Post-Discharge Needs of Victims of Gun Violence in Chicago: A Qualitative Study

Exploring the Role of Fear, Civic Disengagement, and Economic Disenfranchisement Within Communities that Experience Gun Violence

A growing body of research has documented how gun violence can affect mental and physical health outcomes among adults. Likewise, the literature is also beginning to reveal negative psychological effects related to distress and hypervigilance and sociological implications around diminished community engagement and economic opportunity. However, there remains a need to fully explore the role of fear related to the experience of gun violence. Through a qualitative inquiry consisting of community resident focus groups and community leader interviews, this study examined how participants' perceptions of fear related to their exposures to and experiences of gun violence. The findings highlight the pervasive emotional experience of existing in a fearful, distressed, and/or anxious state within certain communities, and how civic disengagement, neighborhood disconnection, and economic disenfranchisement exist in communities that disproportionately experience violence.

Racial discrimination increases the risk for nonremitting posttraumatic stress disorder symptoms in traumatically injured Black individuals living in the United States

Traumatic, life-threatening events are experienced commonly among the general U.S. population, yet Black individuals in the United States (i.e., Black Americans) exhibit higher prevalence rates of posttraumatic stress disorder (PTSD) and more severe symptoms than other populations. Although empirical research has noted a range of symptom patterns that follow traumatic injury, minimal work has examined the role of racial discrimination in relation to PTSD symptom trajectories. The current study assessed racial discrimination and PTSD symptom trajectories at 6 months postinjury across two separate samples of traumatically injured Black Americans (i.e. emergency department (ED)-discharged and hospitalized). Identified PTSD symptom trajectories largely reflect those previously reported (i.e., ED: nonremitting, moderate, remitting, and resilient; hospitalized: nonremitting, delayed, and resilient), although the resilient trajectory was less represented than expected given past research (ED: 55.8%, n = 62; hospitalized: 46.9%, n = 38). Finally, higher racial discrimination was associated with nonremitting, ED: relative risk ratio (RR) = 1.32, hospitalized: RR = 1.23; moderate, ED: RR = 1.18; and delayed, hospitalized: RR = 1.26, PTSD symptom trajectories. Overall, the current findings not only emphasize the inimical effects of racial discrimination but also demonstrate the unique ways in which race-related negative events can impact PTSD symptom levels and recovery across time.

Community-Level Disadvantage of Adults With Firearm- vs Motor Vehicle-Related Injuries

Importance

Motor vehicle crash (MVC) and firearm injuries are 2 of the top 3 mechanisms of adult injury-related deaths in the US.

Objective

To understand the differing associations between community-level disadvantage and firearm vs MVC injuries to inform mechanism-specific prevention strategies and appropriate postdischarge resource allocation.

Design, Setting, and Participants

This multicenter cross-sectional study analyzed prospectively collected data from the American College of Surgeons (ACS) Firearm Study. Included patients were treated either for firearm injury between March 1, 2021, and February 28, 2022, or for MVC-related injuries between January 1 and December 31, 2021, at 1 of 128 participating ACS trauma centers.

Exposures

Community distress.

Main outcome and Measure

Odds of presenting with a firearm as compared with MVC injury based on levels of community distress, as measured by the Distressed Communities Index (DCI) and categorized in quintiles.

Results

A total of 62 981 patients were included (mean [SD] age, 42.9 [17.7] years; 42 388 male [67.3%]; 17 737 Black [28.2%], 9052 Hispanic [14.4%], 36 425 White [57.8%]) from 104 trauma centers. By type, there were 53 474 patients treated for MVC injuries and 9507 treated for firearm injuries. Patients with firearm injuries were younger (median [IQR] age, 31.0 [24.0-40.0] years vs 41.0 [29.0-58.0] years); more likely to be male (7892 of 9507 [83.0%] vs 34 496 of 53 474 [64.5%]), identified as Black (5486 of 9507 [57.7%] vs 12 251 of 53 474 [22.9%]), and Medicaid insured or uninsured (6819 of 9507 [71.7%] vs 21 310 of 53 474 [39.9%]); and had a higher DCI score (median [IQR] score, 74.0 [53.2-94.8] vs 58.0 [33.0-83.0]) than MVC injured patients. Among admitted patients, the odds of presenting with a firearm injury compared with MVC injury were 1.50 (95% CI, 1.35-1.66) times higher for patients living in the most distressed vs least distressed ZIP codes. After controlling for age, sex, race, ethnicity, and payer type, the DCI components associated with the highest adjusted odds of presenting with a firearm injury were a high housing vacancy rate (OR, 1.11; 95% CI, 1.04-1.19) and high poverty rate (OR, 1.17; 95% CI, 1.10-1.24). Among patients sustaining firearm injuries patients, 4333 (54.3%) received no referrals for postdischarge rehabilitation, home health, or psychosocial services.

Conclusions and Relevance

In this cross-sectional study of adults with firearm- and motor vehicle-related injuries, we found that patients from highly distressed communities had higher odds of presenting to a trauma center with a firearm injury as opposed to an MVC injury. With two-thirds of firearm injury survivors treated at trauma centers being discharged without psychosocial services, community-level measures of disadvantage may be useful for allocating postdischarge care resources to patients with the greatest need.

Utilization of rehabilitation services in violent versus nonviolent traumatic spinal cord injury

BACKGROUND

Violence is the third leading cause of spinal cord injury (SCI) in the United States, and people with violence-related SCI have worse long-term outcomes compared to other traumatic SCI etiologies. Little is known, however, about the underlying reasons for these differences. Access to and utilization of rehabilitation services may differ in this population, but their outpatient care has not been previously investigated.

OBJECTIVE

To evaluate differences in utilization patterns of outpatient rehabilitation services between people with violence-related SCI and other traumatic SCI etiologies.

DESIGN

Retrospective cohort study.

SETTING

Academic tertiary care hospital system.

PATIENTS

A total of 41 patients with violence-related SCI residing in King County at the time of injury who completed inpatient rehabilitation (IPR) in our institution were identified from the hospital trauma registry and matched with 41 control patients with nonviolent traumatic SCI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

The number of appointments attended, canceled, and missed during the first year after discharge from IPR were obtained by chart review for physical medicine & rehabilitation (PM&R) physicians and therapy services.

RESULTS

People with violence-related SCI had decreased follow-up with outpatient rehabilitation services after IPR discharge compared to non-violent traumatic SCI, including PM&R (2.50 ± 2.44 vs. 3.76 ± 2.21 visits, β = -1.28, p = .017), physical therapy (8.91 ± 11.02 vs. 17.57 ± 15.26, β = -9.79, p = .009), occupational therapy (4.28 ± 7.90 vs. 10.04 ± 14.42, β = -6.18, p = .033), and recreational therapy (0.293 ± 0.955 vs. 1.37 ± 2.86, β = -1.07, p = .035). The rate of missed appointments was also higher among people with violence-related SCI compared to controls for PM&R (25.2% ± 28.5% vs. 9.9% ± 16.5%, β = 14.6%, p = .014) and physical therapy (26.0% ± 32.0% vs 4.2% ± 13.2%, β = 22.1%, p = .009).

CONCLUSIONS

Individuals with violence-related SCI had fewer follow-up appointments with PM&R physicians and other allied health professionals and were more likely to miss scheduled appointments compared to other traumatic SCI etiologies. Decreased outpatient follow-up may affect long-term outcomes for people with violence-related SCI.

A pilot project of a Post Discharge Care Team for firearm injury survivors decreases emergency department utilization, hospital readmission days, and cost

BACKGROUND

Persons of low socioeconomic status are overrepresented in the firearm injury patient population and may experience challenges in accessing complex outpatient health systems. Consequently, outpatient care for these patients is plagued by poor follow-up and increased emergency department (ED) utilization. We developed a Post Discharge Care Team (PDCT) consisting of a dedicated trauma nurse navigator and medical social worker to bridge the gap between hospital discharge and outpatient care to improve recovery.

METHODS

Adult firearm injury survivors admitted to the trauma service were randomized 1:1 to receive either PDCT services or standard of care (SOC) workflows. The PDCT nurse provided education and set expectations regarding injuries, wound care, and outpatient follow-up. The PDCT social worker performed a comprehensive assessment to identify concerns including housing and financial instability, food insecurity, or transportation issues. The primary outcome was ED utilization, with secondary outcomes including readmissions and overall health care costs compared between groups.

