BACKGROUND:Trauma surgery patients are at risk for developing mental health sequelae following injury. In response, the American College of Surgeons Committee on Trauma developed guidelines for mental health care in this population. We aim to evaluate current practices, determine guideline adherence, and identify areas for improvement in the mental health services provided to trauma patients. METHODS:We conducted a qualitative evaluation using semistructured interviews with hospital social workers. Nine social workers were interviewed. Data were analyzed thematically to identify the patient pathway, successes, and barriers to mental health care utilization in trauma patients. RESULTS:Social workers described existing clinical practices for trauma patients, including a lack of structured mental health care during admission. Most were unaware of the American College of Surgeons Committee on Trauma guidelines but engaged in practices that closely aligned with the guideline recommendations. Social workers reflected on personal practices and team strengths, emphasizing clinical competence, compassion, and leadership in developing mental health resources. Social workers identified barriers that included insurance limitations, the absence of standardized follow-up protocols, and high patient-to-social worker ratios. CONCLUSION:This study conveys perspectives on mental health care for trauma patients, including strengths in current practice and opportunities for improvement. We noted how the social work clinical model reflects the American College of Surgeons Committee on Trauma guidelines despite no deliberate mention of the guidelines, indicating a discrepancy in dissemination at our site. These findings can help create a framework for continued success in caring for mental health concerns and highlight the need for additional training to support consistent implementation of established guidelines.

INTRODUCTION:Video-assisted thoracic surgery (VATS) is recommended for approximately 30% of hemothoraces that become retained, yet the optimal timing for VATS remains debated. We sought to compare the relationship between VATS timing and associated outcomes. METHODS:The pulmonary morbidity and mortality of early (≤4d), intermediate (5-10d) and late (≥10d) VATS in adults were compared in the 2017-2021 Trauma Quality Improvement Program. RESULTS:Of the 9784 VATS identified, pulmonary morbidity (57%) and mortality (4.5%) were higher in the early group relative to the intermediate (41, 3.0%) and late groups (48, 2.9%, p < 0.01) with higher rates of reintervention including secondary thoracotomy (4.5 vs. 3.1 vs. 3.2% p = 0.04) and tube thoracostomy (51 vs. 24 vs. 24%, p < 0.01). Risk-adjusted rates of both outcomes were inversely proportional to VATS days (p < 0.01). CONCLUSION:This study adds to ongoing debate regarding the optimal timing of VATS for retained hemothorax, supporting the need for prospective study.

INTRODUCTION:Social determinants of health impact outcomes after traumatic injury. Patient factors, including race, insurance status, and household income, have been associated with increased risk of mortality and worse outcomes. The social vulnerability index (SVI) is a comprehensive tool that quantifies these factors at the census tract or county level. We hypothesized that mortality after admission for penetrating trauma would be associated with higher vulnerability. MATERIALS AND METHODS:We queried our level 1 trauma center supplemental database from 2019 to 2021 for mortality among adult patients presenting with a penetrating traumatic injury (n = 103). We assigned SVI based on patient address and location of injury. We used chi-square tests for association for all categorical variables and Mann-Whitney U tests for continuous variables. We then conducted a logistic regression and mediation analysis to assess the effect of injury severity score on mortality. RESULTS:We found a significant association between SVI and mortality after comparing low and high SVI. While most patients with penetrating trauma came from the areas of highest SVI (64%), patients with low SVI (2nd and 3rd quartiles) had a higher mortality than those of the highest quartile (33.3% versus 14.1%, P = 0.021). High vulnerability was associated with improved survival and lower rates of all-cause mortality; however, this association was entirely mediated by the greater range of injury severity seen in the high-vulnerability group. The correlation between individual SVI and SVI of place of injury was strong. CONCLUSIONS:SVI is associated with patient mortality after penetrating trauma in our locale, but not in the ways that we assumed. Our data suggest that we are missing the areas where disparity in care exists when considering only patients who make it to a trauma center. This may reflect the vulnerability of the immediate area around our institution such that a greater range of survivable injury presents and emphasizes the utility of secondary and tertiary violence prevention in the communities immediately surrounding our hospital.

