EDBased Secondary Prevention Programs for Youth Violence: Should They be Based at Trauma or NonTraum

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ED-Based Secondary Prevention Programs for Youth
Violence Should They be Based at Trauma or
Non-Trauma Centres?

• Carolyn Snider MD, MPH, FRCPC
• St. Michaels Hospital, University of Toronto
• CAEP 2009
• June 7, 2009

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Disclosure

• I do not have an affiliation (financial or
  otherwise) with any commercial organization that
  may have a direct or indirect connection to the
  content of my presentation.

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Acknowledgements

• Avery Nathens
• Canadian Institute for Health Information

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Background

• Homicide is the fourth leading cause of death in
  Canadian youth aged 15 to 19
• Most common reason for emergency department (ED)
  visits among 15-24 year olds in Ontario is being
  struck by/against a person or object

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Violent Crime and Homicide Rates, Canada (1977
2006)
Data from CANSIM Table 252-0014 from Uniform
Crime Reporting Survey
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Teachable Moment

• victims of violence are more likely to become
• repeat victims of violence
• perpetrators of future violence
• Recurrent Violent Injury rates 22 44
• In Toronto, 89 of those lt 19 years who were
  injured by violence are discharged directly from
  the emergency department

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Background

• Opportunity
• To break the cycle of violence for these youth
• Identification of those youth at high risk of
  recurrent injury and the provision of secondary
  prevention initiatives in emergency departments.
• Trauma Centres
• charged with developing these prevention
  initiatives

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Hypothesis

• The majority of youth who are injured by violence
  are treated in non-Trauma centres.
• May be misdirected

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Objective

• To determine which type of emergency departments
  (ie. trauma vs. non-trauma hospitals) youth
  injured by violence are presenting to

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Methods

• A retrospective population-based cohort study of
  youth intentional injury episodes
• An injury episode is defined as the first visit
  for a new injury requiring either an ED visit or
  hospitalization.
• National Ambulatory Care Reporting System (NACRS)

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Inclusion

• April 1, 2002 - March 31, 2008
• Reporting facility provinceOntario
• Age 15 24 (Youth as defined by StatCan)
• Any Intentional (assault or homicidal intent)
  Injury
• from External Cause of Injury Mortality Matrix
  for ICD-10

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Exclusion

• Non-emergent/Elective admissions
• No HCN identified
• ED visits that resulted in a transfer to another
  ED (only kept the 2nd hospital)

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Analysis

• Hospital Characteristics
• What proportion of violent injuries present to
  trauma vs. non-trauma hospitals
• Do the majority of injuries go to a select number
  of non-trauma hospitals?
• Patient Characteristics
• Average Age (mean, median)
• Gender ( male)
• Injury Characteristics
• Violent injuries by mechanism
• Severity of Injury
• Disposition of patient ( discharged home)

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Analysis

• All data analyzed using SAS (version 9.1, Cary,
  NC).
• Study was approved by the St. Michaels Hospital
  Research Ethics Board

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Results

• 86546 injury episodes
• presenting to 193 hospitals

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Hospital Characteristics
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Hospital Characteristics

• 25 of injuries go to 13(6.7) of the hospitals

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Hospital CharacteristicsHighest volume hospitals

• Certain Non-Trauma Hospitals have high volumes

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Patient Characteristics

• Gender (M) 80.7 Non-Trauma, 82.2 Trauma
• Statistically significant, but not clinically
  significant

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Mechanism of Injury
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Disposition of Patient
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Discussion

• Majority of injuries go to Non-Trauma Centres
• Trauma Centres
• higher severity
• More penetrating injuries
• Prevention initiatives must be implemented at
  Non-Trauma Centres

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Limitations

• Administrative Data
• Definition of an injury episode
• NACRS
• Exploratory work looking at concordance between
  injuries, CTAS

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Conclusion

• Must implement intervention programs at
  Non-Trauma hospitals
• Burden of Illness

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Selected References

• Leading causes of Death, 2004, Public Health
  Agency of Canada
• Injury Atlas, ICES, 2003
• Snider et al. CJEM 2007
• Reiner et al. Am Surg 1990
• Smith et al. Arch Surg. 1992
• Snider et al. CJEM 2009

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Questions/Comments