RESULTS

In the first 6 months of the study, a total of 44 patients were randomized to PDCT and 47 to SOC. There were 10 patients who visited the ED in the PDCT group compared with 16 in the SOC group ( p = 0.23) for a total of 14 and 23 ED visits, respectively. There were 14 patients in the PDCT and 11 patients in the SOC groups who were readmitted ( p = 0.31), but the PDCT group was readmitted for 27.9 fewer hospital days. After accounting for programmatic costs, the PDCT had a hospital savings of $34,542.71.

CONCLUSION

A collaborative, specialized PDCT for firearm injury survivors consisting of a dedicated trauma nurse navigator and medical social worker decreased outpatient ED utilization, readmission days, and was cost effective. Trauma centers with high volumes of penetrating trauma should consider a similar model to improve outpatient care for firearm injury survivors.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Examining the role of social vulnerability, neighborhood characteristics, and geospatial patterns of firearm-related injuries and clinical outcomes in Milwaukee county

BACKGROUND

Previous work has shown socioenvironmental factors can influence firearm injury. Milwaukee County, Wisconsin is a diverse midwestern county with historic disinvestment in marginalized communities yielding stark segregation along racial and ethnic lines. It is also one of the many U.S. counties burdened by surging firearm injuries. The differences among communities within Milwaukee County provides a unique opportunity to explore the intersection of socioenvironmental factors that may affect clinical outcomes and geospatial patterns of firearm injury.

METHODS

The trauma registry from the regional adult level 1 trauma center was queried for patients who sustained a firearm-related injury from 2015 to 2022 (N = 2402). The Social Vulnerability Index (SVI) ranking was derived using patient residence addresses to evaluate its association with traumatic injury clinical outcomes (i.e., in-hospital mortality, length of hospital stay, ICU or ventilator treatment, or injury severity score) and risk screening results for alcohol use disorder (AUD), posttraumatic stress disorder (PTSD), and depression. We evaluated hotspots of firearm injury density over time for patient residences and injury locations and distances between locations. A spatially lagged regression model tested the association between firearm injury density and SVI domains, alcohol outlet types, and park coverage.

RESULTS

Most firearm injury patients were younger, male, racial or ethnic minorities from disadvantaged neighborhoods (SVI total; M = 0.86, SD = 0.15). SVI was not associated with any clinical outcomes. Of those screened, 12.9% screened positive for AUD and 44.5% screened at risk for PTSD, depression, or both. Hotspot analysis indicated consistent concentrations of firearm injury density. There were no differences in clinical outcomes between those injured inside or outside the home. Census tracts with lower socioeconomic status, greater off-premises and lower on-premises alcohol outlet density were associated with greater firearm injury density.

CONCLUSIONS

In Milwaukee County, firearm injury patients are injured in and often return to the same disadvantaged neighborhoods that may hamper recovery. Results replicate and expand previous work and implicate specific socioenvironmental factors for intervention and prevention of firearm injury.

History of Racial Discrimination by Police Contributes to Worse Physical and Emotional Quality of Life in Black Americans After Traumatic Injury

BACKGROUND

Black Americans are more likely than their White counterparts to experience traumatic injury and worse functional outcomes. Unfair police treatment has been identified as one specific form of racial discrimination potentially driving these deleterious outcomes. The aim of the investigation was to better understand the relationship between experiences of discrimination by police and trauma-specific quality of life outcomes, including PTSD symptom severity, in Black Americans following traumatic injury.

METHOD

Traumatically injured Black American adults (N = 53) presenting to a level 1 trauma center completed a measure of police and law enforcement discrimination at baseline, and quality of life and PTSD were assessed 6 months later.

RESULTS

Stepwise regressions results showed more frequent discrimination by police and law enforcement significantly predicted lower emotional and physical well-being 6 months after injury. Further, more frequent police discrimination resulted in more severe PTSD symptoms by 6 months after injury.

CONCLUSIONS

Findings underscore that following an injury not specifically related to discrimination by police, patients' historical, negative police experiences contributed to worse physical and emotional recovery in the present. These findings, in unison with prior investigations, reveal the need to consider patients' history of negative police experiences as a social determinant of health in their recovery.

"I am a survivor!": Violently Injured Black Men's Perceptions of Labeling After a Violent Firearm Injury

Self-appraisal after a life-altering event is a critical process for individuals, often comprised by assigned labels that may not align with an individuals' perceptions of themselves or of their situation. Existing research within this victim-survivor dichotomy largely rests in the interpersonal violence space, with a victim assuming legal recourse and wrongdoing, and a survivor associating with positive personal characteristics like grit and resilience. Much existing literature on self-appraisal after interpersonal injury is heavily concentrated within the sexual violence literature, and this study applies these concepts to a sample of Black men injured by firearms. Ten Black men enrolled in a hospital-based violence intervention program (HVIP) were interviewed to understand how they label their experience of firearm injury, and if their perceptions aligned with common labels seen among other populations and/or in other areas of study (e.g., cancer, domestic violence). Each participant assigned themselves their own label, with three labels emerging: survivor, victim and survivor, and neither victim nor survivor. The results illustrate the nuance of experiences beyond the victim-survivor dichotomy, and how labels and personal identities may shift following injury into new terms and considerations of resilience and trauma processing. More research is warranted to understand the factors that shape self-labeling within this population, including influences of masculine norms, racialized stereotypes, community context, and availability of services. Findings support public awareness campaigns to reframe surviving violence as a strength, and for community partners and practitioners to increase access to culturally competent and trauma-informed mental healthcare.

Recommendations for the Clinician Role in Reducing Gun Violence

There is a growing need for clear and definitive guidelines to prevent firearm violence in communities across the United States. Recommendations explore the utility and feasibility of universal screenings and recommend utilizing universal screening due to a lack of a clear risk to it. Providers should also work to create risk reduction plans with patients as well. Furthermore, recommendations for mental health care, counseling, and bystander training are made for institutions and their providers.

Improved follow-up care for gun violence survivors in the Trauma Quality of Life Clinic

Background

Outpatient follow-up represents a crucial opportunity to re-engage with gun violence survivors (GVS) and to facilitate positive health outcomes. Current outpatient models for firearm-related injuries and trauma care are inconsistent and unstandardized across trauma centers. This project describes the patient population served by the multidisciplinary Trauma Quality of Life (TQoL) Clinic for GVS. Also of primary interest was the outpatient follow-up services used by patients prior to their clinic appointment. Subsequent referrals placed during Clinic, as well as rate of attendance, was a secondary aim.

Methods

This was a descriptive retrospective analysis of a quality improvement project of the TQoL Clinic. Data were extracted from the electronic medical record and were supplemented with information from the trauma registry and the hospital-based violence intervention program database. Descriptive statistics characterized the patient population served. A Χ2 analysis was used to compare no-show rates for the TQoL Clinic against two historical cohorts of trauma clinic attendees.

Results

Most attendees were young (M=32.0, SD=1.8, range=15-88 years), Black (80.1%), and male (82.0%). Of the 306 total TQoL Clinic attendees, 82.3% attended their initial scheduled appointment. Most non-attendee patients rescheduled their appointments (92.1%), and 89.5% attended the rescheduled appointment. TQoL Clinic demonstrated a significantly lower no-show rate than the traditional trauma clinic model, including after the implementation of the hospital's inpatient violence intervention program (χ2(2)=75.52, p<0.001).

Conclusion

The TQoL Clinic has demonstrated improved outpatient follow-up to address the comprehensive needs of GVS. Trauma centers with high gunshot wound volume should consider the implementation of the multidisciplinary TQoL Clinic model to increase access to care and to continue partnership with violence intervention programs to address health outcomes in those most at risk of future morbidity and mortality.

Level of evidence

Therapeutic/care management, level III.

Factors Associated with Discharge to Skilled Nursing Facility Following Gunshot Wounds

INTRODUCTION

Firearm injury is a public health crisis. Most victims are minorities in underserved neighborhoods. Measuring firearm injury by mortality underestimates its impact, as most victims survive to discharge. This study was done to determine if race and insurance status are associated with discharge disposition for gunshot wound (GSW)-related trauma.

