Emergency department dispositions among 4100 youth injured by violence: a population-based study

EM Advances

CJEM 2007;9(3):164-169

Abstract

Résumé

Introduction

Canadians are increasingly concerned with youth violence,1 particularly in urban centres. Overall crime, including youth crime, has decreased in Canada over the last decade, but serious violent youth crime increased in 2005, and homicide increased by 47% from 2004.2 This demonstrates an ongoing need for youth violence prevention efforts. Victims of violence are more likely to become repeat victims, and are often perpetrators of future violence.3,4These people often present to emergency departments (EDs), meaning there are opportunities for emergency physicians to intervene with these youth in an effort to reduce the risk of recurrence.

Emergency physicians have led successful injury prevention programs — notably in the areas of domestic violence and impaired driving.5-7 Injury control literature shows that passive protection through legislation, regulation and bioengineering (e.g., airbags) can change injury patterns.8,9 In addition to our advocacy role, physicians have the important, albeit difficult, challenge of recognizing the "teachable moment" and attempting to effect behavioural change. American emergency physicians have documented success in modifying violent youth behaviours by linking patients with appropriate intervention programs; these efforts have led to promising reductions in attitudes toward violence and in injury rates.10-13

Little has been published about youth violence prevention efforts in Canadian EDs. The primary objectives of this study were to describe the frequency and patterns of violent injuries among youth, to determine how many injured youth are discharged directly from EDs and to estimate the proportion of injured youth who may benefit from ED-based intervention programs.

Methods

Study design

We completed a population-based observational study using data from the National Ambulatory Care Reporting System (NACRS) database, compiled by the Canadian Institute for Health Information. This database includes demographic, clinical, administrative, financial and service-specific data from all Ontario EDs. All NACRS data are gathered from the ED chart by trained data-entry staff at each site. No identifiable information for individuals or institutions was provided from the database. This project was approved by the Sunnybrook and Women's College Health Science Centre Research Ethics Board without requiring individual informed consent.

Settings and patients

We studied all Greater Toronto Area EDs as well as full-service hospital-based urgent care centres that offered laboratory and diagnostic imaging services. We included 13 hospitals with 19 sites, comprising about half a million annual patient visits.14 Youth, patients aged 12-19 years as defined by the Public Health Agency of Canada,15 were included if they visited 1 of the sites between April 1, 2002 and March 31, 2004, and exhibited an external cause of injury due to violence.

Measurements and outcomes

We used International Classification of Disease (ICD-10CA) External Cause of Injury codes to classify the cause of injury (Table 1). Sex, disposition and patient referrals were documented, and postal code data were used for targeting potential interventions. Population data were obtained from 2001 census data using the Greater Toronto Area federal electoral district data for calculating incidence rates.16

Data analysis

Data were analyzed using Stata (Intercooled Stata Version 9.2, StataCorp LP, College Station, Tex.), and 95% confidence intervals (CIs) were reported for all point estimates. Proportions were compared using the 2-sample test of proportion, and p values were reported.

Results

During the study period, 4100 eligible youth attended a Greater Toronto Area ED after violent injury, accounting for 2.6% of ED patients in this age range. Table 2 shows that 72.8% of the victims were male (95% CI 71.4%-74.1%). Patients aged 17 and 18 years had the highest incidence rates with 69 and 74 per 10000 youth injured annually, respectively (Fig. 1).

Bodily force was the most common cause of injury, accounting for 48.7% of injuries (95% CI 47.1%-50.2%), while knives or other sharp objects accounted for 27.7% of injuries (95% CI 26.3%-29.1%). Sexual assaults accounted for 6% of injuries, and the specific cause of injury was not reported in 9.9% of cases. Table 2 shows that, despite growing concern over firearms, gunshot wounds accounted for only 1.5% of injuries (95% CI 1.1%-1.9%). Table 3 shows a statistically significant increase in gun- related injuries between the first and second year of the study, from 24 (1.0% of injuries) to 37 (2.1% of injuries) patients (z = -2.86, p < 0.01). Additionally, there was a statistically significant increase of 5.2% (z = -3.70, p < 0.001) in proportions of those injured by knives or sharp objects between the first and second year.

Males were more likely than females to suffer blunt object injuries (7.1% v. 3.9%; p < 0.001), bodily force injuries (52.2% v. 39.3%; p < 0.001), knives or sharp object injuries (29.0% v. 24.3%; p < 0.05) and gun-related injuries (1.8% v. 0.5%; p < 0.05); whereas, females were more likely to be victims of sexual assault (21.3% v. 0.3%; p < 0.001).

