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Figure.  Disposition of Firearm Injuries by Trauma Presentation and Intent, US Emergency Departments, 2009-2014
Disposition of Firearm Injuries by Trauma Presentation and Intent, US Emergency Departments, 2009-2014
Table.  Firearm Injuries Treated in US Emergency Departments, 2009-2014
Firearm Injuries Treated in US Emergency Departments, 2009-2014
1.
Centers for Disease Control and Prevention. Fatal injury reports, national, regional, and state, 1981–2016. https://webappa.cdc.gov/sasweb/ncipc/mortrate.html. Published February 19, 2017. Accessed April 27, 2018.
2.
Stewart  RM, Kuhls  DA, Rotondo  MF, Bulger  EM.  Freedom with responsibility: a consensus strategy for preventing injury, death, and disability from firearm violence.  J Am Coll Surg. 2018;227(2):281-283. doi:10.1016/j.jamcollsurg.2018.04.006PubMedGoogle ScholarCrossref
3.
Juillard  C, Smith  R, Anaya  N, Garcia  A, Kahn  JG, Dicker  RA.  Saving lives and saving money: hospital-based violence intervention is cost-effective.  J Trauma Acute Care Surg. 2015;78(2):252-257. doi:10.1097/TA.0000000000000527PubMedGoogle ScholarCrossref
4.
Rowhani-Rahbar  A, Simonetti  JA, Rivara  FP.  Effectiveness of interventions to promote safe firearm storage.  Epidemiol Rev. 2016;38(1):111-124.PubMedGoogle Scholar
5.
Ranney  ML, Fletcher  J, Alter  H,  et al; ACEP Technical Advisory Group on Firearm Injury Research, a Subcommittee of the ACEP Research Committee.  A consensus-driven agenda for emergency medicine firearm injury prevention research.  Ann Emerg Med. 2017;69(2):227-240. doi:10.1016/j.annemergmed.2016.08.454PubMedGoogle ScholarCrossref
6.
Wintemute  GJ, Betz  ME, Ranney  ML.  Yes, you can: physicians, patients, and firearms.  Ann Intern Med. 2016;165(3):205-213. doi:10.7326/M15-2905PubMedGoogle ScholarCrossref
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    Research Letter
    January 23, 2019

    US Emergency Department Encounters for Firearm Injuries According to Presentation at Trauma vs Nontrauma Centers

    Author Affiliations
    • 1Department of Emergency Medicine, Yale University, New Haven, Connecticut
    • 2Yale–Drug Use, Addiction, and HIV Research Scholars Program, New Haven, Connecticut
    • 3Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
    • 4Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
    • 5Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
    • 6Penn Injury Science Center, University of Pennsylvania, Philadelphia
    JAMA Surg. 2019;154(4):360-362. doi:10.1001/jamasurg.2018.4640

    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.

    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.

    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.

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    Article Information

    Accepted for Publication: September 29, 2018.

    Published Online: January 23, 2019. doi:10.1001/jamasurg.2018.4640

    Correction: This article was corrected on March 13, 2019, to fix errors in an Author Affiliation and the Funding/Support paragraph.

    Corresponding Author: Edouard Coupet Jr, MD, MS, Department of Emergency Medicine, Yale University, 464 Congress Ave, Ste 260, New Haven, CT 06519 (edouard.coupet@yale.edu).

    Author Contributions: Dr Coupet had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Coupet, Delgado.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Coupet.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Coupet, Delgado.

    Obtained funding: Delgado.

    Administrative, technical, or material support: Huang.

    Supervision: Delgado.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Research reported in this article was supported by grant T32HL098054 from the National Heart, Lung, and Blood Institute (Dr Coupet), award K12DA033312-06 from the National Institute on Drug Abuse (Dr Coupet), and award K23HD090272001 from the National Institute of Child Health and Human Development (Dr Delgado).

    Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Meeting Presentation: This work was presented at the 2018 Society for Academic Emergency Medicine Annual Meeting; May 16, 2018; Indianapolis, Indiana.

    Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

    References
    1.
    Centers for Disease Control and Prevention. Fatal injury reports, national, regional, and state, 1981–2016. https://webappa.cdc.gov/sasweb/ncipc/mortrate.html. Published February 19, 2017. Accessed April 27, 2018.
    2.
    Stewart  RM, Kuhls  DA, Rotondo  MF, Bulger  EM.  Freedom with responsibility: a consensus strategy for preventing injury, death, and disability from firearm violence.  J Am Coll Surg. 2018;227(2):281-283. doi:10.1016/j.jamcollsurg.2018.04.006PubMedGoogle ScholarCrossref
    3.
    Juillard  C, Smith  R, Anaya  N, Garcia  A, Kahn  JG, Dicker  RA.  Saving lives and saving money: hospital-based violence intervention is cost-effective.  J Trauma Acute Care Surg. 2015;78(2):252-257. doi:10.1097/TA.0000000000000527PubMedGoogle ScholarCrossref
    4.
    Rowhani-Rahbar  A, Simonetti  JA, Rivara  FP.  Effectiveness of interventions to promote safe firearm storage.  Epidemiol Rev. 2016;38(1):111-124.PubMedGoogle Scholar
    5.
    Ranney  ML, Fletcher  J, Alter  H,  et al; ACEP Technical Advisory Group on Firearm Injury Research, a Subcommittee of the ACEP Research Committee.  A consensus-driven agenda for emergency medicine firearm injury prevention research.  Ann Emerg Med. 2017;69(2):227-240. doi:10.1016/j.annemergmed.2016.08.454PubMedGoogle ScholarCrossref
    6.
    Wintemute  GJ, Betz  ME, Ranney  ML.  Yes, you can: physicians, patients, and firearms.  Ann Intern Med. 2016;165(3):205-213. doi:10.7326/M15-2905PubMedGoogle ScholarCrossref
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