key: cord-0791847-tglk6wsd
authors: Abdallah, Hatem O.; Zhao, Cindy; Kaufman, Elinore; Hatchimonji, Justin; Swendiman, Robert A.; Kaplan, Lewis J.; Seamon, Mark; Schwab, William; Pascual, Jose L.
title: Increased Firearm Injury During the COVID-19 Pandemic: A Hidden Urban Burden
date: 2020-11-06
journal: J Am Coll Surg
DOI: 10.1016/j.jamcollsurg.2020.09.028
sha: a8615eff03db588376706e9cb1c598ea95da4693
doc_id: 791847
cord_uid: tglk6wsd

BACKGROUND: Public health measures were instituted to reduce COVID-19 spread. A decrease in total emergency department (ED) volume followed, but the impact on injury is unknown. With lockdown and social distancing potentially increasing domicile discord, we hypothesized that intentional injury increased during COVID-19 primarily driven by an increase in penetrating trauma. STUDY DESIGN: A retrospective review of acute adult patient care in an urban, level 1 trauma center assessed injury patterns. Presenting patient characteristics and diagnoses from 6 weeks pre- to 10 weeks post- a statewide stay-at-home order (SAHO, 3/16/2020) were compared; as well as to 2015- 2019. Subsets were defined by intentionality (intentional vs. non-intentional) and mechanism of injury (MOI, blunt vs. penetrating). Fisher exact and Wilcoxon tests were used to compare proportions and means. RESULTS: 357 and 480 trauma patients presented pre- and post-SAHO, respectively. Pre and post groups demonstrated differences in sex (35.6% vs. 27.9% female, p = 0.02), age (47.4 ± 22.1 vs. 42 ± 20.3, p = 0.009), and race (1.4% vs. 2.3% Asian; 63.3% vs. 68.3% Black; 30.5% vs. 22.3% White; 4.8% vs. 7.1% Other; p=0.03). Post-SAHO MOI revealed more intentional injury (p=0.0008). Decreases in non-intentional trauma after adoption of social isolation paralleled declines in daily ED visits. Compared to prior years, 2020 demonstrated a significantly greater proportion of intentional violent injury during the peri-pandemic months, especially from firearms. CONCLUSIONS: Unprecedented social isolation policies to address COVID-19 were associated with increased intentional injury, especially gun violence. Meanwhile, ED and non-intentional trauma visits decreased. Pandemic-related public health measures should embrace intentional injury prevention and management strategies.

In October 2019, reports began emerging from Wuhan, China about a novel coronavirus which could result in severe respiratory failure. It was not until late February 2020 to early March 2020 that the gravity of this situation became clear and US public health initiatives emerged to address the crisis (1) (2) (3) . Fund reallocation and lockdown practices as directed by Stay at Home orders (SAHO) were instituted in a variety of states in March 2020. Pennsylvania declared a state of emergency on March 6, 2020 and issued a SAHO on March 16, 2020 (4-7) .

The PA SAHO effectively cancelled elective procedures and severely curtailed inpatient and outpatient medical visits to increase hospital capacity to care for COVID-19 patients and reduce viral spread by limiting contact in high-risk locations (8, 9) . Concurrently, Emergency Department (ED) visits nationwide abruptly declined, a trend noted globally as well (10) (11) (12) (13) (14) (15) (16) .

The decline in ED visits was ascribed to patient fear of contracting SARS-CoV-2 infection -a fear that seemed unimpacted by non-viral acute illness. Mandated SAHOs along with an unprecedented levels of unemployment may have impacted these behavioral changes (17) .

While decreases in presentations of acute non-injury related illness was reported, it was less clear whether injury-related ED visits would decrease in parallel.

With the pandemic surge, anecdotal lay press reports noted increases in intentional or violent trauma (IVT), such as firearm violence, stabbings and assaults (18) (19) (20) . Some attempted to link locations with increases in IVT with locally high rates of successful social distancing and isolation, including in Philadelphia (21) (22) (23) (24) Nationwide, as government officials trend rates of both crash and violent injury (25, 26) such data may guide adaptations of policy, healthcare access, and public health measures.

We therefore sought to evaluate the incidence of trauma and non-trauma patients presenting to the ED of an urban, metropolitan, Level one trauma center during the COVID-19 crisis. We hypothesized that while acute care ED utilization declined, intentional injury careand specifically firearm-related injury care -would increase.

Approval for this study was secured from the University of Pennsylvania's Office of Regulatory Affairs Institutional Review Board. A retrospective trauma and ED registry review evaluated patients presenting for emergency care to Penn Presbyterian Medical Center (PPMC), one of four Level One Adult Trauma Centers in Philadelphia County that is underpinned by ground ambulance, air ambulance and police drop off services to transport injury care.

