Characteristics of Firearm Injury by Injury Intent: The Need for Tailored Interventions.

INTRODUCTION: While the U.S. has high quality data on firearm-related deaths, less information is available on those who arrive at trauma centers alive, especially those discharged from the emergency department. This study sought to describe characteristics of patients arriving to trauma centers alive following a firearm injury, postulating that significant differences in firearm injury intent might provide insights into injury prevention strategies. METHODS: This was a multi-center prospective cohort study of patients treated for firearm-related injuries at 128 U.S. trauma centers from 3/2021-2/2022. Data collected included patient-level sociodemographic, injury and clinical characteristics, community characteristics, and context of injury. The outcome of interest was the association between these factors and the intent of firearm injury. Measures of urbanicity, community distress, and strength of state firearm laws were utilized to characterize patient communities. RESULTS: 15,232 patients presented with firearm-related injuries across 128 centers in 41 states. Overall, 9.5% of patients died, and deaths were more common among law enforcement and self-inflicted (SI) firearm injuries (80.9% and 50.5%, respectively). These patients were also more likely to have a history of mental illness. SI firearm injuries were more common in older White men from rural and less distressed communities, whereas firearm assaults were more common in younger, Black men from urban and more distressed communities. Unintentional injuries were more common among younger patients and in states with lower firearm safety grades whereas law enforcement-related injuries occurred most often in unemployed patients with a history of mental illness. CONCLUSIONS: Injury, clinical, sociodemographic, and community characteristics among patients injured by a firearm significantly differed between intents. With the goal of reducing firearm-related deaths, strategies and interventions need to be tailored to include community improvement and services that address specific patient risk factors for firearm injury intent. LEVEL OF EVIDENCE: Level III, Prognostic/Epidemiological.

The national trauma triage protocol: how EMS perspective can inform the guideline revision.

OBJECTIVES: The Field Triage Guidelines (FTG) support emergency medical service (EMS) decisions regarding the most appropriate transport destination for injured patients. While the components of the algorithm are largely evidenced-based, the stepwise approach was developed with limited input from EMS providers. FTG are only useful if they can easily be applied by the field practitioner. We sought to gather end-user input on the current guidelines from a broad group of EMS stakeholders to inform the next revision of the FTG. METHODS: An expert panel composed an end-user feedback tool. Data collected included: demographics, EMS agency type, geographic area of respondents, use of the current FTG, perceived utility, and importance of each step in the algorithm (1: physiologic, 2: anatomic, 3 mechanistic, 4: special populations). The American College of Surgeons Committee on Trauma (ACS COT), in partnership with several key organizations, distributed the tool to reach as many providers as possible. RESULTS: 3958 responses were received (82% paramedics/emergency medical technicians, 9% physicians, 9% other). 94% responded directly to scene emergency calls and 4% were aeromedical providers. Steps 2 and 3 were used in 95% of local protocols, steps 1 and 4 in 90%. Step 3 was used equally in protocols across all demographics; however, step 1 was used significantly more in the air medical services than ground EMS (96% vs 88%, p<0.05). Geographic variation was demonstrated in FTG use based on the distance to a trauma center, but step 3 (not step 1) drove the majority of the decisions. This point was reinforced in the qualitative data with the comment, "I see the wreck before I see the patient." CONCLUSION: The FTG are widely used by EMS in the USA. The stepwise approach is useful; however, mechanism (not physiological criteria) drives most of the decisions and is evaluated first. Revision of the FTG should consider the experience of the end-users. LEVEL OF EVIDENCE: V.

Survey of American College of Surgeons Members on Firearm Injury Prevention.

BACKGROUND: Firearm-related injuries and deaths continue to be a substantial public health burden in the US. The purpose of this study was to describe the results of a survey of US members of the American College of Surgeons (ACS) on their practices, attitudes, and beliefs about firearms and firearm policies. The survey was designed to gain a representative understanding of the views of all US ACS members to help inform ACS positions related to firearm injury prevention. STUDY DESIGN: A professional survey firm was engaged to facilitate the design of the survey and to support a web-based platform. Data collection through an anonymous survey began in July 2018, with the survey closing in September 2018. Survey data were weighted and analyses included descriptive and bivariate statistics. RESULTS: There were 54,761 ACS members invited to participate in the survey. Of those, 11,147 respondents completed the survey, for an overall response rate of 20.4%. Respondents were questioned on firearm experience, purpose of firearm ownership, opinions on firearm ownership, and importance of ACS support for specific firearm legislation. Survey results varied by practice and training location, practice type, military experience, gender, age, presence of children in the home, level of training, and race and ethnicity. Most survey respondents were ACS fellows (n = 7,579 [68%]), male (n = 8,671 [77.8%]), and White (n = 8,639 [77.5%]). Forty-two percent of respondents keep guns in their home. Seventy-five percent of respondents believe that it is very or extremely important for the ACS to support policy initiatives to lower the incidence of firearm injury. CONCLUSIONS: There is broad support among ACS members for many initiatives related to firearm injury prevention. The degree of support for these measures varies based on both the specific initiative and demographic characteristics. The results align with the ACS strategy of healthcare professionals working together to better understand and address the root causes of violence, and simultaneously working together to make firearm ownership as safe as reasonably possible.

A reassessment of the impact of trauma systems consultation on regional trauma system development.

BACKGROUND: Previous studies have shown that trauma systems decrease morbidity and mortality after injury, but progress in system development has been slow and inconsistent. This study evaluated the progress in 20 state or regional systems following a consultative visit conducted by the Trauma Systems Evaluation and Planning Committee (TSEPC) of the Committee on Trauma, expanding on a previous study published in 2008, which demonstrated significant progress in six systems following consultation. METHODS: Twenty trauma systems that underwent TSEPC consultation between 2004 and 2010 were studied. Status was assessed using a set of 16 objective indicators. Baseline scores for 14 regions were calculated during the consultation visit and taken from the 2008 study for the remaining six. Postconsultation status was assessed during facilitated teleconferences. Progress was assessed by comparing changes in indicator scores. RESULTS: There was significant improvement in approximately 80% of systems evaluated within 60 months following the consultation. There was no progress in five of six systems reevaluated over 80 months after consultation, and all four systems evaluated over 100 months after consultation showed erosion of progress. Significant improvements were seen in 10 of the 16 individual indicators, with the greatest gains related to system standards, data systems, performance improvement, prehospital triage criteria, and linkages with public health. Consistent with the 2008 study, the two indicators related to financing for the trauma system showed no improvement. CONCLUSION: The TSEPC consultation process continues to be associated with improvements in trauma system development in approximately 80% of cases, consistent with the 2008 study, but gains are not self-sustaining. There was a stagnation in progress and a deterioration in total score over time, suggesting that a repeat consultation may be beneficial. System funding remains a challenge and was the area most likely to suffer setbacks over during study period. LEVEL OF EVIDENCE: Care management study, level V.