The majority of injury victims (89.3%; 95% CI 88.3%-90.2%) were discharged directly from the ED (Table 2). Only 6.0% (95% CI 5.3%-6.7%) were admitted or transferred to another facility, while 4.6% (95% CI 4.0%-5.3%) left without being seen or left against medical advice. Four patients (0.1%) died in the ED as a result of their injuries. Of those injured by guns, 44.3% (95% CI 31.6%-56.8%) were discharged directly, 49.1% (95% CI 36.5%-61.8%) were admitted or transferred to another facility and 3 patients (4.9%; 95% CI, -0.6% to 10.4%) died. Of those injured by knives or sharp objects, 86.2% (95% CI 84.2%-88.2%) were discharged directly, 9.3% (95% CI 7.6%-11.0%) were admitted or transferred to another facility and 1 patient (0.09%, 95% CI -0.08% to 0.3%) died.

Discussion

Youth violence is a major national concern.1 Ours is the first Canadian study to document youth violence patterns, demonstrating that 89.3% of injured youth who attended EDs and urgent care centres were discharged directly from these environments. This suggests that ED staff were the only health professionals involved with these youth immediately following the violent experience and that the ED may be an optimal location for violence prevention interventions.

This study's low admission rate for youth injured by violence is consistent with that of other countries. A Boston pediatric ED surveillance study demonstrated that only 6.4% of patients requiring treatment for violence-related injuries required hospital admission.17 In an Israeli study of youth, 84% were discharged directly from the ED.18 This high percentage of direct ED discharges highlights the fact that ED staff are often the only health care workers who treat patients after violent injuries. As a result, EDs in other countries are developing ED-based youth violence intervention programs. In Oakland, Calif., the "Caught in the Crossfire" program aims to intervene with youth in the ED.13 Case workers, referred to as "intervention specialists," arrive within 1 hour of a patient's ED presentation and offer long-term case management. A retrospective case-control evaluation comparing hospitalized youth enrolled in the program with hospitalized youth not enrolled in the program showed a 70% relative risk reduction in re-arrest and a 60% relative risk reduction in criminal involvement.13 EDs in Philadelphia have implemented similar programs. A Chicago ED cohort study to test the effectiveness of a case-management based program found 81% of the treatment group, compared with 10% of the control group, made use of linked services, mainly for education, job readiness and mental health.10

While emergency physicians must take a leadership role in linking at-risk youth to preventative programs, they should not be responsible for program delivery. The skills required to provide such interventions would be difficult for emergency physicians to obtain and maintain given the small volume of violently injured youth the average emergency physician sees. Overcrowding and the already stretched resources of Canadian EDs raise potential concerns for the implementation of ED behavioural interventions. Linking patients to outside programs similar to "Caught in the Crossfire" will likely place the least burden on limited ED resources while fulfilling emergency physicians' patient advocate responsibilities. Emergency physicians should assume leadership in establishing protocols for referral by any ED personnel (e.g., nurses and social workers) and consulting services (e.g., trauma).

Despite concerns about increasing gun violence among youth, our data show that most injuries in Toronto continue to be due to bodily force. Given the small but statistically significant increase in firearm injuries in the second year of our study, it will be important to see if this becomes a trend; however, we can make no further conclusions to this, as this study was not designed to detect time trends. This issue should be addressed in a future time-series analysis.

Limitations

This study has several limitations. Administrative data have inherent limitations, thus it is impossible to determine from the data set whether the perpetrator was another youth or an adult. The effect of violence inflicted by parents or other adults will likely have a different effect on youth, necessitating different postinjury interventions. Data for the NACRS data set are coded from emergency physician and nurse chart records; therefore, the data may underestimate the number of violent injuries if they were not recorded as such on the charts. This method of data collection may also account for the 9.9% of violent injuries recorded as having unspecified causes, as physicians or nurses may not have recorded more specific information. Additionally, NACRS data are coded and collected by different people at each site. There is likely some variability as to how some injuries are coded. The Canadian Institute for Health Information has a data quality enhancement program that maintains uniformity.19 Each record in our data set was unidentifiable and unable to be linked to other records due to privacy legislation. Therefore, we were unable to determine multiple visits. Our data includes only injuries that resulted in ED visits. Of particular concern are victims of violence who did not survive long enough to present to an ED. Those who chose to seek help from other health care professionals or received no health care assistance at all were also not included in this database. Additionally, our data was collected in one urban centre and therefore may not be generalizable to rural populations; however, 80% of Canadians now live in urban areas.20

The majority (89.3%) of youth victims of violence are discharged directly from EDs. These victims often become repeat victims or future perpetrators of violence. Therefore, opportunities exist for the development of ED youth violence prevention initiatives.3,4 This study's authors are currently completing a systematic review of ED youth violence interventions. While intervention programs have shown promise in the United States, we cannot make the assumption that the same programs will work in Canada. A formative community evaluation and subsequent development and evaluation of an ED-based youth violence prevention program is planned. This future research will be necessary in Canada to help EDs determine what role they can play in effectively reducing youth violence in our communities.