INTRODUCTION:Firearm-related injuries are the leading cause of death in children aged 1-19 y in the United States. Access to post-discharge services (PDS) may be an important factor in preventing recurrent injuries. However, it is unclear which factors in patient care influence referral to PDS. METHODS:We conducted a retrospective study of pediatric firearm injuries using the American College of Surgeons Firearms Study Database (2021-2022). We used chi-square, Kruskal-Wallis, and Mann-Whitney U tests for bivariate comparisons. We conducted a multivariable logistic regression to determine independent factors associated with PDS referral. RESULTS:Of the 2988 pediatric firearm injuries meeting inclusion criteria, the median age was 16 (14-17) y with injuries predominantly occurring in non-Hispanic Black individuals (67%) injured by assault (75%). A history of prior firearm injury occurred in 20% of patients and was associated with increased referral (49.4% referral versus 43.4% no referral, P = 0.02) and mortality (11.4% history of prior injury versus 5.2% no prior injury, P = 0.003). Approximately one-third of youth (36%) were referred to services. PDS were less commonly referred to those who were self-pay (6.9%) compared to those insured by Medicaid (70.9%) or private insurance (19.6% P = 0.002). Referrals to PDS were more common in those with a higher injury severity score (9 [1-14] versus 5[1-10], P < 0.01). Independent factors increasing likelihood of referral to PDS included prior firearm injury (1.67 [1.23-2.28], P < 0.01), Black race (1.66 [1.05-2.62], P < 0.05), Hispanic ethnicity (1.84 [1.20-2.83], P < 0.01), self-inflicted mechanism (3.78 [1.19-12.0], P < 0.05), and severe injury (injury severity score >15; 2.61 [1.46-4.67], P < 0.01). CONCLUSIONS:Youth who are insured, suffer a severe injury, or have a repeat firearm injury are more likely to be referred to PDS. Expansion of discharge service programs is crucial to prevent cycles of repeated violence in this vulnerable population.

This Viewpoint advocates for the inclusion of social determinants of health and health-related social needs data into the electronic health record as a measure for improving provision of equitable surgical care.

INTRODUCTION:Prehospital tourniquet placement is not a required criterion for standard trauma team activation (TTA-S) as recommended by the American College of Surgeons Committee on Trauma. Educational campaigns such as STOP THE BLEED have led to an increase in tourniquet applications in the prehospital setting. We intend to evaluate if using extended trauma team activation (TTA-T) criteria, which includes tourniquet application, would lead to an acceptable amount of overtriage. METHODS:This was a multicenter retrospective analysis, utilizing the American Association for the Surgery of Trauma Major Extremity Trauma Tourniquet Database, comparing the overtriage rate of TTA-S criteria against the TTA-T criteria. RESULTS:A total of 1235 patients were included, with 687 meeting the TTA-S criteria and an additional 175 patients meeting the TTA-T criteria. The overtriage rate was calculated to be 21.2%, within the accepted over triage rate of 25%-35%. CONCLUSIONS:Field tourniquet application for life-threatening hemorrhage, although not an American College of Surgeons Committee on Trauma criterion for TTA, should be considered for full TTA. Utilizing this as a criterion for TTA is associated with an acceptable rate of overtriage, while also having the benefit of rapid surgical team evaluation and intervention for possible life- or limb-threatening injuries.

INTRODUCTION:Emergency general surgery (EGS) has disproportionate morbidity and mortality relative to elective surgery. With earlier intervention, many emergent conditions could be treated electively. Social determinants of health (SDoH) negatively impact access to healthcare, leading to increased utilization of EGS. The goal of this study is to determine why patients with potentially elective disease receive EGS. METHODS:Adults undergoing EGS with elective alternatives were identified during 2018-2019 at a single academic center. Patient demographics, clinical course, and circumstances of surgical timing were abstracted from the medical record. We compared factors influencing referral or evaluation by surgeon with chi-square and Mann-Whitney U tests where appropriate. Concurrent, multi-methods were used to determine why patients fail to receive elective surgery. RESULTS:We identified 995 patients undergoing EGS with an elective alternative. Although 70% had insurance and a primary care physician, only 104 were evaluated by primary care, with 59 referred to and 46 evaluated by general surgery, and 22 ultimately scheduled for elective surgery. Reasons for failure of elective management included comorbidity optimization (42%), difficulties scheduling (28%), SDoH (22%), missed diagnosis (14%), and patient preference (11%). Patients cited difficulties with money, childcare, transportation, and employment within SDoH category. No significant differences in patient demographics were found for patients with and without preoperative outpatient care. CONCLUSIONS:At our institution, most patients are never seen by a physician prior to their admission for EGS. Even with primary care evaluation, individuals still have only a 20% chance of being scheduled for elective surgery. Future efforts must focus on increasing preventive care access within the community and streamlining the process from diagnosis to elective general surgery.