The PPMC trauma registry follows strict state requirements articulated by the Pennsylvania Trauma Outcomes Systems (PTOS) foundation with dedicated registrars, who daily collect admitted patient data. The PPMC ED database provides basic demographics for all ED patients, including data from all visits, discharges, and admissions. Abstracted data included demographics (age, sex, race), mechanism and cause of injury, injury descriptors, injury severity, diagnostic and therapeutic procedures, and outcome (disposition, hospital length of stay). We queried publicly available data on the number of Philadelphia COVID-19 patients (27, 28) .

For trauma and ED visits, all patients aged 14 and above who received emergency or injury care at PPMC during the specified dates were included. Assessment periods bracketed the J o u r n a l P r e -p r o o f PA SAHO (March 16, 2020) to include variations that might reflect influences besides the SAHO. Therefore, we assessed care between February 1 and May 30, 2020 and compared care to the same timeframes in each year from 2015 to 2019, accounting for annual and seasonal variation.

Intentional violent injuries (IVT) were defined as assaults, firearm-related injury and stabbings; all others were labeled as non-intentional injuries (NIT: fall, found down, motor vehicle collision, pedestrian crash). This categorization intended to separate trauma inflicted with the intent to harm versus all others. Intentional injuries were then subclassified into firearm or stabbing-related penetrating injury. All other intentional trauma was considered blunt assault.

For the primary analysis, we compared the incidence and proportion of cases within each mechanism of injury (MOI) in the weeks before and after SAHO. These data were contrasted to the city-wide new daily COVID-19 cases in Philadelphia. Planned analyses were parsed on the basis of race, intentionality (IVT vs. NIT), as well as penetrating vs. blunt trauma within IVT.

Except when otherwise noted as proportion of cases, data were expressed as a daily frequency with 95% confidence intervals. Data were missing for key variables in fewer than 1% of cases. We therefore conducted a complete case analysis. The Fisher test for proportions and the Wilcoxon test for continuous variables compared group data as appropriate. Two-tailed significance was set at P <0.05. Data analysis was facilitated using R statistical software version 4.0.0. We generated plots using the "ggplot2" package (R Core Team, 2018).

J o u r n a l P r e -p r o o f Trauma rates and characteristics in the time period before and after SAHO.

Trauma patient triage in the City of Philadelphia did not change during the time periods evaluated and the four Level 1 trauma centers received similar proportions of all types of injured patients as in the past (eTable 1). Similarly, no intentional rearrangement of ambulance volume was directed to favor bringing COVID-19 victims to one city hospital over another. Pre-(n=357) and post-SAHO (n=480) 2020 trauma patient data are presented in Table 1 . This data disclosed significant differences in sex (35.6% female vs. 27.9% female, p = 0.019) and age The proportion of patients presenting after a fall decreased (36.9 % vs 28.1%, p = 0.007) while firearm injuries nearly doubled (gunshot wounds, GSWs:12.6% vs. 22.9%, p < 0.0001).

No differences were noted for other MOIs when comparing the two time frames (p > 0.05). All combined penetrating trauma increased post-SAHO (17.4% vs. 29.9%, p < 0.0001). There was no significant difference in mortality or severity of injury as measured by the trauma injury severity score (ISS) in the overall cohorts or those stratified by MOI. (Table 1, 

J o u r n a l P r e -p r o o f IVT significantly increased post-SAHO. Both prior to and during the lockdown, there were more non-intentional trauma (NIT) cases than IVT, but post-SAHO there was a significant rise in IVT (19.81% pre-SAHO to 30.83% post-SAHO), and a decrease in NIT from 80.2% to 69.2% (p = 0.0002) (Table 1, Figure 1 ). The post-SAHO period also demonstrated steadily decreasing NIT ( Figure 1A ) Similarly, in the weeks that followed SAHO, penetrating trauma (gunshot wounds and stabbings) incidence remained the same or increased slightly while non injury ED cases and blunt trauma decreased ( Figure 1B ). During the post-SAHO period, the citywide new daily COVID-19 case incidence rose steadily and peaked in mid-April ( Figure 1 ).

Trauma patient and non-injury care ED visits at the same facility were compared before and after the SAHO was enacted. ED visits declined as the pandemic surged, with a sharp decline noted following the SAHO; total trauma patient volume remained consistent across periods ( Figure 2A ). With respect to intentionality, with SAHO, NIT declined in parallel to total non-injury ED visits, whereas IVT visits increased ( Figure 2B ).