METHODS

Using the 2019 Trauma Quality Improvement Program database, we identified GSW patients with Abbreviated Injury Scale (AIS) = 1-3. Exclusion criteria included patients who died in hospital and routine home discharge. We compared discharge patterns of patients based on demographics (age, gender, race, ethnicity, payor, AIS, hospital designation, and length of stay [LOS]) and injury severity. Multivariable logistic regression models identified factors associated with discharge disposition.

RESULTS

Our sample included 2437 patients with GSWs. On univariable analysis, Black patients were more likely to discharge to home with home health (64.1% Black versus 34.7% White; P < 0.001). White patients were more likely to discharge to skilled nursing facility (SNF) (51.4% White versus 44.6% Black; P < 0.001). Controlling for age, race, Latin ethnicity, primary payor, LOS, AIS severity, and injury severity score factors independently associated with discharge to SNF included age (0.0462, P < 0.001), Medicaid (1.136, P < 0.0003), Medicare (1.452, P < 0.001), and LOS (0.03745, P < 0.001).

CONCLUSIONS

Postacute care following traumatic injuries is essential to recovery. Black GSW victims are more likely to be discharged to home health than White patients, who are more likely to be discharged to SNF. Targeted programs to reduce barriers to appropriate aftercare are necessary to eliminate this bias and improve the care of underserved populations.

Can stepped collaborative care interventions improve post-traumatic stress disorder symptoms for racial and ethnic minority injury survivors?

Objectives

No large-scale randomized clinical trial investigations have evaluated the potential differential effectiveness of early interventions for post-traumatic stress disorder (PTSD) among injured patients from racial and ethnic minority backgrounds. The current investigation assessed whether a stepped collaborative care intervention trial conducted at 25 level I trauma centers differentially improved PTSD symptoms for racial and ethnic minority injury survivors.

Methods

The investigation was a secondary analysis of a stepped wedge cluster randomized clinical trial. Patients endorsing high levels of distress on the PTSD Checklist (PCL-C) were randomized to enhanced usual care control or intervention conditions. Three hundred and fifty patients of the 635 randomized (55%) were from non-white and/or Hispanic backgrounds. The intervention included care management, cognitive behavioral therapy elements and, psychopharmacology addressing PTSD symptoms. The primary study outcome was PTSD symptoms assessed with the PCL-C at 3, 6, and 12 months postinjury. Mixed model regression analyses compared treatment effects for intervention and control group patients from non-white/Hispanic versus white/non-Hispanic backgrounds.

Results

The investigation attained between 75% and 80% 3-month to 12-month follow-up. The intervention, on average, required 122 min (SD=132 min). Mixed model regression analyses revealed significant changes in PCL-C scores for non-white/Hispanic intervention patients at 6 months (adjusted difference -3.72 (95% CI -7.33 to -0.10) Effect Size =0.25, p<0.05) after the injury event. No significant differences were observed for white/non-Hispanic patients at the 6-month time point (adjusted difference -1.29 (95% CI -4.89 to 2.31) ES=0.10, p=ns).

Conclusion

In this secondary analysis, a brief stepped collaborative care intervention was associated with greater 6-month reductions in PTSD symptoms for non-white/Hispanic patients when compared with white/non-Hispanic patients. If replicated, these findings could serve to inform future American College of Surgeon Committee on Trauma requirements for screening, intervention, and referral for PTSD and comorbidities.

Level of evidence

Level II, secondary analysis of randomized clinical trial data reporting a significant difference.

Trial registration number

NCT02655354.

A Conceptual Model of Help-Seeking by Black Americans After Violent Injury: Implications for Reducing Inequities in Access to Care

Many inequities exist in serving and supporting Black survivors of violent crime. A key question in reducing inequities in care after victimization is whether police first responders and other formal system providers identify the victim as an "offender" and/or someone who is "undeserving" of supports. These labels and associated biases can directly reduce access to supports through a variety of mechanisms that include police withholding information about one's rights as a victim, among other direct and indirect barriers to social and health services. Unaddressed financial, mental, and physical health consequences of victimization contribute to poorer health outcomes later in life. This paper seeks to bring together the extant research on help-seeking, discrimination in criminal legal system functioning, and barriers to victim services by synthesizing these discrete threads into a theoretically and empirically informed conceptual model that captures the range of factors that shape Black Americans' decision to report their victimization to the police and subsequent help-seeking. Qualitative and quantitative data from a purposive sample of 91 Black victims of community violence is used to ground the developing model. The conceptual model can help lay the foundation for research that seeks to remedy the marked mismatch between the prevalence of violent victimization and help-seeking among Black Americans. Research findings can be applied to guide policies and programming to reduce inequities in care for victims of violence.

Police Violence in Health Care Settings in US Media Coverage

Importance

Hospitals do not collect or share data tracking their policing and security activities despite their reliance on police and security personnel, including armed officers. Thus, little is known about how hospital security is associated with patient and staff safety.

Objective

To examine the harms exerted by health care-affiliated police and security personnel.

Design, Setting, and Participants

For this qualitative study, data were collected using a systematic Media Cloud search for US news media coverage from January 2011 to May 2022. A total of 18 987 articles on policing and hospitals were screened and a content and thematic analysis of articles that met the search criteria was conducted, which involved incidents that revealed harm to patients, patients' families, and staff. Data were analyzed from October 2022 to April 2023.

Main Outcomes and Measures

Incident year, incident location (hospital name, city, state), survivor and victim characteristics (race and ethnicity, presence of mental illness), and a narrative description of the incident focusing on outcomes of harm exerted by police and security personnel in the health care setting.

Results

A total of 48 unique stories across 25 US states were included. The median (range) year published was 2017 (2009-2022). Harms reported to have been perpetuated by health care-affiliated police and security personnel were identified within 5 domains from 48 unique incidents: (1) patients shot by police or security personnel (17 patients); (2) patients subject to excessive use of force (17 patients); (3) patients arrested (7 patients); (4) patients subject to sexual assault (2 patients); and (5) hospital personnel or those considered collateral damage shot, injured, or arrested (5 individuals). Most survivors and victims were Black, although the race and/or ethnicity of involved individuals was not routinely reported across the news stories. Mental illness was the most documented medical condition among patients injured or killed by health care-affiliated police and security personnel.

Conclusions and Relevance

This qualitative study of US news media found that police and security personnel in hospitals were reported to have perpetuated harm via excessive force, sexual assaults, injuring patients and health care workers, and fatal shootings. Compounded by a lack of transparency and accountability mechanisms, this may represent an underrecognized manifestation of structural racism at the organizational level. Policy suggestions include introducing accountability measures, deescalation techniques, and removing arms from hospital security personnel to reduce harm and fulfill health care's healing mission.

Patient Experiences of Acute and Postacute Care After Trauma

INTRODUCTION

Traumatic injury can transform a healthy, independent individual into a patient with complex health needs. Little is known about how injured patients understand their health and healthcare needs during postacute recovery, limiting our ability to optimize care. This multiple-methods study explored injured patients' experiences of care up to 30 days after discharge.

METHODS

Injured adults admitted to an urban, Level I trauma center August 1, 2019-November 30, 2020 were sampled purposively to balance blunt and penetrating injuries. Patient experience and health status were assessed at baseline and 30 days postdischarge using the Quality of Trauma Care Patient-Reported Experience Measure. Fifteen qualitative interviews were conducted with a purposive subset and analyzed using qualitative content analysis.

RESULTS

Of 67 participants (76% male, 73% Black, 51% penetrating, median age 34 years), 37 completed follow-up surveys. Quality of acute care was rated 9-10/10 by 81% of the sample for acute and 65% for postacute care (P = 0.09). Thirty percent described fair or poor mental health, but only mental health concerns were addressed for only 2/3. Pain control was inadequate in 31% at baseline and for 46% at follow-up (P = 0.09). Qualitative analysis revealed general satisfaction with acute care but challenges in recovery with unmet needs for communication and care coordination.

CONCLUSIONS

Trauma patients appreciated the quality of their acute care experiences but identified opportunities for improvement in prognostic communication, pain management, and mental health support. Unmet mental and physical care needs persist at least 1 month after hospital discharge and reinforce the need for interventions that optimize postacute trauma care.