OBJECTIVE:Improvement of surgical care is dependent upon evidence-based practices (EBPs), policies, procedures, and innovations. The objective of this study was to understand and synthesize the use of implementation science (IS) in surgical care. BACKGROUND:This article summarizes the existing literature to identify the frequency and types of EBPs selected for surgical care, IS frameworks that guided the published research, and prominent facilitators and barriers. METHODS:A modified version of the Arksey and O'Malley framework and the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews Checklist were used to provide the guidance and standards to conduct this scoping review. We queried Ovid MEDLINE, American Psychological Association PsycINFO, Embase, Cumulated Index to Nursing and Allied Health Literature, Web of Science, and Google Scholar for manuscripts published January 2001-June 2023. RESULTS:The initial search found 3674 citations, of which 129 met the inclusion criteria. The heterogeneity and volume of innovations within the surgical IS field were vast. The most frequent innovations were in perioperative care, safety in surgery, and Enhanced Recovery After Surgery. Six constructs were identified as both major facilitators and barriers: support from leadership, surgeon and staff knowledge regarding EBPs, relationship/team building, environmental context, data, and resources. CONCLUSION:Identifying these implementation factors used in the surgical field enables us to determine variables that support and inhibit the adoption and implementation of new practices, support practice change, enhance quality and equity of surgical care, and identify research gaps for future IS in surgical care.

INTRODUCTION:Hepatic angioembolization is highly effective for hemorrhage control in hemodynamically stable patients with traumatic liver injuries and contrast extravasation. However, there is a paucity of data regarding the specific location of angioembolization within the hepatic arterial vasculature and its implications on patient outcomes. METHODS:A post-hoc analysis of a multicenter prospective observational study across 23 centers was performed. Adult patients undergoing main hepatic artery angioembolization or segmental hepatic artery angioembolization within 8 hours of arrival were included. The primary outcome was liver-related complications, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. Secondary outcomes were liver-related complication interventions, length of stay, and mortality. RESULTS:A total of 55 patients underwent hepatic angioembolization, with 23 (41.8%) undergoing main hepatic artery angioembolization and 32 (58.2%) receiving segmental hepatic artery angioembolization. Both groups were comparable in age, vitals, mechanism of injury, liver injury grade distribution, and injury severity score (all P > .05). The main hepatic artery angioembolization group had greater rates of overall liver-related complications (65.2% vs 31.2%, P = .039), specifically perihepatic fluid collection (26.1% vs 6.3%, P = .040) and bile-leak/biloma (34.8% vs 12.5%, P = .048). Main hepatic artery angioembolization had greater rates of 2 or more liver-related complications (47.8% vs 9.4%, P = .001) and readmission within 30 days (30.4% vs 9.4%, P = .046). No significant differences were observed in hospital length of stay and mortality (all P > .05). CONCLUSIONS:Main hepatic artery angioembolization is associated with increased rates of liver-related complications, multiple liver-related complications, and readmission within 30 days compared with segmental hepatic artery angioembolization. Thus, main hepatic artery angioembolization should be reserved for use only when segmental hepatic artery angioembolization is not feasible, albeit with significantly increased morbidity.

