Longitudinal assessment of injury recidivism among adults in the United States: findings from a population-based sample

Trauma recidivism is reduced with engagement in psychosocial programming following orthopaedic trauma

INTRODUCTION

Recidivism is common following injury. Interventions to enhance patient engagement may reduce trauma recidivism. Education, counseling, peer mentorship, and other resources are known as Trauma Recovery Services (TRS). The authors hypothesized that TRS use would reduce trauma recidivism.

METHODS

Over five years at a level 1 trauma center, 954 adults treated operatively for pelvic, spine, and femoral fractures were reviewed. Recidivism was defined as return to trauma center for new injury within 30-months. All patients were offered TRS. Multivariate logistic regression statistical analysis was used to identify predictors of recidivism.

RESULTS

Three hundred and ninety-seven of all patients (42 %) utilized TRS, including educational materials (n = 293), peer visits (n = 360), coaching (n = 284), posttraumatic stress disorder (PTSD) screening (n = 74), and other services. Within the entire sample, 136 patients (14 %) returned to the emergency department for an unrelated trauma event after mean 21 months. 13 % of TRS users became recidivists. Overall, 49 % of recidivists had history of pre-existing mental illness. High rates of TRS engagement between recidivists and non-recidivists were seen (75 %); however, non-recidivists were more likely to use multiple types of recovery services (49 % vs 34 %, p = 0.002), and were more likely to engage with trauma peer mentors (former trauma survivors) more than once (91 % vs 81 %, p = 0.03). After multivariable analysis, patients using multiple different recovery services had a lower risk of recidivism (p = 0.04, OR 0.42, 95 % CI [0.19-0.96]).

CONCLUSIONS

Multifaceted engagement with recovery programming is associated with less recidivism following trauma. Future study of resultant reductions in healthcare costs are warranted.

LEVEL OF EVIDENCE

Level II; Prognostic.

Safety and Health Management System, Safety Climate, and Accident Occurrences in Hospitals: The Study of Needlestick, Sharp Injuries and Recidivism Rates

Background

Hospital Safety and Health Management System (HSH-MS) and Hospital Safety Climate (HSC) are the significant elements to develop safe work practices. The current study aimed to examine the dimensions of HSH-MS and HSC and the association with the prevalence of Needlestick and Sharp Injury (NSI) and NSI recidivism.

Materials and Methods

A cross-sectional study was conducted among 1070 nurses in Iranian hospitals (89% response rate).

Results

More than 54% (n = 579) had sustained at least 1 NSI in the previous year. The NSI recidivism rate was 8.6% and recidivists were more likely to be younger, female, married, with higher Body Mass Index (BMI), and on night shift. Two aspects of HSH-MS including management leadership and employee participation were associated with the incidence of NSIs Odds Ratio (OR): 1.91 and 95% Confidence Interval (CI): 0.69-1.21; OR: 1.29 and 95% CI: 0.92-1.82) and NSI recidivism rate (OR: 1.98 and 95% CI: 0.55-1.74; OR: 1.12 and 95% CI: 0.83-1.49). Furthermore, three dimensions of HSC comprising management support (OR: 1.02 and 95% CI: 0.93-1.11 for NSIs; OR: 1.21 and 95% CI: 0.77-1.22 for NSI recidivism), absence of job hindrances (OR: 1.06 and 95% CI: 0.98-1.16 for NSIs; OR: 1.11 and 95% CI: 0.96-1.30 for NSI recidivism) and cleanliness/orderliness (OR: 1.07 and 95% CI: 0.98-1.08 for NSIs; OR: 0.84 and 95% CI: 0.87-0.97 for NSI recidivism) were correlated with reduced NSIs risk.

Conclusions

This study suggests that HSH-MSs and employees' safety climate are significant factors, which are correlated with not only the prevalence of recurrent NSIs but also the single NSI in hospitals.

Recidivism after orthopaedic trauma has diminished over time

PURPOSE

The purpose was to analyze our trauma population during two periods to assess for predictors of recidivism.

METHODS

Prior (2007-2011, n = 879) and recent (2014-2019, n = 954) orthopaedic trauma patients were reviewed. Recidivists were those returning with an unrelated injury. Recidivism rates were compared, and factors associated with recidivism were identified.

RESULTS

Recidivism decreased: 18.7% to 14.3% (p = 0.01). Mean age and sex of the two cohorts were not different. Recent recidivists were more likely to sustain gunshot wound (GSW) injuries (22.1% vs 18.9%, p = 0.09), and mental illness was more common (56.6% vs 28.1%, p < 0.0001). The recent recidivist population was less often married (12.9% vs 23.8%, p = 0.03), and both recidivist groups were often underinsured (Medicaid or uninsured: (60.6% vs 67.0%)).