Holistic Approach to Gun Violence

The purpose of this manuscript is to provide holistic practice strategies for the care of victims of gun violence. Gun violence is a public health crisis with a significant increase following the pandemic. The impact of Covid-19 restrictions placed an increase burden on some communities already overwhelmed with poverty, crime, and deteriorating homes. The overrepresentation of African American males as victim of gun violence indicates a health care disparity which needs to be addressed. The Theory of Reasoned Action and Theory of Planned Behavior are a theoretical framework that provides insight to the social behaviors associated with gun violence. The holistic approach recognizes the interconnection between individuals and environment, in order to facilitate the healing process for victims of gun violence, social factors and environment must be incorporated into their care.

Engagement With Mental Health Services Among Survivors of Firearm Injury

Importance

Despite the prevalence of posttraumatic stress symptoms after firearm injury, little is known about how firearm injury survivors connect with mental health services.

Objective

To determine facilitators and barriers to mental health care engagement among firearm injury survivors.

Design, Setting, and Participants

A qualitative study of 1-on-1, semistructured interviews conducted within a community setting in Indianapolis, Indiana, between June 2021 and January 2022. Participants were recruited via community partners and snowball sampling. Participants who survived an intentional firearm injury, were shot within Indianapolis, were aged 13 years or older, and were English speaking were eligible. Participants were asked to discuss their lives after firearm injury, the emotional consequences of their injury, and their utilization patterns of mental health services. Data were analyzed from August 2022 to June 2023.

Main Outcomes and Measures

Survivors' lived experience after firearm injury, sources of emotional support, mental health utilization, and their desired engagement with mental health care after firearm injury.

Results

A total of 18 participants (17 were Black [94%], 16 were male [89%], and 14 were aged between 13 and 24 years [77%]) who survived a firearm injury were interviewed. Survivors described family members, friends, and informal networks as their main source of emotional support. Barriers to mental health care utilization were perceived as a lack of benefit to services, distrust in practitioners, and fear of stigma. Credible messengers served as facilitators to mental health care. Survivors also described the emotional impact their shooting had on their families, particularly mothers, partners, and children.

Conclusions and Relevance

In this study of survivors of firearm injury, findings illustrated the consequences of stigma and fear when seeking mental health care, inadequate trusted resources, and the need for awareness of and access to mental health resources for family members and communities most impacted by firearm injury. Future studies should evaluate whether community capacity building, digital health delivery, and trauma-informed public health campaigns could overcome these barriers to mitigate the emotional trauma of firearm injuries to reduce health disparities and prevent future firearm violence.

Impact of firearm injury in children and adolescents on health care costs and use within a family

In 2020, firearm injury became the leading cause of death in U.S. children and adolescents. This study examines sequelae of firearm injury among children and adolescents in terms of health care costs and use within a family over time using an event study design. Using data from a large U.S. commercial insurance company from 2013 to 2019, we identified 532 children and adolescents aged 1-19 years who experienced any firearm-related acute hospitalization or emergency department (ED) encounter and 1667 of their family members (833 parents and 834 siblings). Outcomes included total health care costs, any acute hospitalization and ED visits (yes/no), and number of outpatient management visits, each determined on a quarterly basis 2 years before and 3 years after the firearm injury. Among injured children and adolescents, during the first quarter after the firearm injury, quarterly total health care costs were $24,018 higher than pre-injury; probability of acute hospitalization and ED visits were 27.9% and 90.4% higher, respectively; and number of outpatient visits was 1.8 higher (p < .001 for all). Quarterly total costs continued to be elevated during the second quarter post-injury ($1878 higher than pre-injury, p < .01) and number of outpatient visits remained elevated throughout the first year post-injury (0.6, 0.4, and 0.3 higher in the second through fourth quarter, respectively; p < .05 for all). Parents' number of outpatient visits increased during the second and third years after the firearm injury (0.3 and 0.5 higher per quarter than pre-injury; p < .05). Youth firearm injury has long-lasting impact on health care within a family.

The gap between hospital-based violence intervention services and client needs: A systematic review

BACKGROUND

Survivors of intentional interpersonal violence face social challenges related to social determinants of health that led to their initial injury. Hospital-based violence intervention programs reduce reinjury. It is unclear how well they meet clients' reported needs. This systematic review aimed to quantify how well hospital-based violence intervention program services addressed clients' reported needs.

METHODS

Medline, The Cochrane Library, CINAHL Plus with Full Text, and PsycInfo were queried for studies addressing hospital-based violence intervention programs services and intentional injury survivors' needs in the United States. Case reports, reviews, editorials, theses, and studies focusing on pediatric patients, victims of intimate partner violence, or sexual assault were excluded. Data extracted included program structure, hospital-based violence intervention program services, and client needs assessments before and after receiving hospital-based violence intervention program services.

RESULTS

Of the 3,339 citations identified, 13 articles were selected for inclusion. Hospital-based violence intervention programs clients' most reported needs included mental health (10 studies), employment (7), and education (5) before receiving hospital-based violence intervention programs services. Only 4 studies conducted quantitative client needs assessments before and after receiving hospital-based violence intervention program services. All 4 studies were able to meet at least 50% of each of the clients' reported needs. The success rate depended on the need and program location: success in meeting mental health needs ranged from 65% to 90% of clients. Conversely, time-intensive long-term needs were least met, including employment 60% to 86% of clients, education 47% to 73%, and housing 50% to 71%.

CONCLUSION

Few hospital-based violence intervention programs studies considered clients' reported needs. Employment, education, and housing must be a stronger focus of hospital-based violence intervention programs.

Costs for Long-Term Health Care After a Police Shooting in Ontario, Canada

Importance

Police shootings can cause serious acute injury, and knowledge of subsequent health outcomes may inform interventions to improve care.

Objective

To analyze long-term health care costs among survivors of police shootings compared with those surviving nonfirearm police enforcement injuries using a retrospective design.

Design, Setting, and Participants

This population-based cohort analysis identified adults (age ≥16 years) who were injured by police and required emergency medical care between April 1, 2002, and March 31, 2022, in Ontario, Canada.

Exposure

Police shootings compared with other mechanisms of injury involving police.

Main Outcomes and Measures

Long-term health care costs determined using a validated costing algorithm. Secondary outcomes included short-term mortality, acute care treatments, and rates of subsequent disability.

Results

Over the study, 13 545 adults were injured from police enforcement (mean [SD] age, 35 [12] years; 11 637 males [86%]). A total of 13 520 individuals survived acute injury, and 8755 had long-term financial data available (88 surviving firearm injury, 8667 surviving nonfirearm injury). Patients surviving firearm injury had 3 times greater health care costs per year (CAD$16 223 vs CAD$5412; mean increase, CAD$9967; 95% CI, 6697-13 237; US $11 982 vs US $3997; mean increase, US $7361; 95% CI, 4946-9776; P < .001). Greater costs after a firearm injury were not explained by baseline costs and primarily reflected increased psychiatric care. Other characteristics associated with increased long-term health care costs included prior mental illness and a substance use diagnosis.

Conclusions and Relevance

In this longitudinal cohort study of long-term health care costs, patients surviving a police shooting had substantial health care costs compared with those injured from other forms of police enforcement. Costs primarily reflected psychiatric care and suggest the need to prioritize early recognition and prevention.

Exploring Collaborative Care Effects on the Mental and Physical Health of Patients With and Without Violent Victimization Histories

Collaborative care is a multicomponent intervention delivered by frontline social work, nursing, and physician providers to address patients' physical, emotional, and social needs. We argued that collaborative care may particularly benefit patients with a violent victimization history because it practices three principles of trauma-informed care: patient-provider collaboration, preventing repeat trauma in clinical and community settings, and delivering comprehensive mental and physical healthcare. We conducted an exploratory secondary data analysis of a collaborative care randomized clinical trial involving patients who presented with traumatic physical injury at a Level I trauma center in Washington state between 2006 and 2009. We used random-effect linear regression models to estimate how histories of multiple violent traumas moderated the effects of the collaborative care intervention on Short Form-36 Mental Component Summary (MCS) and Physical Component Summary (PCS) T-scores over time. Collaborative care significantly improved follow-up MCS scores among patients who experienced three to four types of violent victimization in their lifetime. Additionally, intervention effects on MCS scores at the 3- and 6-month follow-up were clinically stronger for patients who reported three to four types of violent victimization (3-month = 7.5, 95% confidence level [CI] = 5.1 to 18.7; 6-month = 11.9, 95% CI = 5.1 to 18.7) than those without a history of violent victimization (3-month = 0.8, 95% CI = -5.1, 6.6; 6-month = 5.6, -2.4 to 13.5). We did not find that intervention effects on PCS scores differed between these groups at any wave. Collaborative care may be a promising approach to delivering trauma-informed mental healthcare to patients with histories of multiple types of violent victimization.