BACKGROUND: Prior studies evaluating observation versus angioembolization (AE) for blunt liver injuries (BLT) with contrast extravasation (CE) on computed tomography imaging have yielded inconsistent conclusions, primarily due to limitations in single-center and/or retrospective study design. Therefore, this multicenter study aims to compare an observation versus AE-first approach for BLT, hypothesizing decreased liver-related complications (LRCs) with observation. METHODS: We conducted a post hoc analysis of a multicenter, prospective observational study (2019-2021) across 23 centers. Adult patients with BLT + CE undergoing observation or AE within 8 hours of arrival were included. The primary outcome was LRCs, defined as perihepatic fluid collection, bile leak/biloma, pseudoaneurysm, hepatic necrosis, and/or hepatic abscess. A multivariable logistic regression analysis was used to evaluate risk factors associated with LRCs. RESULTS: From 128 patients presenting with BLT + CE on imaging, 71 (55.5%) underwent observation-first and 57 (45.5%) AE-first management. Both groups were comparable in age, vitals, mechanism of injury, and shock index (all p > 0.05), however the AE group had increased frequency of American Association for the Surgery of Trauma Grade IV injuries (51.0% vs. 22.0%, p = 0.002). The AE cohort demonstrated increased rates of in-hospital LRCs (36.8% vs. 12.7%, p = 0.038), emergency department representation (25.0% vs. 10.0%, p = 0.025), and hospital readmission for LRCs (12.3% vs. 1.4%, p = 0.012). However, the two cohorts had similar mortality rates (5.7% vs. 5.3%, p = 0.912). After adjusting for age, ISS, and grade of liver injury, an AE-first approach had a similar associated risk of LRCs compared with observation-first management (odds ratio, 1.949; 95% confidence interval, 0.673-5.643; p = 0.219). CONCLUSION: Patients with blunt liver injury and CE undergoing an observation-first approach were associated with a similar adjusted risk of LRCs and rate of mortality compared with AE-first approach. Overall, this calls for reevaluation of the role of routine AE in blunt liver trauma patients with CE. Future prospective randomized trials are needed to confirm these findings.

ObjectiveGrowing evidence supports the impact of sociodemographics on cancer outcomes. The objective of this study was to examine the Social Vulnerability Index (SVI) and its association with oncologic presentation and subsequent treatments across 8 major cancers.MethodsThis was a retrospective-cohort study using one institution’s contribution to the National Cancer Database (2011–2021). Patients were grouped into low SVI (<75th percentile) and high SVI (≥75th percentile) cohorts. Un-adjusted comparison between groups was performed followed by multivariable regression to control for the effect of demographic characteristics on oncologic presentation, and for demographic and oncologic characteristics on subsequent treatments. A subgroup analysis was performed comparing cancers that have national screening protocols versus those without.ResultsOf 12,712 cases, 2,842 (22.4%) were in the high SVI group and 9,870 (77.6%). After risk-adjustment, high SVI patients presented at more advanced T-stage (odds ratio 1.09, 95% confidence interval 1.00-1.19); N-stage (1.11, 1.01–1.23); M stage (1.16, 1.03–1.30); and overall stage (1.14, 1.04–1.24) and were more frequently not recommended for surgery (1.15, 1.01–1.32) or chemotherapy (1.20, 1.07–1.38). Screening protocols tended to increase the association between high SVI and advanced oncologic presentation. After adjustment high SVI remained significantly associated with decreased odds of survival (0.85, 0.79 - 0.91).ConclusionsHigh SVI is associated with advanced stage presentation and decreased likelihood of being recommended surgery or chemotherapy even after risk-adjustment. Differences in presentation stage are predominantly driven by cancers with screening protocols and ultimately high SVI is associated with decreased odds of survival.

BACKGROUND:High-grade liver injuries with extravasation (HGLI ​+ ​Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI ​+ ​Extrav. Therefore, we evaluated the management of HGLI ​+ ​Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS:HGLI ​+ ​Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS:From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p ​= ​0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p ​> ​0.05). CONCLUSION:Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI ​+ ​Extrav patients.

