It is no secret that the citizens of Chicago face an ongoing struggle with gun violence, with over 700 homicides reported in 2016. Beyond the absolutely vital discussions and action around prevention that need to occur, what may be overlooked are the gaps in resources for treatment of victims of gun violence.
A recent study in JAMA Surgery sought to examine the prevalence, spatial distribution, and clinical outcomes of the patients who were undertriaged for firearm-related injuries— that is, those who qualified for higher-level of trauma care according to anatomic triage criteria, but instead received care in non-designated (community, non-trauma) facilities. This study highlights the need for resources and training be directed to community-based hospitals to treat these injuries optimally.
The research team analyzed data derived from hospital records of residents of Cook County, IL who initially received care at a hospital in or adjacent to Cook County for a firearm-related injury between 2009-2013. After assessing the type of injury and part of the body affected by the gunshot wound, demographic characteristics, injury severity, and hospital course-of-treatment were compared for appropriately triaged and undertriaged patients. Several statistical models analyzing the association between in-hospital mortality and triage status were performed to assess:
- all the patients in the study
- those who were under-triaged only
- those who were inpatient only
- those were outpatient only
During the study period, there were 9,886 firearm-related injuries treated in a hospital setting, almost 30 percent of which were treated at non-trauma-designated facilities and approximately 70 percent at designated trauma centers.
Major findings from this study include:
- A disproportionate number of residents living on the west side and south side of Chicago were treated in non-designated facilities, both overall and when assessing cases of injuries that met anatomic triage criteria for higher level trauma care.
- Although patients who were treated in non-designated facilities had lower New Injury Severity scores (NISS), indicating less serious injuries, a sizeable proportion (approximately 30 percent) met anatomic triage criteria for higher level trauma care.
- Of patients who were initially triaged at a non-designated trauma center but met triage criteria for a higher-level trauma center, only 10 percent were transferred to a higher-level of care.
- NISS score was not a particularly good predictor of fatal injury, at either a designated or non-designated trauma center.
- Among those who met anatomic criteria for triage at a higher-level trauma center, mortality rate was higher among patients at designated trauma centers (15.9 percent) compared to those treated at non-designated facilities (8.3 percent). This remained true among those who did not meet anatomic criteria for higher-level triage as well.
- All of the models analyzing the association between mortality and hospital triage showed that patients in non-designated facilities were less likely to die than patients at higher-level trauma centers.
The higher mortality among patients at designated trauma centers is likely due to increased acuity and severity of injury. However, this study still highlights that non-designated hospitals play a significant role in treating firearm-related injuries, including those that meet criteria for higher-level trauma care. This disparity appears to be particularly evident in the west and south sides of Chicago, and suggests the need for increased resources and training among non-designated community-based hospitals. While the results cannot be directly applied to all areas of the country, one would expect similar disparities to exist-- highlighting the need to not lose focus on providing resources to optimize trauma systems of care.
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