Use of ShotSpotter detection technology decreases prehospital time for patients sustaining gunshot wounds

Six Square Miles of Urban America: Association Between Firearm Discharge, Injury, and Fatality

BACKGROUND

Despite the increase in firearm injury observed across the country, significant gaps remain relevant to our understanding of how firearm exposure translates to injury. Using acoustic gunshot detection and a collaborative hospital and law enforcement firearm injury database, we sought to identify the relationship between firearm discharge and injury over time.

STUDY DESIGN

From 2018 to 2021, instances of firearm discharge captured via acoustic detection in 6 square miles of Louisville, KY, were merged with data from the collaborative firearm injury database. Key outcomes included the total number of rounds fired, injury and fatality rates per round, and the percentage of rounds discharged from automatic weapons and high-capacity magazines.

RESULTS

During the study period, 54,397 rounds of ammunition were discharged resulting in 914 injuries, 435 hospital admissions, 2,442 hospital days, 155 emergent operations, and 180 fatalities. For each round of ammunition fired, the risk of injury and fatality was 1.7% and 0.3%, respectively. The total number of rounds fired per month nearly tripled (614 vs 1,623, p < 0.001) leading to increased injury (15 vs 37, p < 0.001) and fatality (3 vs 7, p < 0.001). The percentage of rounds fired from automatic weapons (0 vs 6.8%, p < 0.001) and high-capacity magazines (7.6 vs 28.9%, p < 0.001) increased over time.

CONCLUSIONS

The increased burden of firearm injury is related to an overall increase in firearm exposure as measured by the total number of rounds discharged. High-capacity magazines and automatic weaponry are being used with increasing frequency in urban America.

Detect, Dispatch, Drive: A Study of ShotSpotter Acoustic Technology and Transport of Gunshot Victims

INTRODUCTION

Our previous work demonstrated that use of ShotSpotter (SS), a gunfire detection system, and use of police department (PD) transport decreased response and transport time for gunshot wound (GSW) victims versus events with non-ShotSpotter (NSS). The purpose of this study was to evaluate transport trends and how they are linked to SS in the period of 2016-2021 in Camden, NJ.

METHODS

This was a single-center, retrospective observational study. Demographics, response time, transport time, and clinical data were collected. Independent t-test, Mann-Whitney U test, chi-squared test, and linear regression to correct for transport time and method of transport were used to compare outcomes (P < 0.05).

RESULTS

A total of 267 GSWs were included: 77 emergency medical technicians (EMS)-SS, 41 EMS-NSS, 116 PD-SS, and 33 PD-NSS. When comparing response from 2016 to 2021, PD improved from 4 to 2 min (P = 0.001). EMS improved from 6.4 min (EMS-NSS) and 4.5 min (EMS-SS) to 5 min (EMS- NSS) and 4 min (EMS-SS) (P = 0.281). In addition, PD transport times, 5 min (SS) and 4 min (NSS), were faster than EMS, 9 min (SS and NSS) (P < 0.001). Overall PD transport volume increased with a peak in 2020 (68.3%). There was also an increase in PD-NSS transport 4% to 37.9% (P < 0.001). EMS-SS transport decreased from 54.7% to 6.9% (P < 0.001).

CONCLUSION

The presence of SS technology in a small urban setting continues to be associated with a higher rate of PD transport of GSW victims. The critical time of dispatch and transport for both PD and EMS has shown durable improvement.

A global perspective on gun violence injuries

INTRODUCTION AND DEFINITIONS

Civilian gunshot violence is a growing public health issue on a global scale. Treatment of patients with gunshot injuries is based on algorithms derived from military studies, but the distinct differences in weaponry, energy of injury, timing and type of care, and environment translate to a gap in knowledge. With a focus on non-accidental gunshot trauma and excluding suicide etiologies, we propose to build a collaborative research group to address important questions focused on best practices for gunshot injury patients.

PRE-HOSPITAL CARE

There are important differences in the care of gunshot victims across the globe; some countries provide advanced interventions in the field and others deliver basic support until transport to a higher level of care in hospital. Some simple interventions include the use of extremity tourniquets and intravenous fluid support; others to consider are tranexamic acid, whole blood, and hemostatic agents.

ACUTE TREATMENT

Control of exsanguinating hemorrhage is a key priority for gunshot injuries. Military doctrine has evolved to prioritize exsanguination over airway or breathing as the critical first step. The X-ABC protocol focuses on exsanguinating hemorrhage, then standard evaluation of Airway, Breathing and Circulation (ABCs) to enhance survival in trauma patients. The timing of bony stabilization, in terms of damage-control vs definitive care, needs further study in this population, as does use of antibiotics for bony extremity injuries. Finally, recognition of the mental health effects of gun trauma, including post-traumatic stress disorder (PTSD), anxiety disorders, substance abuse and depression is important in advocating for prevention such as implementation of social support and specific interventions.