Objective: The purpose of this study was to determine if an association between Social Vulnerability Index (SVI) and risk-adjusted complications exists in a broad spectrum of surgical patients. Summary background data: Growing evidence supports the impact of social circumstances on surgical outcomes. SVI is a neighborhood-based measure accounting for sociodemographic factors putting communities at risk. Methods: This was a multi -hospital, retrospective cohort study including a sample of patients within one healthcare system (2012-2017). Patient addresses were geocoded to determine census tract of residence and estimate SVI. Patients were grouped into low SVI (score<75) and high SVI (score >= 75) cohorts. Perioperative variables and postoperative outcomes were tracked and compared using local ACS-NSQIP data. Multivariable logistic regression was performed to generate risk-adjusted odds ratios of postoperative complications in the high SVI cohort. Results: Overall, 31,224 patients from five hospitals were included. Patients with high SVI were more likely to be racial minorities, have 12/18 medical comorbidities, have high ASA class, be functionally dependent, be treated at academic hospitals, and undergo emergency operations (all p < 0.05). Patients with high SVI had significantly higher rates of 30-day mortality, overall morbidity, respiratory, cardiac and infectious complications, urinary tract infections, postoperative bleeding, non -home discharge, and unplanned readmissions (all p < 0.05). After riskadjustment, only the associations between high SVI and mortality and unplanned readmission became nonsignificant. Conclusions: High SVI was associated with multiple adverse outcomes even after risk adjustment for preoperative clinical factors. Targeted preventative interventions to mitigate risk of these specific complications should be considered in this high -risk population.

Objectives There is little evidence guiding the management of grade I–II traumatic splenic injuries with contrast blush (CB). We aimed to analyze the failure rate of nonoperative management (NOM) of grade I–II splenic injuries with CB in hemodynamically stable patients.Methods A multicenter, retrospective cohort study examining all grade I–II splenic injuries with CB was performed at 21 institutions from January 1, 2014, to October 31, 2019. Patients >18 years old with grade I or II splenic injury due to blunt trauma with CB on CT were included. The primary outcome was the failure of NOM requiring angioembolization/operation. We determined the failure rate of NOM for grade I versus grade II splenic injuries. We then performed bivariate comparisons of patients who failed NOM with those who did not.Results A total of 145 patients were included. Median Injury Severity Score was 17. The combined rate of failure for grade I–II injuries was 20.0%. There was no statistical difference in failure of NOM between grade I and II injuries with CB (18.2% vs 21.1%, p>0.05). Patients who failed NOM had an increased median hospital length of stay (p=0.024) and increased need for blood transfusion (p=0.004) and massive transfusion (p=0.030). Five patients (3.4%) died and 96 (66.2%) were discharged home, with no differences between those who failed and those who did not fail NOM (both p>0.05).Conclusion NOM of grade I–II splenic injuries with CB fails in 20% of patients.Level of evidence IV.

INTRODUCTION:The social vulnerability index (SVI) is a census tract-level population-based measure generated from 16 socioeconomic and demographic variables on a scale from 1 (least) to 100 (most) vulnerable. This study has three objectives as follows: 1) to analyze multiple ways of utilizing SVI, 2) compare SVI as a group measure of marginalization to individual markers, and 3) to understand how SVI is associated with choice of surgery in metabolic surgery. METHODS:We retrospectively identified adults undergoing Roux-en-Y gastric bypass and gastric sleeve in 2013-2018 National Surgical Quality Improvement Program data from a single academic center. High SVI was defined as >75th percentile. Low SVI was coded as <75th percentile in measure 1 and < 25th percentile in measure 2. Chi-square and Mann-Whitney U tests were utilized for categorical and continuous variables, respectively. Multivariable regression models were performed comparing SVI to marginalized status as a predictor for type of metabolic surgery. RESULTS:We identified 436 patients undergoing metabolic surgery, with a low overall morbidity (6.1%). Complication and readmission rates were similar across comparator groups. The logistic regression models had similar area under the curve, supporting SVI as a proxy for individual measures of marginalization. CONCLUSIONS:SVI performed as well as marginalized status in predicting preoperative risk. This suggests the validity of using SVI to identify high risk patients. By providing a single, quantitative score encompassing many social determinants of health, SVI is a useful tool in identifying patients facing the greatest health disparities.