Interactions With Police in the Emergency Care of Children: Ethical and Legal Considerations

OBJECTIVES

Emergency medicine providers may interface with law enforcement personnel (LEP) on behalf of their pediatric patients for a variety of reasons, from reporting child abuse to caring for children who are in police custody. Given the unique nature of caring for minors who may not have legal or medical autonomy, interactions with LEP can raise ethical concerns for emergency providers, specifically with regard to legal representation, developmental immaturity, and the civil rights of children and their parents/guardians.

METHODS

We review 4 patient scenarios, based on real cases experienced by the authors, to demonstrate the legal and ethical issues that may arise when LEP are involved in the emergency care of a child. These scenarios discuss parental/guardian visitation for children in police custody in the emergency department (ED), the practice of making arrests on hospital grounds, and police interviews of children in the ED.

RESULTS

Using the ethical principles of autonomy, beneficence, and justice, we offer recommendations for emergency providers on how to advocate for their pediatric patients in LEP custody within the constraints and protections of the law. We also suggest best practices for hospital systems to develop policies surrounding LEP activity in the ED.

CONCLUSIONS

These nuanced situations require careful advocacy for the child and a collaborative approach between medical providers and LEP to balance the child's well-being with public safety. We offer recommendations here, and we maintain that clear, widely adopted best practices for the care of minors in LEP custody are long overdue.

Health Effects of Policing in Hospitals: a Narrative Review

IMPORTANCE

Law enforcement activity, in the form of outside agencies or hospital security forces, is increasingly common in American healthcare. Little is known about the potential effects of this prevalent, modifiable exposure on hospital staff and patient health. This narrative review characterizes existing evidence on the direct and indirect health effects of law enforcement activity in hospitals.

OBSERVATIONS

Law enforcement activity in hospitals can affect health outcomes through four mechanisms: (1) physical health effects related to workplace violence, restraint use, excessive force, and weapon use; (2) mental health effects involving perceptions of safety and psychological distress; (3) social effects related to the patient-provider relationship, mistrust, and bias and discrimination; and (4) legal and ethical considerations affecting overall well-being.

CONCLUSIONS AND RELEVANCE

Unchecked law enforcement activity in hospitals may risk patient physical and mental health, reduce patient trust, result in bias and discrimination, and contribute to legal and ethical rights violations. Importantly, law enforcement activity in hospitals may also contribute to staff perceptions of safety. To fill knowledge gaps on the measurable impact of law enforcement activity in the hospital on staff and patients, hospitals should collect and publicly share robust data on law enforcement activity in their facilities, create and adopt patient-centered policies to ensure safety and protect patient health and privacy, and implement evidence-based interventions that safely reduce law enforcement involvement with patients.

Comprehensive Framework of Firearm Violence Survivor Care: A Review

Importance

Firearm violence is a public health crisis placing significant burden on individuals, communities, and health care systems. After firearm injury, there is increased risk of poor health, disability, and psychopathology. The newest 2022 guidelines from the American College of Surgeons Committee on Trauma require that all trauma centers screen for risk of psychopathology and provide referral to intervention. Yet, implementing these guidelines in ways that are responsive to the unique needs of communities and specific patient populations, such as after firearm violence, is challenging.

Observations

The current review highlights important considerations and presents a model for trauma centers to provide comprehensive care to survivors of firearm injury. This model highlights the need to enhance standard practice to provide patient-centered, trauma-informed care, as well as integrate inpatient and outpatient psychological services to address psychosocial needs. Further, incorporation of violence prevention programming better addresses firearm injury as a public health concern.

Conclusions and Relevance

Using research to guide a framework for trauma centers in comprehensive care after firearm violence, we can prevent complications to physical and psychological recovery for this population. Health systems must acknowledge the socioecological context of firearm violence and provide more comprehensive care in the hospital and after discharge, to improve long-term recovery and serve as a means of tertiary prevention of firearm violence.

Law enforcement in the trauma bay: a survey of members of the American Academy for the Surgery of Trauma

Background

Trauma patients frequently come into contact with law enforcement officers (LEOs) during the course of their medical care, but little is known about how LEO presence affects processes of care. We surveyed members of the American Association for the Surgery of Trauma (AAST) to assess their perspectives on frequency, circumstances, and implications of LEO presence in trauma bays nationwide.

Methods

Survey items addressed respondents' experience with the frequency and context of LEO presence and their perspectives on the impact of LEO presence for patients, clinical care, and public safety. Respondent demographics, professional characteristics, and practice setting were collected. The survey was distributed electronically to AAST members in September and October of 2020. Responses were compared by participant age, gender, race, ethnicity, urban versus rural location using χ2 tests.

Results

Of 234 respondents, 189 (80.7%) were attending surgeons, 169 (72.2%) identified as white, and 144 (61.5%) as male. 187 respondents (79.9%) observed LEO presence at least weekly. Respondents found LEO presence was most helpful for public safety, followed by clinical care, and then for patients. Older respondents rated LEO presence as helpful more often than younger respondents regarding the impact on patients, clinical care, and public safety (p<0.001 across all domains). When determining LEO access, respondents assessed severity of the patient's condition, the safety of emergency department staff, the safety of LEOs, and a patient's potential role as a threat to public safety.

Conclusions

Respondents described a wide range of perspectives on the impact and consequence of LEO in the trauma bay, with little policy to guide interactions. The overlap of law enforcement and healthcare in the trauma bay deserves attention from institutional and professional policymakers to preserve patient safety and autonomy and patient-centered care.

Level of evidence

IV, survey study.

Differences in mental health engagement and follow-up among Black and White patients after traumatic injury

BACKGROUND

Severe injury necessitating hospitalization is experienced by nearly three million US adults annually. Posttraumatic stress disorder and depression are prevalent clinical outcomes. The mechanisms by which programs equitably promote mental health recovery among trauma-exposed patients are understudied. We evaluated clinical outcomes and engagement among a cohort of Black and White patients enrolled in the Trauma Resilience and Recovery Program (TRRP), a stepped-care model to accelerate mental health recovery after traumatic injury.

METHODS

Trauma Resilience and Recovery Program is a four-step model that includes (1) bedside psychoeducation about mental health recovery following traumatic injury, (2) a text-messaging symptom tracking system, (3) a 30-day postinjury mental health screen, and (4) referrals to mental health services. Data describe 1,550 patients enrolled in TRRP within a Level I trauma center ( Mage = 40.86; SD, 17.32), 611 of whom identified as Black (74.5% male) and 939 of whom identified as White (67.7% male).

RESULTS

Enrollment in TRRP was nearly universal (97.9%) regardless of race or injury mechanism. Enrollment and usage of the text-message system were statistically similar between Black (35.7%) and White patients (39.5%). Trauma Resilience and Recovery Program reengaged Black and White patients at a similar rate at the 30-day postinjury follow-up. However, Black patients were more likely to report peritraumatic distress at the bedside and clinical elevations in posttraumatic stress disorder and depression on the 30-day screen. Referrals were more likely to be accepted by Black patients relative to White patients with clinically elevated symptoms.

CONCLUSION

Enrollment and engagement were comparable among Black and White patients served by TRRP. Data provide preliminary evidence to suggest that TRRP is feasible and acceptable and engages patients in mental health follow-up equitably. However, research that includes careful measurement of social determinants of health and long-term follow-up examining initiation, completion, and benefit from treatment is needed.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

"We're playing on the same team": Communication (dis)connections between trauma patients and surgical residents

BACKGROUND

Patient-physician communication is key to better clinical outcomes and patient well-being. Communication between trauma patients and their physicians remains relatively unexplored. We aimed to identify and characterize the range of strengths and challenges in patient-physician communication in the setting of trauma care.