To distinguish the impact of the SAHO from seasonal crossover from winter (and the holiday seasons) to spring, pre-and post-SAHO period data from 2020 were compared to that from 2015-2019 (Table 2 ). Only the rate of MVC's was different during the pre-SAHO period comparing 2020 to 2015-2019 with reduced MVCs noted in 2020 (p = 0.008); demographics and other domains including overall trauma volume, gender, and age distribution remained similar 

COVID management has a number of elements that do not appear to directly interface with injury care. Public health measures directed at viral transmission reduction both inside and outside of healthcare facilities may seem remote from urgent, emergent acute health conditions, or injury management. Nonetheless, public health measures like SAHO reshape the fabric of human interaction in ways that impact the frequency any healthcare is sought. For instance, social isolation derails key elements of social interaction, including interpersonal communication, basic supply availability, and finances, therefore altering healthcare access and utilization.

We normally expect the frequency of ED visits for urgent or emergent conditions such as myocardial ischemia, appendicitis, or stroke to remain relatively stable, even with socioeconomic disturbances. A pandemic presents a unique environment where fear of contagion in the hospital may impede a patient's willingness to present for care. Our data supports this notion and aligns J o u r n a l P r e -p r o o f with other reports on reduced acute care frequency on contagion fear. This is further supported by the steady decrease in ED visits as the prevalence of COVID-19 increased. This was not likely driven by the virus itself, but rather by the fact that as public reports of COVID-19 cases increased so did contagion fear and compliance with SAHO. This theory would need testing as the reason for overall decreased visits to the ED in Philadelphia or elsewhere was not explored in this study. On the other hand, given the reduced social contact mandated by a SAHO, the belief that injury frequency would also decrease during a pandemic is intuitively attractive. Indeed, reduced ED acute care visits were paralleled by decreases in NIT visits. Unfortunately, the opposite was noted for IVT at our center, meriting further inquiry.

Major societal disruptions directly affect urban violence and injury through the interface between public health measures and injury care. The duration of societal disruption appears to be an important element driving increases in injury. While New York City noted no change in homicide rate after 9/11, Houston saw substantial increases in violent injury after Hurricane Katrina (29, 30) . Perhaps, the longer lasting social disturbance duration correlates with economic instability and unemployment compared to the point devastation of 9/11 -despite its great emotional and political impact (31) . Public health measures during a pandemic have broad overlap with financial peril since enforced economy reductions, social distancing, and reduced mechanisms for social outlet are shuttered. Therefore, increased social tension plausibly forces individuals to stay in close quarters, perhaps increasing intentional or violent injury in domiciles or communities. Although assault and other forms of blunt violent trauma may also be expected to increase, we only saw an increase in penetrating violent injury only with no increase in blunt assault IVT. This lack of a significant increases in non-penetrating violent injury was similar in both Whites and Blacks. It is unclear how this can be explained other than the existing J o u r n a l P r e -p r o o f pervasiveness of gun violence in the city which was further compounded by the high-tension circumstances around the SAHO further bolstering the preexisting public health problems in these communities. Specifically, the isolated increase in GSWs could be driven by decreased numbers of people present in city streets and urban spaces, allowing violence and crime to progress unwitnessed and unchecked by overtaxed law enforcement agencies.

We suggest that there may be two distinct harms from social isolation: (1) Social isolation policies instituted in March 2020 were associated with a sharp increase in IVT, despite a decrease in NIT and overall ED patient volume. Decreases in MVC were anticipated as the early SAHO period was anecdotally characterized by markedly decreased road traffic. A corresponding decrease is pedestrian injury was similarly expected. Since the increase in IVT is unique compared to the preceding five years, trauma and public health systems are presented with an opportunity to mitigate future occurrences during periods of social norm disruption.

Neither injury severity nor patient mortality changed across periods. This was a surprising finding, since during other periods of major disturbances two key behaviors have been J o u r n a l P r e -p r o o f observed that may increase both ISS and mortality: (1) participation in dangerous behavior (that may predispose to trauma) due to higher risk thresholds, or (2) inadvertent existence in a dire circumstance that may predispose to greater injury severity (35) . That neither was observed in our study further serves to strengthen the link between social isolation and IVT. Furthermore, our data suggest that within the catchment area for our urban center, the increase in IVT asymmetrically impacts blacks more than whites.

