Emergency Department Visits for Firearm Injuries Before and During the COVID-19 Pandemic

United States, January 2019-December 2022

Marissa L. Zwald, PhD; Miriam E. Van Dyke, PhD; May S. Chen, PhD; Lakshmi Radhakrishnan, MPH; Kristin M. Holland, PhD; Thomas R. Simon, PhD; Linda L. Dahlberg, PhD; Norah W. Friar, MPH; Michael Sheppard, MS; Aaron Kite-Powell, MS; James A. Mercy, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2023;72(13):333-337.

Abstract and Introduction

Introduction

During the COVID-19 pandemic, the U.S. firearm homicide rate increased by nearly 35%, and the firearm suicide rate remained high during 2019–2020.^[1] Provisional mortality data from the National Vital Statistics System indicate that rates continued to increase in 2021: the rates of firearm homicide and firearm suicide in 2021 were the highest recorded since 1993 and 1990, respectively.^[2] Firearm injuries treated in emergency departments (EDs), the primary setting for the immediate medical treatment of such injuries, gradually increased during 2018–2019;^[3] however, more recent patterns of ED visits for firearm injuries, particularly during the COVID-19 pandemic, are unknown. Using data from the National Syndromic Surveillance Program (NSSP),* CDC examined changes in ED visits for initial firearm injury encounters during January 2019–December 2022, by year, patient sex, and age group. Increases in the overall weekly number of firearm injury ED visits were detected at certain periods during the COVID-19 pandemic. One such period during which there was a gradual increase was March 2020, which coincided with both the declaration of COVID-19 as a national emergency^† and a pronounced decrease in the total number of ED visits. Another increase in firearm injury ED visits occurred in late May 2020, concurrent with a period marked by public outcry related to social injustice and structural racism,^[4] changes in state-level COVID-19–specific prevention strategies,^§ decreased engagement in COVID-19 mitigation behaviours,^[5] and reported increases in some types of crime.^[4] Compared with 2019, the average number of weekly ED visits for firearm injury was 37% higher in 2020, 36% higher in 2021, and 20% higher in 2022. A comprehensive approach is needed to prevent and respond to firearm injuries in communities, including strategies that engage community and street outreach programs, implement hospital-based violence prevention programs, improve community physical environments, enhance secure storage of firearms, and strengthen social and economic supports.

CDC used near real-time electronic health record data from NSSP to examine changes in ED visits for initial firearm injury encounters during the COVID-19 pandemic. Temporal trends were assessed for three surveillance periods (calendar years 2020, 2021, and 2022) and compared with visits from calendar year 2019. Only facilities consistently reporting more complete data^¶ during 2019–2022 were included. Firearm injury ED visits were identified using a categorization including administrative diagnosis codes and free-text reason-for-visit (chief complaint terms), developed and validated by CDC in partnership with state, tribal, local, and territorial health departments** (Supplementary Table, https://stacks.cdc.gov/view/cdc/125985). The mean number of weekly ED visits for firearm injuries, percent change in mean weekly ED visits for firearm injuries,^†† and visit ratios (VRs)^§§ with 95% CIs were examined overall, and by age group (0–14, 15–24, 25–34, 35–64, and ≥65 years) for females and males. All analyses were conducted using R software (version 4.1.2; R Foundation). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.^¶¶

Coinciding with the declaration of COVID-19 as a national emergency on March 13, 2020, the weekly number of firearm injury ED visits began to increase, despite a steep decline in the total number of ED visits (Figure). The weekly number of firearm injury ED visits also sharply increased during the week of May 24, 2020, and remained high for the rest of 2020. Trends were similar among females and males.

(Enlarge Image)

Figure.