METHODS

A qualitative, grounded theory approach was used to explore communication strengths and challenges for patients and residents. Patients previously admitted to the trauma service for violent injuries were recruited and interviewed in-person during their trauma clinic appointments. Surgical residents were recruited via email and interviewed virtually via Zoom. Anonymous, semistructured interviews were conducted until thematic saturation was reached.

RESULTS

Twenty-nine interviews with patients and 14 interviews with residents were conducted. Patients reported feeling ignored and misunderstood and having inadequate communication with physicians. Residents cited lack of time, patients' lack of health literacy, differences in background, and emotional responses to trauma as barriers to effective communication with patients. Patients and residents reported an understanding of each other's stressors, similar emotional experiences regarding traumatic stress, and a desire to communicate with each other in greater depth both inside and outside of the hospital.

CONCLUSION

Trauma patients and residents can feel disconnected due to the lack of time for thorough communication and differences in background; however, they understand each other's stressors and share similar emotional responses regarding trauma and a desire for increased communication, connection, and solidarity. Leveraging these shared values to guide interventions, such as a resident curriculum, may help bridge disconnects and improve their communication.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Trauma-Informed Acute Care of Patients With Violence-Related Injury

Violently-injured individuals presenting to the emergency department (ED) have an elevated risk of repeat injury after being discharged from acute care settings and a high rate of unaddressed mental health and social needs. While there is a growing body of programmatic interventions to address these needs, including hospital-based violence intervention programs, there is a lack of data regarding physician perspectives of current practice for this patient population. Understanding current practice is critical for integrating new programs into workflow and developing evidence-based medical education to improve care. The aim of this study is to elucidate current trauma-informed care practices of emergency medicine and general surgery trainee physicians to inform future curriculum development surrounding care of violently injured patients. In this study, emergency medicine and surgical trainees with at least one year of residency experience participated in simulation-primed interviews in pairs or small groups. Interviews garnered perspectives on the physician role in treating violently injured youth, using simulation as a priming event focused on previously known patient concerns. Qualitative themes that emerged were participants (1) perceived their role as managing medical/surgical concerns and seek others to build trust and manage psychosocial and legal concerns, (2) had a high level of knowledge of ED stressors and de-escalation strategies, (3) perceived that patient distrust can negatively impact their ability to provide care, and (4) perceived that law enforcement can negatively impact care and are sometimes uncertain about how to interact with law enforcement. These findings support that medical education for providers should focus on medicolegal issues, particularly managing law enforcement presence in the ED, structural and interpersonal causes of distrust of medical providers and the medical system, and addressing postdischarge mental health and social needs.

Not All Survivors Are the Same: Qualitative Assessment of Prior Violence, Risks, Recovery and Perceptions of Firearms and Violence Among Victims of Firearm Injury

Qualitative exploration into the risk, experiences, and outcomes of victims of firearm injury is imperative to informing not only further research, but prevention and intervention strategies. The purpose of this study was to explore prior violent exposures, risks, recovery, supportive services, outcomes, and views of firearms and violence among survivors of firearm assaults and unintentional injuries. Adults treated at a level 1 trauma center in Seattle, WA, for assault and unintentional firearm injuries were interviewed utilizing a semistructured instrument. Interview responses were coded to identify common themes and representative quotes are reported. Sixteen participants were interviewed. Notable themes included the following: (a) prior violent exposures were experienced by half of survivors, mostly through community violence; (b) risk for firearm injury was felt to be related to general societal violence, unsafe communities, and firearm practices; (c) important aspects of recovery included family/social support, mental health care and financial support services; (d) notable outcomes included psychological problems such as PTSD and anxiety, changes in relationships, and developing a new sense of purpose or mission in life; (e) generally negative views toward firearms, supporting restricted access and firearm safety practices; (f) acknowledgement of the complexity of firearm violence in society with prevention geared toward equitable education, economic opportunities and safety net programs to reduce community violence; and (g) disappointment in the criminal justice system. These findings demonstrate the varied experiences, needs, and outcomes after injury, but highlight the significance of community and societal violence, and need for improved mental health services. Integration of mental health services and victim assistance programs into trauma centers and hospital-based violence intervention programs is imperative for all survivors. Encouraging survivors to engage in new aspirations after injury can be empowering, and there is an unmet need for victim support and advocacy within the criminal justice system.

Healthcare utilization and mental health outcomes among nonfatal shooting assault victims

Victims of nonfatal shooting (NFS) assaults suffer from emotional and physical trauma; however, little is understood about clinical care utilization patterns among victims. This study examines the healthcare utilization and mental health outcomes before and after an index NFS victimization. A longitudinal dataset of police and clinical data were linked at the individual level to define a cohort of NFS victims with one or more clinical encounter in the 24-months preceding an index NFS injury (N = 2,681) in Indianapolis, Indiana between 2005 and 2018. Mental health was defined using ICD diagnosis codes from any emergency department, inpatient, or outpatient encounter and clinical care utilization was the number of unique encounters within the 24-months preceding and following an index NFS injury. Multivariable logistic regression was conducted to examine factors associated with a mental health diagnosis in the post injury period. Analyses were conducted in October 2021-March 2022. Overall clinical care utilization (Mean: pre = 277.7 (SD 235.3) vs. post = 333.9 (SD 255.1), p < 0.001) and mental health prevalence (14.4% pre vs. 18.8% post, p < 0.001) increased in the 24-months following an index NFS compared to the prior 24-months. Preinjury mental health utilization increased the odds of receiving a mental health diagnosis in the 24-months following an index NFS injury - particularly for Black victims (Odds Ratio 1.69, 95% CI 1.01, 2.85). The findings indicate missed opportunities within the healthcare system to connect NFS victims with needed mental health services, as well as the importance of premorbid connection to mental health care.

Compounding Trauma: the Intersections of Racism, Law Enforcement, and Injury

Purpose of Review

Traumatic injury sits at the nexus of law enforcement and structural racism. This narrative review aims to explore the major impacts of law enforcement on health, its intersections with US structural racism, and their joint impacts on traumatic injury and injury care.

Recent Findings

Many of the same forces of systemic disadvantage that put Black people, other people of color, and other marginalized groups at risk for violent injury also expose these same individuals and communities to intensive policing. Recent evidence speaks to the broad impact of police exposure and police violence on individual and community physical and mental health. Moreover, injured patients who are exposed to law enforcement during their care are at risk for erosion of trust in and relationships with their healthcare providers. To optimize the role of law enforcement agencies in injury prevention, collaboration across sectors and with communities is essential.

Summary

A broad approach to the prevention of injury and violence must incorporate an understanding of the intersecting impacts of law enforcement and structural racism on health and traumatic injury. Clinicians who seek to provide trauma-informed injury care should incorporate an understanding of the role of law enforcement in individual and community health.

Changing epidemiology of firearm injury: a cohort study of non-fatal firearm victimisation before and during the COVID-19 pandemic, Indianapolis, Indiana

OBJECTIVE

To examine victimisation rates, geographic patterns and neighbourhood characteristics associated with non-fatal firearm injury rates before and during the COVID-19 pandemic.

DESIGN

A retrospective cohort study.

SETTING

City of Indianapolis, Indiana, USA, 1 January 2017-30 June 2021.

PARTICIPANTS

Intentional non-fatal firearm injury victims from Indianapolis Metropolitan Police Department records. The study included information on 2578 non-fatal firearm injury victims between ages 0 and 77 years. Of these victims, 82.5% were male and 77.4% were black.

PRIMARY AND SECONDARY OUTCOME MEASURES

Rates of non-fatal firearm injuries per 100 000 population by victim age, race, sex and incident motive. Prepandemic and peripandemic non-fatal firearm injury rates.