INTRODUCTION:Health disparities in the Asian and Pacific Islander Americans (APIAs) community have not been well described, unlike non-Hispanic Black and Hispanic communities. However, there has been a rise in violence against the APIA community. This study explores and characterizes violent death by incident (e.g., homicide, suicide), weapon (e.g., firearm, strangulation), and location types among APIAs as they compare with other racial or ethnic groups. METHODS:We used the National Violent Death Reporting System from 2003 to 2018 to characterize violent deaths among APIA and compared them to all other races. We compared these racial categories in two ways. First, we compared all races as a categorical variable that included six non-Hispanic racial categories including "Other or unspecified" and "two or more races. We then created a binary variable of APIA versus All Other Races for analysis. We explored the incident type of death, substance abuse disorders, mental health history, and gang involvement among other variables. We used Chi-square tests for categorical variables and Mann-Whitney U-tests for continuous variables. RESULTS:Overall, APIAs had a unique pattern of violent death. APIAs were more likely to commit suicide (71.74%-62.21%, P<0.001) and less likely to die of homicide than other races (17.56%-24.31%, P<0.001). In the cases of homicide, APIAs were more likely to have their deaths precipitated by another crime (40.87% versus 27.87%, P < 0.001). APIAs were more than twice as likely to die of strangulation than other races (39.93%-18.06%, P<0.001). Conversely, APIAs were less likely to die by firearm than other races (29.69-51.51, P<0.001). CONCLUSIONS:APIAs have a unique pattern of violence based on analysis of data from the National Violent Death Reporting System. Our data reveal a significant difference in the incident, weapon and location type as compared to Americans of other races, which begs further inquiry into the patterns of change in time and factors that contribute to inter-racial differences in death patterns.

Introduction: Ventral hernias can be repaired electively; however, many circumstances require emergency repair. The association between sociodemographic status and rate of emergency repair are unclear and the Social Vulnerability Index may be a useful tool to better understanding this association. The purpose of this study was to investigate the association between Social Vulnerability Index and emergency ventral hernia repair. Methods: This was a retrospective cohort study using the National Surgical Quality Improvement Program (2012-2018) data for patients at a level 1 trauma center. We included patients who had an open ventral hernia repair. Social Vulnerability Index was based on residential address at the time of surgery. We conducted univariate and bivariate statistics, including x(2) and Mann-Whitney U tests to compare high and low social vulnerability. Results: Our sample had 1,017 patients. Patients who underwent emergency operations were older (P = .025) and had higher Social Vulnerability Index (P = .029). Patients in the high Social Vulnerability Index group were 1.5 times more likely to receive emergency surgery (P = .047). Emergency repair was also associated with increased frequency of nonhome discharge (9% vs 2%, P = .001) and higher mean work relative value unit (15.4 vs 11.9, P < .001). Conclusion: Patients requiring emergency ventral hernia repair have significantly higher Social Vulnerability Index than those undergoing elective repair. This vulnerable population also has increased cost associated with the repair and higher rates of nonhome discharge. This work provides a foundation for efforts to reach patients in high Social Vulnerability Index environments at an earlier stage to achieve earlier elective repair. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

ABSTRACT The prior articles in this series have focused on measuring cost and quality in acute care surgery. This third article in the series explains the current ways of defining value in acute care surgery, based on different stakeholders in the health care system—the patient, the health care organization, the payer and society. The heterogenous valuations of the different stakeholders require that the framework for determining high-value care in acute care surgery incorporates all viewpoints. LEVEL OF EVIDENCE Expert Opinion; Level V.

INTRODUCTION:This project aims to characterize trauma-associated deaths of the American incarcerated population through legal intervention (LI) or death by law enforcement officials while in custody before and during incarceration. We determined the preceding events leading to violent death, including initiation of medical care, use of restraints and force, and demographics of the victims. METHODS:We used National Violent Death Reporting System data from the years 2003-2019 to identify deaths that occurred while in custody or incarcerated, including discriminate and narrative data. Event information included weapon type, location of death, incident type, incarceration status, use of restraints, and prone positioning. RESULTS:There were 86 victims who died from LI included in the analysis. Most events occurred after incarceration. All victims in our cohort were male, and race was an associated factor for death by LI. Only 16% of victims had an education level above high school/general educational development. Death by firearm compared to other weapons was significantly more common in the in-custody but not yet incarcerated group (83% versus 42%, P ≤ 0.0001). Other associated factors included a history of mental health, physical confrontations, the belief that the victim had a weapon, and being restrained in prone positioning. CONCLUSIONS:Our study shows that racial minority victims are disproportionately affected by LI deaths. Firearms and restraint type were important factors in LI deaths. Our findings suggest that violence prevention in the justice system should focus on prevention and de-escalation across setting with specific attention to use of force and inmate access to the weapons of police, guards, and other law and justice system workers. More transparent quality data is sorely needed to adequately define and address this problem.