Weekly number of emergency department visits for firearm injury,* overall (A) and among females (B) and males† (C) — National Syndromic Surveillance Program,^§ United States, January 2019–December 2022^¶
Abbreviations: ED = emergency department; NSSP = National Syndromic Surveillance Program.
*ED visits for an initial firearm injury encounter were identified by querying a categorization developed and validated by CDC in partnership with state, tribal, local, and territorial health departments. The following intent types were included in the definition: unintentional, intentional self-directed, assault, undetermined intent, legal intervention, and terrorism.
^†The y-axis scales differ among overall, female, and male figure panels.
^§NSSP is a collaboration among CDC, local and state health departments, and federal, academic, and private sector partners. NSSP receives medical record data from approximately 75% of EDs nationwide, although fewer than 50% of facilities from California, Hawaii, Minnesota, and Oklahoma currently participate in NSSP. https://www.cdc.gov/nssp/index.html
^¶Data through December 2022 are included even though November and December are not included on the x-axes.

During the study period, compared with 2019, mean weekly ED visits for firearm injury were 37% higher in 2020, 36% higher in 2021, and 20% higher in 2022, with differences by sex-specific age group (Table). Among both females and males, mean weekly ED visits for firearm injuries were consistently highest among persons aged 15–24 years across the entire study period. However, the largest increases in the proportion of firearm injury ED visits were among persons aged 0–14 years during 2020 (VRs = 2.81 for females and 2.31 for males, respectively), 2021 (VRs = 2.20 and 1.85), and 2022 (VRs = 1.49 and 1.44), compared with 2019.

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Abstract and Introduction
Discussion
References
Sidebar

*NSSP is a collaboration among CDC, local and state health departments, and federal, academic, and private sector partners. NSSP receives medical record data from approximately 75% of EDs nationwide, although fewer than 50% of facilities from California, Hawaii, Minnesota, and Oklahoma currently participate in NSSP. https://www.cdc.gov/nssp/index.html
^† https://www.federalregister.gov/documents/2020/03/18/2020-05794/declaring-a-national-emergency-concerning-the-novel-coronavirus-disease-covid-19-outbreak
^§ https://www.nga.org/coronavirus-reopening-plans/
^¶To reduce artifactual impact from changes in reporting patterns, analyses were restricted to facilities with more consistent reporting of more complete data (coefficient of variation ≤40 and average weekly informative discharge diagnosis ≥75% complete during 2019–2022). https://www.cdc.gov/nssp/dqc/articles/how-data-quality-filters-work.html
**NSSP collects chief complaint, discharge diagnosis, and patient demographics. Diagnosis information is collected using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification; International Classification of Diseases, Tenth Revision, Clinical Modification; and Systematized Nomenclature of Medicine. Diagnostic codes and free-text keywords were combined using Boolean searches to create categorizations to identify visits for an initial encounter for a firearm injury (including unintentional, intentional self-directed, assault, undetermined intent, legal intervention, and terrorism) and negate subsequent encounters or sequelae.
^††Percent change in visits per week during each surveillance period was calculated as ([mean weekly ED visits for firearm injury during surveillance period − mean weekly ED visits for firearm injury during comparison period]/mean weekly ED visits for firearm injury during comparison period) × 100.
^§§VR = (ED visits for firearm injury [surveillance period]/all ED visits [surveillance period])/(ED visits for firearm injury [comparison period]/all ED visits [comparison period]). Ratios >1 indicate a higher proportion of ED visits for firearm injury during the surveillance period than the comparison period; ratios <1 indicate a lower proportion during the comparison period than during the surveillance period; 95% CIs that do not include 1 were considered statistically significant.
^¶¶45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