RESULTS

Non-fatal shooting rates increased 8.60%, from 57.0 per 100 000 person-years in prepandemic years to 65.6 per 100 000 person-years during the pandemic (p<0.001). Rates of female victims (15.2 vs 23.8 per 100,000; p<0.001) and older victims (91.3 vs 120.4 per 100,000; p<0.001) increased significantly during the pandemic compared with the prepandemic period. Neighbourhoods with higher levels of structural disadvantage (IRR: 1.157, 95% CI 1.012 to 1.324) and prepandemic firearm injury rates (IRR: 1.001, 95% CI 1.001 to 1.002) was positively associated with higher rates of non-fatal firearm injuries during the pandemic, adjusting for neighbourhood characteristics.

CONCLUSIONS

Non-fatal firearm injuries increased significantly during the COVID-19 pandemic, particularly among female and older victims. Efforts are needed to expand and rethink current firearm prevention efforts that both address the diversification of victimisation and the larger societal trauma of firearm violence.

The Impact of Intentionality of Injury and Substance Use History on Receipt of Discharge Opioid Medication in a Cohort of Seriously Injured Black Men

Black patients are less likely than white patients to receive pain treatment, especially opioids, for both acute and chronic pain. Black men are at higher risk than other populations of being "assumed criminal" regardless of any involvement in criminal activity. Additionally, certain injury and patient characteristics such as intentionality of injury and substance use history may lead providers to suspect criminal involvement and impact pain treatment decisions. The purpose of this study was to describe factors that predict receipt of opioid prescription at hospital discharge. We conducted a secondary analysis of data from a cohort of 623 seriously injured Black men treated at trauma centers in Philadelphia between 2013 and 2017. Regression models were used to examine relationships between discharge opioid prescriptions, injury intent, and substance use history. Controlling for age, injury severity, pain score, length of hospital stay (LOS), insurance type, and year of study, receipt of opioids was not impacted by injury intent. However, patients who self-reported substance overuse were less likely to receive opioids than those who did not. Patients with higher injury severity, pain scores, and longer LOS were more likely to receive opioids. Of patients who received opioids, patients with higher pain scores and longer LOS received higher dosages than those with lower scores and shorter LOS. While previous research highlights stigmatization experienced by intentionally injured patients, injury intent did not impact receipt of discharge opioid prescriptions in this study. Future research should continue to explore the effect of injury intent on patients' experiences in the healthcare system.

Identifying nonfatal firearm assault incidents through linking police data and clinical records: Cohort study in Indianapolis, Indiana, 2007-2016

Nonfatal firearm assault incidents are more prevalent than gun homicides, however, little is understood about nonfatal firearm assault incidents due to a lack of accurate data in the United States. This is a descriptive study of all nonfatal firearm assault incidents identified through police and clinical records from 2007 to 2016 in Indianapolis, Indiana. Records were linked at the incident level to demonstrate the overlap and non-overlap of nonfatal firearm assault incidents in police and clinical records and describe differences in demographic characteristics of the victims. Incidents were matched within a 24-h time window of the recorded date of the police incident. Data were analyzed in fall 2020. There were 3797 nonfatal firearm assault incidents identified in police reports and 3131 clinical encounters with an ICD 9/10 diagnosis-based nonfatal firearm-related injury. 62% (n = 2366) of nonfatal firearm assault incidents matched within 24 h to a clinical encounter, 81% (n = 1905) had a firearm related ICD code: 40% (n = 947) were coded as a firearm-related assault, 32% (n = 754) were coded as a firearm-related accident; and 8.6% (n = 198) were coded as undetermined, self-inflicted or law enforcement firearm-related. The other 20% (n = 461) did not have an ICD firearm related diagnosis code. Results indicate most nonfatal firearm assault incidents overlap between police and clinical records systems, however, discrepancies between the systems exist. These findings also demonstrate an undercounting of nonfatal firearm assault incidents when relying on clinical data systems alone and more efforts are needed to link administrative police and clinical data in the study of nonfatal firearm assaults.

Community gun violence and functional disability: An ecological analysis among men in four U.S. cities

This study uses data on neighborhoods in four U.S. cities over five years to examine the relationship between fatal and non-fatal gun violence and rates of functional disability among men. Descriptive analyses indicate significant disparities in shooting rates across neighborhoods and heightened associated disability in high shooting communities. Multivariate results show that rates of non-fatal shootings correspond to greater functional disability among young men, but not older men. Fatal gun violence is not associated with increased community disability. The findings suggest that improvements in local gun violence prevention may serve to address broader community disparities in health and well-being.

"The cops didn't make it any better": Perspectives on police and guns among survivors of gun violence

BACKGROUND

Survivors of gun violence in the United States (US) are twenty times more likely to be re-injured with a firearm and three times more likely to be arrested under a violence or a weapons-related charge. The mechanisms for these outcomes are multifactorial and remain largely understudied. We aimed to examine perspectives on both the police and guns among survivors of guns violence.

METHODS

We conducted a secondary analysis of qualitative data from a study that examined the post-hospitalization recovery experience of survivors of firearm violence. Using a conceptual framework derived from sociology literature and a coding team made up of researchers, community members and former police officers, we used directed content analysis to construct themes.

RESULTS

The data set included interviews with 20 survivors of gun violence that were all Black males, aged 20-51 years. The recurring themes around the police included: (1) Legal cynicism: "I don't like police, none of them"; (2) Interactions with the police in a medical setting: "The cops didn't make it any better" and (3) Ambivalence around police presence within the community: "That's their job to protect me, too." Themes related to guns in the community encompassed: (1) The availability of guns: "Getting a gun is about as easy as buying a pair of sneakers"; (2) Symbolic meaning: "Guns give them courage"; (3) Social meaning: "I just let them know: I have a gun, too." and (4) Strategic meaning: "It's just for protection."

CONCLUSIONS

Survivors of gun violence describe distrust for the police and an ecology of guns that confers symbolic, social and strategic meaning to owning a gun. Interventions to decrease gun violence should address the cultural value of a gun as well as focus on improving police relations with the community.

Non-fatal gun violence and community health behaviors: A neighborhood analysis in Philadelphia

Research shows that community violence is associated with an array of negative health outcomes, yet no study has examined the specific association between different types of gun violence and collective health behaviors in local neighborhoods. Using data from neighborhoods in the city of Philadelphia, this study examines the association between total, fatal, and non-fatal gun violence and measures of physical inactivity, obesity, sleep, and smoking. We find the rate of non-fatal shootings is associated with a composite measure of health behaviors, net of all neighborhood-level covariates and general community violence. Ancillary analyses show that non-fatal shootings are particularly associated with physical inactivity and obesity. Notably, fatal shootings are not associated with any behavioral health measure after accounting for nonlethal shootings. The results support improved data collection efforts to measure non-fatal shootings across the U.S. and greater attention to the collective health consequences of gun violence in local communities.

Is It "True" Pain? Pain Treatment Discharge Planning for Seriously Injured Patients

Background

The United States is experiencing an opioid overdose crisis accounting for as many as 130 deaths per day. As a result, health care providers are increasingly aware that prescribed opioids can be misused and diverted. Prescription of pain medication, including opioids, can be influenced by how health care providers perceive the trustworthiness of their patients. These perceptions hinge on a multiplicity of characteristics that can include a patient's race, ethnicity, gender, age, and presenting health condition or injury. The purpose of this study was to identify how trauma care providers evaluate and plan hospital discharge pain treatment for patients who survive serious injuries.

Methods

Using a semi-structured guide from November 2018 to January 2019, we interviewed 12 providers (physicians, nurse practitioners, physician assistants) who prescribe discharge pain treatment for injured patients at a trauma center in Philadelphia, PA. We used thematic analysis to interpret these data.

Results

Participants identified the importance of determining "true" pain, which was the overarching theme that emerged in analysis. Subthemes included perceptions of the influence of reliable methods for pain assessment, the trustworthiness of their patient population, and the consequences of not getting it right.

Conclusions

Trauma care providers described a range of factors, beyond patient-elicited pain reports, in order to interpret their patients' analgesic needs. These included consideration of both the risks of under treatment and unnecessary suffering, and overtreatment and contribution to opioid overdoses.

Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma

Background

Time to definitive hemorrhage control is a primary driver of survival after penetrating injury. For these injuries, mortality outcomes after prehospital transport by police and emergency medical service (EMS) providers are comparable. In this study we identify patient and geographic predictors of police transport relative to EMS transport and describe perceptions of police transport elicited from key stakeholders.