DEFINITIVE CARE

The need for abdominal closure after exploratory laparotomy, definitive fracture treatment, and other treatment all contribute to length of stay for gunshot injured patients. Optimizing stabilization allows earlier mobilization and decreases nosocomial complications. Nerve injuries are often a source of long-term disability and their evaluation and treatment require further investigation.

RESOURCES AND ETHICS

There are growing numbers of mass-casualty gunshot events, which require consideration of how to organize and use resources for treatment, including staff, operating room access, blood products, and order of treatment. Drills and planning for incident command hierarchy and communication are key to optimizing resource utilization. The ethics of choosing treatment priorities and resources are important considerations as well.

Association Between Geospatial Access to Care and Firearm Injury Mortality in Philadelphia

Importance

The burden of firearm violence in US cities continues to rise. The role of access to trauma center care as a trauma system measure with implications for firearm injury mortality has not been comprehensively evaluated.

Objective

To evaluate the association between geospatial access to care and firearm injury mortality in an urban trauma system.

Design, Setting, and Participants

Retrospective cohort study of all people 15 years and older shot due to interpersonal violence in Philadelphia, Pennsylvania, between January 1, 2015, and August 9, 2021.

Exposures

Geospatial access to care, defined as the predicted ground transport time to the nearest trauma center for each person shot, derived by geospatial network analysis.

Main Outcomes and Measures

Risk-adjusted mortality estimated using hierarchical logistic regression. The population attributable fraction was used to estimate the proportion of fatalities attributable to disparities in geospatial access to care.

Results

During the study period, 10 105 people (910 [9%] female and 9195 [91%] male; median [IQR] age, 26 [21-28] years; 8441 [84%] Black, 1596 [16%] White, and 68 other [<1%], including Asian and unknown, consolidated owing to small numbers) were shot due to interpersonal violence in Philadelphia. Of these, 1999 (20%) died. The median (IQR) predicted transport time was 5.6 (3.8-7.2) minutes. After risk adjustment, each additional minute of predicted ground transport time was associated with an increase in odds of mortality (odds ratio [OR], 1.03 per minute; 95% CI, 1.01-1.05). Calculation of the population attributable fraction using mortality rate ratios for incremental 1-minute increases in predicted ground transport time estimated that 23% of shooting fatalities could be attributed to differences in access to care, equivalent to 455 deaths over the study period.

Conclusions and Relevance

These findings indicate that geospatial access to care may be an important trauma system measure, improvements to which may result in reduced deaths from gun violence in US cities.

Talk and Die: A Descriptive Analysis of Penetrating Trauma Patients

INTRODUCTION

"Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma.

METHODS

We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018.

RESULTS

Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively.

CONCLUSIONS

Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration.

Firearm Acoustic Detection in Hartford, Connecticut: Outcomes of a Trauma Center - Law Enforcement Collaboration

Introduction Firearm homicide is a leading cause of violence-related death in the United States.Unfortunately, more than 80% of illegal firearm discharges are never reported to police by traditional means.ShotSpotter^TM (Newark, California) is an acoustic firearm event detection system that can localize gunfire, prompting police, and subsequent emergency medical services (EMS) presence. Previously reported healthcare effects of acoustic detection are speculative in nature. We sought to investigate Hartford, Connecticut's experience with ShotSpotter​​​​​​​^TM given its smaller size and broad coverage.  Methods The three trauma centers in Hartford (two for adults and one for pediatric) collaborated with the Hartford Police to review outcomes of victims with acoustically detected gunshots and compare them to those who went undetected. We performed a retrospective review of patients who presented with gunshot wounds (GSW) over a 30-month period, from January 1, 2016 to June 30, 2018. Victim location and acoustic detection were reconciled by the police department and hospital staff independently. Patients were individually matched for location, prehospital response, treatment durations, and hospital outcomes. Results Of 387 GSW, 157 (40.6%) presented via EMS and were included in the sample. Of these, 89 correlated to a detection event (56.7%) and 68 had no correlating event (43.3%). These two groups had no difference in prehospital treatment times, scene and transport duration, and injury severity. Further, the need for surgery or transfusion, lengths of stay, and disposition, including mortality, did not differ. Conclusions Despite limited previous reports demonstrating conferred benefits to acoustic detection of gunshots, Hartford's experience showed no benefit. The potential for such systems to act as early warning systems is evident but may depend on a city's resources, geography, and technology.

