Study objectives Heightened immigration enforcement may induce fear in undocumented patients when coming to the Emergency Department (ED) for care. Limited literature examining health system policies to reduce immigrant fear exists. In this multi-site qualitative study, we sought to assess provider and system-level policies on caring for undocumented patients in three California EDs. Methods We recruited 41 ED providers and administrators from three California EDs (in San Francisco, Oakland, and Sylmar) with large immigrant populations. Participants were recruited using a trusted gatekeeper and snowball sampling. We conducted semi-structured interviews and analyzed the transcripts using constructivist grounded theory. Results We interviewed 10 physicians, 11 nurses, 9 social workers, and 11 administrators, and identified 7 themes. Providers described existing policies and recent policy changes that facilitate access to care for undocumented patients. Providers reported that current training and communication around policies is limited, there are variations between who asks about and documents status, and there remains uncertainty around policy details, laws, and jurisdiction of staff. Providers also stated they are taking an active role in building safety and trust and see their role as supporting undocumented patients. Conclusions This study introduces ED-level health system perspectives and recommendations for caring for undocumented patients. There is a need for active, multi-disciplinary ED policy training, clear policy details including the extent of providers’ roles, protocols on the screening and documentation of status, and continual reassessment of our health systems to reduce fear and build safety and trust with our undocumented communities.

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A 44-year-old male presented with sudden onset of severe left arm burning dysesthesia and bilateral leg numbness and weakness for several hours. He denied any recent illnesses or trauma and was previously healthy. His exam showed decreased strength to his left upper extremity, decreased light touch sensation to bilateral lower extremities, and urinary retention. Computed tomography (CT) and magnetic resonance imaging (MRI) of the cervical spine were performed, which demonstrated acute cervical myelopathy due to congenital cervical stenosis, a less common finding. Congenital cervical stenosis is the narrowing of the cervical spinal canal that is not due to structural, infectious, vascular, or malignant causes. This is an important diagnosis to consider in patients who present with neurologic symptoms without risk factors for common myelopathy causes (eg, degenerative changes). Early diagnosis and treatment are essential to prevent long term neurologic deficits.