Table. Mean weekly number of emergency department visits, percent change* in emergency department visits, and visit ratios† of emergency department visits for firearm injury, ^§ overall and by sex and age group — National Syndromic Surveillance Program, ^¶ United States, January 2019–December 2022
Sex/Age group, yrs	2019	2020**			2021**			2022**
Sex/Age group, yrs	Mean weekly no. of firearm injury ED visits	Mean weekly no. of firearm injury ED visits	% Change in mean weekly no. of firearm injury ED visits	VR (95% CI)	Mean weekly no. of firearm injury ED visits	% Change in mean weekly no. of firearm injury ED visits	VR (95% CI)	Mean weekly no. of firearm injury ED visits	% Change in mean weekly no. of firearm injury ED visits	VR (95% CI)
All	979.3	1,341.5	37.0	1.66 (1.64–1.68)	1,328.3	35.6	1.46(1.44–1.48)	1,170.0	19.5	1.22(1.20–1.23)
Females
Overall	139.6	190.9	36.7	1.70 (1.64–1.75)	198.0	41.9	1.55(1.51–1.60)	179.7	28.7	1.33(1.29–1.37)
0–14	6.7	11.3	69.3	2.81 (2.47–3.21)	11.4	71.1	2.20(1.93–2.52)	9.5	43.1	1.49(1.30–1.71)
15–24	45.8	64.5	40.8	1.76 (1.67–1.86)	66.4	45.0	1.60(1.52–1.69)	62.1	35.5	1.47(1.40–1.55)
25–34	38.2	54.5	42.6	1.71 (1.62–1.81)	55.5	45.2	1.59(1.50–1.68)	49.6	29.7	1.41(1.33–1.49)
35–64	41.5	50.7	22.2	1.45 (1.37–1.53)	54.5	31.4	1.40(1.33–1.49)	51.0	22.9	1.29(1.22–1.36)
≥65	7.5	10.0	33.7	1.57 (1.38–1.79)	10.2	37.0	1.42(1.24–1.62)	7.6	1.0	0.96(0.83–1.10)
Males
Overall	839.8	1,150.6	37.0	1.62 (1.60–1.64)	1,130.3	34.6	1.42(1.41–1.44)	990.3	17.9	1.18(1.17–1.20)
0–14	22.1	30.1	36.1	2.31 (2.14–2.49)	31.8	43.7	1.85(1.72–2.00)	30.9	39.9	1.44(1.33–1.55)
15–24	291.9	404.6	38.6	1.67 (1.64–1.70)	383.7	31.4	1.42(1.39–1.45)	343.8	17.7	1.24(1.21–1.27)
25–34	250.2	351.1	40.3	1.55 (1.51–1.58)	339.2	35.6	1.40(1.37–1.43)	286.6	14.6	1.21(1.18–1.24)
35–64	222.3	297.5	33.8	1.47 (1.43–1.50)	310.7	39.8	1.42(1.38–1.45)	287.2	29.2	1.31(1.28–1.35)
≥65	53.2	67.3	26.4	1.38 (1.31–1.45)	64.9	21.9	1.20(1.14–1.26)	41.8	-21.5	0.72(0.68–0.76)

Abbreviations: ED = emergency department; NSSP = National Syndromic Surveillance Program; VR = visit ratio.
*Percent change in visits per week during each surveillance period was calculated as ([mean weekly ED visits for firearm injury during surveillance period − mean weekly ED visits for firearm injury during comparison period]/mean weekly ED visits for firearm injury during comparison period) × 100.
^†VR = (ED visits for firearm injury [surveillance period]/all ED visits [surveillance period])/(ED visits for firearm injury [comparison period]/all ED visits [comparison period]). Ratios >1 indicate a higher proportion of ED visits for firearm injury during the surveillance period than the comparison period; ratios <1 indicate a lower proportion during the comparison period than during the surveillance period; 95% CIs that do not include 1 were considered statistically significant.
^§ED visits for an initial firearm injury encounter were identified by querying a categorization developed and validated by CDC in partnership with state, tribal, local, and territorial health departments. The following intent types were included in the definition: unintentional, intentional self-directed, assault, undetermined intent, legal intervention, and terrorism.
^¶NSSP is a collaboration among CDC, local and state health departments, and federal, academic, and private sector partners. NSSP receives medical record data from approximately 75% of EDs nationwide, although fewer than 50% of facilities from California, Hawaii, Minnesota, and Oklahoma currently participate in NSSP. https://www.cdc.gov/nssp/index.html
**Comparison period is calendar weeks 1–52 (December 30, 2018–December 28, 2019).