Impact of ShotSpotter Technology on Firearm Homicides and Arrests Among Large Metropolitan Counties: a Longitudinal Analysis, 1999-2016

Over the past decade, large urban counties have implemented ShotSpotter, a gun fire detection technology, across the USA. It uses acoustic listening devices to identify discharged firearms' locations. We examined the effect of ShotSpotter with a pooled, cross-sectional time-series analysis within the 68 large metropolitan counties in the USA from 1999 to 2016. We identified ShotSpotter implementation years through publicly available media. We used a Poisson distribution to model the impact of ShotSpotter on firearm homicides, murder arrests, and weapons arrests. ShotSpotter did not display protective effects for all outcomes. Counties in states with permit-to-purchase firearm laws saw a 15% reduction in firearm homicide incidence rates; counties in states with right-to-carry laws saw a 21% increase in firearm homicide incidence rates. Results suggest that implementing ShotSpotter technology has no significant impact on firearm-related homicides or arrest outcomes. Policy solutions may represent a more cost-effective measure to reduce urban firearm violence.

A Tale of Two Cities: What’s Driving the Firearm Mortality Difference in Two Large Urban Centers?

Introduction

Per police data, the case fatality rate (CFR) of firearm assault in New Orleans (NO) over the last several years ranged between 27% and 35%, compared with 18%-22% in Philadelphia. The reasons for this disparity are unknown, and potentially reflect important system differences with broader implications for the reduction of firearm mortality.

Methods

A retrospective analysis of police and city-specific trauma databases between 2012 and 2017 was performed. Victims of firearm assaults within city limits were included. Univariate analysis was performed using chi-square for categorical and t-test for continuous variables. Bivariate analysis was conducted using logistic regression.

Results

Per police data, the CFR of firearm assault was 31% in NO and 20% in Philadelphia. However, per trauma registry data, the CFR of firearm assault was 14% in NO and 25% in Philadelphia. Patients in Philadelphia were older, had higher injury severity score, and lower blood pressure. Patients in NO had higher rates of head injury. 51% of patients in Philadelphia arrived via police compared to <1% in NO. There was no mortality difference between police and emergency medical service (EMS) transport. Longer EMS prehospital times were associated with increased mortality in NO but not Philadelphia. A much larger percentage of patients died on-scene in NO than Philadelphia.

Conclusions

Our findings suggest that the major driver of increased mortality following firearm assault in NO compared with Philadelphia is death prior to the arrival of first responders. Interventions that shorten prehospital time will likely have the greatest impact on mortality in NO. This should include the consideration of police transport.

Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma

Background

Time to definitive hemorrhage control is a primary driver of survival after penetrating injury. For these injuries, mortality outcomes after prehospital transport by police and emergency medical service (EMS) providers are comparable. In this study we identify patient and geographic predictors of police transport relative to EMS transport and describe perceptions of police transport elicited from key stakeholders.

Methods

This mixed methods study was conducted in Philadelphia, Pennsylvania, which has the highest rate of police transport nationally. Patient data were drawn from Pennsylvania’s trauma registry and geographic data from the US Census and American Community Survey. For all 7500 adults who presented to Philadelphia trauma centers with penetrating injuries, 2006–2015, we compared how individual and geospatial characteristics predicted the odds of police versus EMS transport. Concurrently, we conducted qualitative interviews with patients, police officers and trauma clinicians to describe their perceptions of police transport in practice.

Results

Patients who were Black (OR 1.50; 1.20–1.88) and Hispanic (OR 1.38; 1.05–1.82), injured by a firearm (OR 1.58; 1.19–2.10) and at night (OR 1.48; 1.30–1.69) and who presented with decreased levels of consciousness (OR 1.18; 1.02–1.37) had higher odds of police transport. Neighborhood characteristics predicting police transport included: percent of Black population (OR 1.18; 1.05–1.32), vacant housing (OR 1.40; 1.20–1.64) and fire stations (OR 1.32; 1.20–1.44). All stakeholders perceived speed as police transport’s primary advantage. For patients, disadvantages included pain and insecurity while in transport. Police identified occupational health risks. Clinicians identified occupational safety risks and the potential for police transport to complicate the workflow.

Conclusions

Police transport may improve prompt access to trauma care but should be implemented with consideration of the equity of access and broad stakeholder perspectives in efforts to improve outcomes, safety, and efficiency.

Level of evidence

Epidemiological study, level III.