Where should we implement emergency department secondary prevention programs for youth injured by violence?

Victims of violence are likely to become repeat victims of violence. Emergency department-based secondary prevention initiatives have been proposed to help break the cycle of violence for these youth. Trauma centers, by nature of their designation, are often charged with the responsibility of developing these prevention initiatives. We hypothesize that the majority of youth who are injured by violence are treated in nontrauma centers. Given the goal is to prevent recurrent injury, trauma center-based initiatives may be misdirected.

We used a retrospective population-based cohort study design in the province of Ontario to evaluate the type of facility (trauma center vs. nontrauma center) where injured youth (aged 15-24 years) presented for assessment after intentional injury. The National Ambulatory Care Reporting System database was used to identify all subjects during the years 2003-2007. Intentional injury was analyzed through E-codes and hospital identifiers were linked to trauma center status. Descriptive statistics and multiple logistic regression were performed to evaluate demographic and injury characteristics predictive of patients presenting to a trauma center.

The cohort included 51,487 patients presenting to 193 hospitals in Ontario. The mean age was 19.4 years and 80% were men. Eighty percent (80%) of youth injured by violence were treated at nontrauma centers. Patients with injuries caused by blunt objects (odds ratio [OR], 1.51 [95% confidence interval {CI}: 1.39-1.65]), stab wounds (OR, 1.62 [95% CI: 1.50-1.75]), and gunshot wounds (OR, 4.18 [95% CI: 3.21-5.45]) were more likely to attend trauma centers than those with injuries because of bodily force. Patients who attended trauma centers were more likely to be admitted (OR, 3.58 [95% CI: 3.25-3.96]) or die in hospital (OR, 2.18 [95% CI: 1.12-4.26]).

Given the vast majority of patients are not seen at trauma centers, any prevention initiatives located here will not achieve the goals of preventing recurrent injury on a population basis. Secondary prevention initiatives should be implemented and evaluated in nontrauma centers.