Methods

This mixed methods study was conducted in Philadelphia, Pennsylvania, which has the highest rate of police transport nationally. Patient data were drawn from Pennsylvania’s trauma registry and geographic data from the US Census and American Community Survey. For all 7500 adults who presented to Philadelphia trauma centers with penetrating injuries, 2006–2015, we compared how individual and geospatial characteristics predicted the odds of police versus EMS transport. Concurrently, we conducted qualitative interviews with patients, police officers and trauma clinicians to describe their perceptions of police transport in practice.

Results

Patients who were Black (OR 1.50; 1.20–1.88) and Hispanic (OR 1.38; 1.05–1.82), injured by a firearm (OR 1.58; 1.19–2.10) and at night (OR 1.48; 1.30–1.69) and who presented with decreased levels of consciousness (OR 1.18; 1.02–1.37) had higher odds of police transport. Neighborhood characteristics predicting police transport included: percent of Black population (OR 1.18; 1.05–1.32), vacant housing (OR 1.40; 1.20–1.64) and fire stations (OR 1.32; 1.20–1.44). All stakeholders perceived speed as police transport’s primary advantage. For patients, disadvantages included pain and insecurity while in transport. Police identified occupational health risks. Clinicians identified occupational safety risks and the potential for police transport to complicate the workflow.

Conclusions

Police transport may improve prompt access to trauma care but should be implemented with consideration of the equity of access and broad stakeholder perspectives in efforts to improve outcomes, safety, and efficiency.

Level of evidence

Epidemiological study, level III.

Beyond Band-Aids for Bullet Holes: Firearm Violence As a Public Health Priority

OBJECTIVES

To review the public health approach to preventing and treating firearm violence.

DATA SOURCES

Peer-reviewed, published scholarship and federal data systems.

STUDY SELECTION

English-language, indexed research articles on the epidemiology, risk, prevention, and consequences of firearm violence.

DATA EXTRACTION

This narrative review includes findings related to the epidemiology and impact of firearm violence, focusing on short- and long-term outcomes. Evidence supporting interventions at the individual, agent, and environmental level to reduce firearm-related harm was examined.

DATA SYNTHESIS

Firearm violence is a major public health challenge in the Unites States. The consequences of firearm violence reach beyond the nearly 40,000 firearm-related deaths and 90,000 firearm-related injuries each year. Firearm violence, including self-harm, assault, and unintentional injury, affects the health of individuals, families, communities, and health systems. Data sources remain inadequate, however, to fully capture these impacts. Treating firearm violence as a disease and taking a public health approach to prevention and treatment is key to reducing the harms of firearm violence. Using a public health framework not only recognizes the physical and mental consequences of firearm violence but also focuses our attention on underlying causes and on innovative, multi-level interventions to reduce the harms of firearm violence.

CONCLUSIONS

The public health approach positions clinicians to change the conversation from political diatribe of pro-gun and anti-gun to systematically reducing injury and death. To achieve comparable success, we must design, test, and implement effective interventions at the environmental, policy, technological, and individual levels to prevent firearm violence. We must collect robust data on firearm violence and its consequences. And we must reckon with the conditions of inequality and disadvantage that feed violence through all means.

Racism and Health in the United States: A Policy Statement From the American College of Physicians

Racial minorities in the United States have reported experiencing widespread racism throughout all aspects of life, from housing to education to employment. Existing research has examined the role of racism, discrimination, and violence in one's interaction with the health care system and their association with poorer mental and physical health. Systemic racism that underlies the fabric of society often manifests itself in prominent institutions, such as law enforcement agencies, regardless of individual intent. Overt and covert racist laws and policies, personal implicit biases, and other factors result in Black individuals and other people of color being the subject of law enforcement violence and criminal justice system interactions at disproportionately high rates. The demonstrated association between discriminatory law enforcement practices and violence and personal and community health necessitates treating these issues as public health issues worthy of a public policy intervention. Addressing some of the sources of institutional racism and harm through transparency and accountability measures is the first of many steps required to begin correcting historical racial injustices.

Death and long-term disability after gun injury: a cohort analysis

BACKGROUND

Gun injury accounts for substantial acute mortality worldwide and many others survive with lingering disabilities. We investigated whether additional health losses beyond mortality can also arise for patients who survive with long-term disability.

METHODS

We conducted a population-based individual patient analysis of adults injured by firearms who had received emergency medical care in Ontario, Canada, from Apr. 1, 2002, to Apr. 1, 2019. Longitudinal cohort analyses were evaluated through deterministic linkages of individual electronic patient files. The primary outcome was death or subsequent application for long-term disability in the years after hospital discharge.

RESULTS

In total, 8313 patients were injured from firearms, of which 3020 were injured from intentional incidents and 5293 were injured from unintentional incidents. A total of 2657 (88.0%) patients with intentional gun injury and 5089 (96.1%) patients with unintentional gun injury survived initial injuries. After a mean 7.75 years of follow-up, patients surviving intentional injuries had a disability rate twice as high as patients surviving unintentional injuries (19.7% v. 10.1%, p < 0.001), equivalent to a hazard ratio of 2.01 (95% confidence interval 1.80-2.25). The higher risk of long-term disability for survivors after intentional gun injury was not explained by demographic characteristics, extended to survivors treated and released from the emergency department, and was observed regardless of whether the incident was self-inflicted or from interpersonal assault. Half of the disability cases were identified after the first year. Additional predictors of long-term disability included a lower socioeconomic status, an urban home location, arrival by ambulance transport, a history of mental illness and a diagnosis of substance use disorder.

INTERPRETATION

Our study shows that gun death statistics underestimate the extent of health losses from long-term disability, particularly for those with intentional injuries. Additional and sustainable follow-up medical care might improve patient outcomes.

Neighborhood Perceptions of Gun Violence and Safety: Findings from a Public Health-Social Work Intervention

Efforts to reduce gun violence have moved away from models that rely solely on law enforcement approaches, toward public health-focused models of intervention. This paper discusses urban gun violence from a public health and social work perspective, examining a method to interrupt, reduce and prevent gun violence at the community level. A qualitative research design was utilized to evaluate perceptions held by thirty-seven community members regarding the impact of a gun and related violence prevention program, Albany SNUG. Five key findings emerged from the data analysis: 1) Violence was viewed as significant, widespread and a source of despair and hopelessness; 2) Residents perceived a lack of resources and opportunities within the community; 3) There was general consensus regarding the program's importance to the community; 4) There were several obstacles and challenges to program implementation as identified by participants; and 5) Community involvement and shared responsibility were viewed as central to the reduction of gun and related violence. Recommendations for practice and policy changes and the potential role for social work in future collective efficacy and social change initiatives are also discussed.

A safe haven for the injured? Urban trauma care at the intersection of healthcare, law enforcement, and race

Patients with traumatic injuries often interact with police before and during hospitalization, particularly when their injuries are due to violence. People of color are at highest risk for violent injuries and have the poorest outcomes after injury. The purpose of this study was to describe how injured, Black patients perceived their interactions with police and what these perceptions reveal about police involvement within trauma care systems. We combined data from two qualitative studies to achieve this aim. The first was ethnographic fieldwork that followed Black trauma patients in the hospital through the physical and emotional aftermath of their injuries. The second was a qualitative, descriptive study of how patients experienced trauma resuscitation in the emergency department (ED). Both studies were conducted between 2012 and 2015 at the Trauma Center at Penn, an academic medical center in Philadelphia, Pennsylvania, United States. The present study includes data from 24 adult, Black participants undergoing treatment for injury. We reanalyzed all interview data related to law enforcement encounters from the scene of injury through inpatient hospitalization and coded data using a constant comparative technique from grounded theory. Participants described law enforcement encounters at the scene of injury and during transport to the hospital, in the ED, and over the course of inpatient care. Injured participants valued police officers' involvement when they perceived that officers provided safety at the scene, speed of transport to the hospital, or support and information after injury. Injured participants also found police questioning to be stressful and, at times, disrespectful or conflicting with clinical care. Communities, trauma centers, and professional societies have the opportunity to enact policies that standardize law enforcement access in trauma centers and balance patients' health, privacy, and legal rights with public safety needs.