A comprehensive national study of firearm injuries in people 21 and younger identified clear risk profiles for young patients in the U.S., paving the way for more targeted interventions in emergency rooms.

Although the emergency department is not always viewed as a site for preventive medicine, during a health emergency, "You're really capturing that family, that patient, when they are more likely to have that 'aha' moment that what happened shouldn't happen again," said Shilpa J. Patel, lead author of the paper and an attending physician in Children's National Hospital's emergency room. The emergency department, she said, is a fruitful place for "teachable moments. … I'm a big believer," she said.

In the broad analysis of emergency department visits by youth between 2009 and 2016, published in Pediatrics on April 1, the researchers compared certain demographic features of the patients with their outcomes and the intention behind the injury — whether the ER visit resulted from an act of self-harm, an assault or an accident. Looking at 178,299 visits logged in the Nationwide Emergency Department Sample, the researchers saw clear correlations that could inform prevention efforts by emergency health practitioners, particularly around telling families about the importance of securing firearms and telling patients about the importance of stopping cycles of violence.

Unintentional injuries were more common in rural areas and in the South, possibly because those areas have higher rates of gun ownership; accidents were also 3.5 times more common in children 12 and under than in youth 18 to 21. Meanwhile, injuries from assaults — a category that included the police shootings that precipitated less than 2% of visits — were more common in 18- to 21-year-olds, youth in urban areas and youth from lower-income ZIP codes. Older children and children in rural areas were more likely to visit the emergency room for self-harm injuries.

Patel, an assistant professor of pediatrics at George Washington University, told The Academic Times that the demographic and intention data the team found "provide[s] more guidance in terms of children who would be at risk for certain types of injuries and what could be done to help prevent those injuries." Hospitals can use the findings to tailor their approach based on their location and patient population.

"We know kids who are in fights with other children are more likely, in the next subsequent visits, to come in with a firearm injury or gain access to firearms," Patel said. For example, a 1998 study in Pediatric Clinics of North America found that youth injured in an assault were 88 times more likely to retaliate and end up back in the emergency department with a new injury. Patel and her colleagues wrote, "At a minimum, providers should counsel and caution youth injured by assault on the serious risks associated with retaliation." 

Patel's study captured only those youth who went to the emergency department, so the results do not include any young people who died at the scene. This partly explains the low percentage of self-harm injuries — only 1.7% of visits were for intentionally self-inflicted injuries, while 39.4% of visits were the result of accidental injuries and 37.7% were assaults. But the self-harm injuries they did see were especially likely to be head, back or spinal cord injuries, and they were far more likely to be fatal: The odds of dying from a self-harm injury were 11 times higher than the odds of being discharged from the emergency room. 

Furthermore, the dataset may have undercounted intentional self-harming behaviors in youth overall and in young children in particular. People who come in to the emergency department may be hesitant to say that an injury was intentional, Patel said. And for young kids, "A lot of those things take time to finally understand in a child," she added. Patients are more likely to get a diagnosis when they're older, but younger children are "probably more likely to present with aggression or behavioral issues or inattention sometimes," she said.

While more research into emergency department visits for youth at risk for suicide may be needed, this study should guide the way emergency health care providers help patients prevent future injury, Patel said. 

"There's really a window of opportunity when a child or a family has been through a traumatic or scary event to essentially lead to effective behavior change," she said. "Using those visits as teachable moments — quick, brief, structured interventions — this has been proven in substance abuse, for instance; structured, brief interventions are effective."

The study, "Sociodemographic Factors and Outcomes by Intent of Firearm Injury," published April 1 in Pediatrics, was authored by Shilpa J. Patel, Gia M. Badolato, Kavita Parikh and Monika K. Goyal, Children's National Hospital and George Washington University; and Sabah F. Iqbal, PM Pediatrics.