Abstract
This study uses the 2009-2014 Nationwide Emergency Department Sample to describe the volume and disposition of individuals with firearm injuries presenting to US emergency departments to determine opportunities to deliver interventions to prevent recurrent injury.
In the United States, there are more than twice as many nonfatal firearm injuries as fatal firearm injuries each year.1 For many of these individuals, their only contact with the health care system may be the emergency department (ED), where there may be an opportunity for clinicians to provide interventions to prevent recurrent injury.2 Effective interventions to address firearm injury for assault (hospital-based violence intervention programs) and unintentional injury (counseling and safe storage) exist.3,4 However violence intervention programs exist in only a fraction of trauma centers and best practices for addressing unintentional injury have not been developed for the hospital setting.5 To determine the opportunities and settings to deliver interventions to prevent recurrent injury, we describe the volume and disposition of individuals with firearm injuries presenting to EDs in the United States according to trauma center presentation and injury intent.
Methods
We analyzed all International Classification of Disease, Ninth Revision, firearm injury diagnosis codes (E922.0-E922.9, E955.0-E955.4, E965.0-E965.4, E979.4, and E985.0-E985.4) in the 2009-2014 Nationwide Emergency Department Sample, a 20% stratified national sample of all US ED encounters. We used discharge weights to provide national estimates. We tabulated ED disposition by presentation to a trauma center (levels I-III) ED vs a nontrauma center ED and stratified by intent of injury (unintentional vs self-harm vs assault vs law enforcement). This study was determined to be exempt by the University of Pennsylvania Institutional Review Board because data were deidentified. Statistical analysis was performed from November 10, 2017, to March 3, 2018.
Results
From 2009-2014, there were 445 915 ED encounters for firearm injury, with a mean of 74 319 per year (95% CI 60 800-87 859), of which 309 930 (69.5%) were treated in trauma centers and 135 985 (30.5%) were treated at nontrauma centers (Table). Most firearm injuries were due to assault (218 113 [48.9%]), followed by unintentional injury (161 337 [36.2%]), and self-harm (23 756 [5.3%]). More patients were discharged from the ED (220 291 [49.4%]) than admitted (164 716 [36.9%]). Of all individuals in the ED with firearm injuries, the largest proportion (33.4%; 95% CI, 31.5%-35.4%) were admitted to trauma centers, followed by 30.4% (95% CI, 28.6%-32.3%) being discharged from trauma center EDs, 19.0% (95% CI, 17.1%-21.1%) discharged from nontrauma center EDs, and 3.5% (95% CI, 3.0%-4.2%) admitted to nontrauma centers.
Table. Firearm Injuries Treated in US Emergency Departments, 2009-2014.
| Variable | Trauma Center, No. (%) (n = 309 930 [69.5%]) | Nontrauma Center, No. (%) (n = 135 985 [30.5%]) |
|---|---|---|
| Age, y | ||
| <12 | 3246 (1.0) | 1827 (1.3) |
| 12-18 | 42 212 (13.6) | 16 609 (12.2) |
| 18-34 | 191 738 (61.9) | 80 428 (59.1) |
| 35-54 | 65 036 (21.0) | 30 600 (22.5) |
| >54 | 22 306 (7.2) | 12 632 (9.3) |
| Female sex | 33 649 (10.9) | 16 000 (11.8) |
| Injury Severity Score | ||
| <9 | 189 160 (61.0) | 116 513 (85.7) |
| 9-15 | 77 626 (25.0) | 14 137 (10.4) |
| >15 | 43 144 (13.9) | 5335 (3.9) |
| Primary payer | ||
| Medicare | 15 408 (5.0) | 9505 (7.0) |
| Medicaid | 80 666 (26.0) | 27 181 (20.0) |
| Private insurance | 57 832 (18.7) | 31 152 (22.9) |
| Uninsured | 125 500 (40.5) | 58 215 (42.8) |
| Other | 28 764 (9.3) | 9393 (6.9) |
| Injury intent | ||
| Assault | 171 142 (55.2) | 46 971 (34.5) |
| Self-harm | 17 802 (5.7) | 5954 (4.4) |
| Unintentional | 92 497 (29.8) | 68 840 (50.6) |
| Legal intervention | 6661 (2.1) | 3961 (2.9) |
| Unspecified | 21 829 (7.0) | 10 259 (7.5) |
Individuals with injuries from assault admitted to trauma centers accounted for 20.7% of all individuals with firearm injuries; those with injuries from assault discharged from trauma center EDs accounted for 14.0% of all individuals with firearm injuries (Figure). Individuals with unintentional injuries discharged from nontrauma center EDs accounted for 11.9% of all individuals with firearm injuries; those with unintentional injuries discharged from trauma center EDs accounted for 11.2% of all individuals with firearm injuries. Of the 218 113 individuals with firearm injuries from assault, most (43.7%; 95% CI, 41.4%-46.1%) were admitted to trauma centers; 29.2% (95% CI, 27.8%-32.0%) of the individuals with firearm injuries from assault were discharged from trauma center EDs.
Figure. Disposition of Firearm Injuries by Trauma Presentation and Intent, US Emergency Departments, 2009-2014.
Discussion
In this analysis of nationwide ED data, 3 of 10 individuals with firearm injuries presented to nontrauma centers. Furthermore, only 1 of 5 firearm injuries (n = 95 931) were assault injuries that led to admission to trauma centers. Given that 25 formal hospital-based violence intervention programs cover less than 10% of trauma centers,3 our findings suggest that there are substantial opportunities to expand efforts to prevent recurrent firearm injury. Expanding the coverage of violence intervention programs across all trauma centers would cover most individuals with firearm injuries from assault, but these programs would benefit from engaging the high volume of patients who are discharged from the ED. Furthermore, we found that most individuals with unintentional firearm injuries are actually discharged from nontrauma center EDs. This finding suggests a need to develop effective counseling and safe storage interventions for individuals with unintentional firearm injuries that can be adopted in a broad range of EDs.5,6
This study has 2 main limitations. First, the Nationwide Emergency Department Sample does not include patients who did not present to the ED. Second, the Nationwide Emergency Department Sample is an administrative data set and is inherently subject to inaccurate coding.
In summary, this study demonstrates a need to expand current firearm injury prevention models beyond individuals with assault injuries presenting to trauma centers.
References
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