We found increases in GSW that disproportionately affected young, black males -the urban demographic already overrepresented across decades of inner-city firearm-related intentional injury (36) . Ironically, similar urban subpopulations also appear at greater risk of COVID-19 infection and mortality (37, 38) . Whereas injury caused by inter-personal violence not only increased in an absolute number, it also greatly increased as a proportion of overall trauma patient volume. This unique increase should inform essential local and regional public This is a single institution study that encompasses one region of West Philadelphia and may therefore not be readily extrapolatable to other regions. We utilized the severity of the COVID-19 pandemic and case surge to present the daily reports that the city population was receiving and informed how their behavior changed in staying in their homes understanding that this is a poor surrogate for how SAHO compliance progressed.. Adherence to social isolation guidelines is difficult to quantify, capture or predict and public behavior in other crises may be different. Suicide attempts were not included in the group of IVT because the trauma registry does not capture this sample well (they often don't present to the Trauma Bay but to the main Emergency Department) though conceivably this group of self-inflicted injury may have been greatly affected by the SAHO-mandated isolation that may have worsened depression and other suicide-related beghaviours. We also did not assess unemployment rates nor did we geolocate injury occurrences to link them with socioeconomic factors in specific locales. Specific triggers of the increased IVT were inferred from context but not from dedicated patient-level query.

Finally, we were unable to determine the physical location of where the violent injury had accured (i.e.: inside vs. outside, home vs. place of work etc) as this information is rarely available in the EMR for trauma victims and not captured by the Trauma Registry.

Nonetheless, this inquiry approached the impact of a SAHO on total ED care and trauma care during a period of reduced transient population through the catchment area. This approach allowed a more focused assessment of the resident population and the impact of the SAHO on injury profiles with the goal of discerning one or more avenues of supporting local population health and survival.

Trauma volumes and routine ED visits appear to decrease with social isolation during a mandated public health approach to pandemic management. Decreases in MVC and nonintentional injury were evident and anticipated during the period of lockdown. However, increased intentional violent injury, particularly penetrating trauma was noted with an asymmetric racial allocation in young black males. Since the increase in IVT associated with the SAHO issued to help address viral containment appears distinct from the rate of IVT in the prior five years, further inquiry is warranted, and specific action should be undertaken addressing the impact of social isolation on injury. While pandemic care serves as the current trigger, natural and man-made disasters may establish many of the same circumstances that promote intentional injury. Public and private health system leaders should develop partnerships that embrace medical professional organization support to proactively reduce violent injury, and specifically firearm-related injury during periods of social isolation. 

Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action

Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide

Practice Management During the COVID-19

Philadelphia orders shutdown of businesses, city services as coronavirus spreads

Philadelphia announces first case of COVID-19 coronavirus | Department of Public Health

Coronavirus Disease 2019 Case Surveillance -United States

Wolf Puts Statewide COVID-19 Mitigation Efforts in Effect, Stresses Need for Every Pennsylvanian to Take Action to Stop the Spread

The daily impact of COVID-19 in gastroenterology

Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services

COVID-19)

Impact of the COVID-19 Pandemic on Emergency Department Visits -United States

Outbreak on ST-Segment-Elevation Myocardial Infarction Care in Hong Kong

Impacto de la pandemia de COVID-19 sobre la actividad asistencial en cardiología intervencionista en España | Gestión | Artículo original

Where Have All the Heart Attacks Gone? -The New York Times

COVID-19 pandemic and its impact on mental health of healthcare professionals

Cardiovascular Implications of the COVID-19 Pandemic: A Global Perspective

COVID-19, unemployment, and suicide

As Nation Stays Home, Early Indicators Suggest Rise In Domestic Violence Killings. HuffPost 400AD

Domestic violence reports rise in China amid COVID-19 lockdown

Impact of social distancing during COVID-19 pandemic on crime in Los Angeles and Indianapolis

Trauma doctors: Amid coronavirus, we expect a surge of violent injury

Amid Coronavirus Lockdowns, Gun Violence Continues to Plague Chicago

Even a pandemic can't slow Philly's gun violence

Opinion | Please

Trauma-Informed Social Policy: A Conceptual Framework for Policy Analysis and Advocacy

Testing and data | Department of Public Health

COVID Tests and Cases -OpenDataPhilly

Effect of the 9-11 terrorist attacks on suicide and homicide in the vicinity of the attacks

Uniform Crime Reporting (UCR) Program. Fed

Unemployment rates and trauma admissions

Identifying temporal patterns in trauma admissions: Informing resource allocation

Weather, and Temporal Factors in the Prediction of Admission to a Pediatric Trauma Center

Seasonality in trauma admissions -Are daylight and weather variables better predictors than general cyclic effects?

Injury and risk-taking behavior-a systematic review

Quantifying Disparities in Urban Firearm Violence by Race and Place in Philadelphia, Pennsylvania: A Cartographic Study

The Fullest Look Yet at the Racial Inequity of Coronavirus

Racial Health Disparities and Covid-19 -Caution and Context

The Relationship Between Structural Racism and Black-White Disparities in Fatal Police Shootings at the State Level