CONCLUSION

Recidivism diminished, although more GSW and mental illness were seen. Recidivists are likely to be underinsured. The changing profile of recidivists may be attributed to socioeconomic trends and new programs to improve outcomes after trauma.

Concomitant Mental Illnesses Diagnoses and Likelihood of Trauma Recidivism

BACKGROUND

Trauma is the leading cause of death among persons aged 1-44 years. Trauma recidivism occurs when an individual experiences more than one significant injury in a 5-year period. The relationship between a trauma recidivist's perception of recurrent injury has been unclear.

OBJECTIVE

To describe the association between select sociodemographic and clinical variables, threat orientation, and the perceived likelihood of recurrent injury of individuals recently experiencing a significant injury.

METHODS

A prospective cross-sectional study was conducted with Level II trauma inpatients ( n = 84) in Southern California from October 2021 to January 2022. Participants completed surveys prior to discharge. Clinical variables were extracted from the electronic health record.

RESULTS

The trauma recidivism rate was 31%. Mental illness and length of hospital stay were associated with trauma recidivism. In individuals with two or more mental illness diagnoses, the odds of trauma recidivism were approximately 6.5 times higher than in those with no mental illness (odds ratio = 6.48, 95% confidence interval: 1.7-24.6).

CONCLUSION

Trauma is a preventable health care concern with timely recognition of risk factors and intervention. This study confirms mental illness as a predominant factor in injury and should be addressed in clinical practice. This study builds upon previous research and emphasizes the necessity of targeting injury prevention and education in the mentally ill. Trauma providers seeking to practice with an upstream mentality have a responsibility in screening patients for mental illness to help prevent further injury and death.

Trauma recidivism is pervasive and is associated with mental and social health opportunities

INTRODUCTION

Recidivism after orthopedic trauma results in greater morbidity and costs. Prior studies explored the effects of social and medical factors affecting the frequency of return to the hospital with new, unrelated injury. Identification of mental, social and other risk factors for trauma recidivism may provide opportunities for mitigation. The purposes of this study are to determine the rates of subsequent, unrelated injury noted among orthopedic trauma patients at a large urban trauma center and to evaluate what patient and injury features are associated with greater rates of trauma recidivism. We hypothesize higher rates of new injuries will be related to ballistic trauma and other forms of assault, alcohol and recreational drug use, unemployment, and unmarried status among our trauma patients.

METHODS

A series of 954 skeletally mature patients at a level 1 trauma center over a 5 year period were included in the study. All were treated operatively for thoracolumbar, pelvic ring, acetabulum, and/or proximal or shaft femoral fractures from a high energy mechanism. Retrospective review of demographic, injury, medical, and social factors, and subsequent care was performed. Trauma recidivism was defined as returning to the emergency department for treatment of any new injury. A backward stepwise logistic regression statistical analysis was used to identify independent predictors of recidivism.

RESULTS

Mean age of all patients was 41.2 years, and 73.2% were male. 136 patients (14.3%) returned with a new injury within a mean of 21 months. These trauma recidivists were more likely to sustain a GSW (22.1% vs 11.4%, p = 0.001). They had higher rates of substance use, including tobacco (57.4% vs 41.8%, p = 0.001) and recreational drugs (50.7% vs 34.4%, p = 0.001), and were less likely to be married (10% vs 25.9%, p<0.001). Mental illness was pervasive, noted in 56.6% of patients with new injury (vs 32.8%, p<0.001). Medicaid insurance was most common in the trauma recidivist population (58.1% vs 35.0%, p = 0.001), and 12.5% were uninsured. Completing high school or more education was protective (93% non-recidivist (vs 79%, p = 0.001). Sixty-nine patients (50.7%) were repeat trauma recidivists within the study period. Independent predictors of new injury included recreational drug use (OR 1.64, p = 0.05) and history of assault due to GSW or other means (OR 1.67, p = 0.05). History of pre-existing mental illness represented the greatest risk factor for trauma recidivism (OR 2.55, p<0.001).

DISCUSSION

New injuries resulting in emergency department presentation after prior orthopedic trauma occurred in 14.3% and were associated with history of assault, lower education, Medicaid insurance, tobacco smoking and recreational drug use. Mental illness was the greatest risk factor. Over half of patients with these additional injuries were repeat trauma recidivists, returning for another new injury within less than 2 years. Awareness of risk factors may promote focused education and other interventions to mitigate this burden.