Conclusion

A large proportion (89.3%) of youth who are injured by violence and who visit Toronto EDs are discharged directly from EDs. Opportunities exist for development of ED-based youth violence prevention initiatives.

References

1. EKOS Research Associates, Inc. 2004 March 26. Canadian attitudes toward the prevention of crime. Presented to Justice Canada. Available: www4.psepc-sppcc.gc.ca/en/library/publications/research/attitudes/index.html (accessed 2006 Nov 2).
2. Crime Statistics in Canada. Statistics Canada. 2005;26(4):13. Cat no. 85-002 Available: www.statcan.ca/english/freepub/85-002-XIE/85-002-XIE2006004.pdf (accessed 2006 Nov 2).
3. Sims DW, Bivins BA, Obeid FN, et al. Urban trauma: a chronic recurrent disease. J Trauma 1989;29:940-6.
4. Rivara FP, Shepherd JP, Farrington DP, et al. Victim as offender in youth violence. Ann Emerg Med 1995;26:609-14.
5. Morrison LJ, Allan R, Grunfeld A. Improving the emergency department detection rate of domestic violence using direct questioning. J Emerg Med 2000;19:117-24.
6. Mello MJ, Nirenberg TD, Longabaugh R, et al. Emergency department brief motivational interventions for alcohol with motor vehicle crash patients. Ann Emerg Med 2005;45:620-5.
7. Rhodes KV, Gordon JA, Lowe RA. Preventive care in the emergency department, part I: clinical preventive services—are they relevant to emergency medicine? Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group. Acad Emerg Med 2000;7:1036-41.
8. Karlson TA. Injury control and public policy. Crit Rev Environ Control 1992;22:195-241.
9. Baker SP. Childhood injuries: the community approach to prevention. J Public Health Policy 1981;2:235-46.
10. Zun SZ, Downey L, Rosen J. Violence prevention in the ED: linkage of the ED to a social service agency. Am J Emerg Med 2003; 21:454-7.
11. Zun SZ, Downey L, Rosen J. The effectiveness of an ED-based violence prevention programme. Am J Emerg Med 2006;24:8-13.
12. Becker MG, Hall JS, Ursic CM, et al. Caught in the crossfire: the effects of a peer-based intervention program for violently injured youth. J Adolesc Health 2004;34:177-83.
13. Youth Alive. Caught in the crossfire. Available: www.youthalive.org/caught.html (accessed 2006 Nov 2).
14. Chan B, Schull MJ, Schultz SE. Emergency department services in Ontario. Institute for Clinical Evaluative Studies Research Atlas. 1st ed. North York (ON): Institute for Clinical Evaluative Sciences, 2001.
15. Totten M. Youth violence fact sheet. Public Health Agency of Canada. Available: www.phac-aspc.gc.ca/ncfv-cnivf/familyviolence/html/nfntsyjviolence_e.html (accessed 2007 Feb 28).
16. Statistics Canada. Age (122) and sex (3) for population, for Canada, Provinces, Territories and Federal Electoral Districts (1996 Representation Order), 2001 Census—100% Data. Census 2001 (95F0300XCB2001003). Available: www.statcan.ca/english/Dli/Data/Ftp/census/2001/tbt/census2001as-tbt.htm (accessed 2006 Nov 2).
17. Sege RD, Kharasch S, Perron C, et al. Pediatric violence-related injuries in Boston. Arch Pediatr Adolesc Med 2002; 156:73-6.
18. Gofin R, Avitzour M, Haklai Z, et al. Intentional injuries among the young: presentation to emergency rooms, hospitalization, and death in Israel. J Adolesc Health 2000;27:434-42.
19. Canadian Institute for Health Information. Executive summary: database background and general data limitations documentation National Ambulatory Care Reporting System (NACRS). Available Online (accessed 2006 Nov 3).
20. Statistics Canada. Population urban and rural, by province and territory, 2001 Census. Available: www40.statcan.ca/l01/cst01/demo62a.htm (accessed 2006 Nov 3).