalence of injury among male prisoners. Additionally, it should also be noted that this study does not represent a cross-section of the state of health of the whole prison population, as prisoners who present to our emergency department suffer from potentially different diseases. In this manuscript, we want to point out that the newly opened prison hospital emergency service has been associated with a reduction in the use of the emergency department for the management of prisoners. Moreover, our data collection was not standardized. The comparison of prisoner presentations before and after introduction of the prison hospital is further limited by the prolonged time period involved.
| Conclusion|| |
Prison is an oppressive and sweltering atmosphere characterized by loss of individual freedom, possessions, and family. Usually, demands of detainees to visit the emergency department are meaningless; therefore, hospital crowding and security has become a widespread problem for normal and prison population. Since the new prison hospital was built in 2012, the city hospital transfers were minimized, security for prisoner escapes increased, healthcare cost for prison health reduced, public and staff safety increased, and the appropriate use of local emergency department was provided. We conclude that this new penitentiary institution hospital was effective and reliable, and this system should be adapt to other institutions.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]