Criminalization in Trauma Care: A National Trauma Registry Analysis by Residence Status

Engagement with the criminal-legal system is known to disproportionately affect and harm marginalized patients, as well as erode institutional trust. However, the degree of law enforcement involvement in the care of traumatically injured patients nationally is not clearly established. This study aims to assess differences in criminal-legal system engagement among marginalized trauma patients by residence status and estimate effects on patient care. This cross-sectional retrospective study of housed, unhoused, or migrant and/or undocumented adult trauma patients utilized trauma registry data (2021-2022) in the Trauma Quality Programs (TQP) database. Pre-hospital police transport or discharge to court/law enforcement represented criminal-legal system engagement. Regression models estimated differences in rate of criminal-legal system engagement by residence status and predicted effect on hospital length of stay (LOS), adjusting for patient age, race, sex, ethnicity, payer, assault as mechanism, and injury severity score. 1,540,173 patients were included, of whom 15,805 were unhoused and 1,564 were migrant/undocumented. Unhoused patients had lower odds of police transport to the hospital (aOR:0.77 [95% CI:0.64-0.92]) but higher odds of discharge to the criminal-legal system (1.30 [1.16-1.45]) compared to housed patients. Migrant/undocumented patients had higher odds of police transport (17.5 [14.6-21.0]) and criminal-legal system discharge (19.6 [17.2-22.3]) than housed patients. Criminal-legal system discharge predicted reduced LOS, particularly for migrant/undocumented patients (beta:-70.9 h [-104.5,-37.3]). The trauma encounter may disproportionately act as a point of entry into the criminal-legal system for unhoused and migrant/undocumented patients regardless of pre-hospital police transport. Criminal-legal system engagement shortens hospital LOS, raising concerns for unwarranted differences in care.