LEVEL OF EVIDENCE

Level 3 retrospective, prognostic.

Violence Prevention Programs Are Effective When Initiated During the Initial Workup of Patients in an Urban Level I Trauma Center

This study represents the first attempt at evaluating the ability of the CureViolence Hospital-Response Intervention Program (previously CeaseFire) to disrupt the pattern of violent reinjury. The clinical data points of 300 African American men who presented to our trauma center with a gunshot wound and received intervention at the bedside between 2005 and 2007 (with a 48-month follow-up) were collected. This cohort was matched with a post hoc historical control group using hospital records from 2003 to 2005. The mean age for both groups was 23.9 years. Odds ratios and 95% confidence intervals were obtained. Using a binary logistical regression model, we assessed the performance of three variables of interest: age at the time of the initial injury, treatment group, and initial disposition group to predict recidivism. We utilized the Nagelkerke R square method, which described the proportion of the variance of the reinjury rate and validated our findings using the Hosmer-Lemeshow test (for goodness-of-fit). Six percent (n = 18) of subjects in the treatment group and 11% (n = 33) in the control group returned with a new injury, yielding a total reinjury rate of 8.5%. Most patients returned only once with another violent injury. Individuals who did not receive CureViolence services were nearly twice as likely (odds ratio = 1.94; 95% confidence interval = 1.065, 3.522) to return with a violent reinjury. This finding suggests that Hospital-Response Intervention Programs (HRIP) have a protective effect in violently injured patients. We therefore conclude our HRIP positively affected at-risk patients and prevented violent reinjury.

Treating trauma more effectively: A review of psychosocial programming

IMPORTANCE

Traumatic events are the leading cause of life-altering disability in adults of working age. The management of patients with traumatic injury has substantially improved due to development of sophisticated trauma centers increasing survival after injury. Unlike the adoption of the trauma system framework, the same has not occurred with specialized trauma recovery services to include mental and social health needs. This literature review will discuss unique issues facing trauma survivors, some current recovery programs available, outcomes and benefits of these programs, and barriers that impair widespread incorporation.

OBSERVATIONS

Studies have shown that patients with traumatic injury experience reduction in quality of life and concurrent threats to mental health, including post-traumatic stress disorder (PTSD), alcohol use disorder, and recreational substance abuse. Patients with traumatic injury also have high recidivism rates, low pain management satisfaction, and poor engagement in care following injury. Screening efforts for PTSD, mental illness, and alcohol and substance abuse are more widely available interventions. Early coordinated efforts included dedicated multidisciplinary recovery teams. Recently, more methodical and organized programs, such as the Trauma Survivors Network, trauma collaborative care, Trauma Recovery Services, and Center of Trauma Survivorship, have been implemented.

CONCLUSIONS AND RELEVANCE

The enrollment of patients with traumatic injury in novel programs to enhance recovery has led to heightened self-efficacy, better coping mechanisms, and increased use of mental health services. Additionally, trauma recovery services have been shown to reduce recidivism and have generated cost savings for hospital systems. While positive outcomes have been demonstrated, they are not consistently predictable. Barriers for widespread implementation include limitations of time, funding, and institutional support. This article describes models of successful programs initiated within some trauma centers, which may be duplicated to serve future trauma survivors.

Evaluation of Injury Recidivism Using the Electronic Medical Record

BACKGROUND

Traumatic injuries remain one of the leading causes of death in the United States. Patients who survive traumatic injuries but return to the emergency department with repeat injuries are said to suffer from injury recidivism. Numerous studies have described trends in injury recidivism using trauma registry and survey data. To our knowledge, no prior study has leveraged electronic medical record (EMR) data to characterize injury recidivism. The EMR is potentially more comprehensive as it contains details of patients who visited the emergency department after injury but did not meet the criteria for inclusion in the trauma registry. Such injuries could be predictive of future recidivism. We therefore aimed to describe patterns of injury recidivism seen at a Level 1 trauma center using the EMR.

METHODS

A retrospective review was conducted of all injury-related encounters between January 2016 and December 2019. Manual review was conducted of all recidivistic encounters with < 11 months between encounters to ensure the recidivistic encounter was not a sequela of the index visit. A general estimating equation logistic regression adjusted for age, race, sex, and insurance payor, estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between injury mechanism and odds of recidivistic encounter.

RESULTS

A total of 20,566 index encounters was included during the study period. Of the 20,566 encounters, 7.6% (n = 1570) had a recidivistic encounter during the study period, half of which (n = 781) occurred within the first year of the index encounter. An over two-fold increased odds of recidivism was observed for blunt assault encounters (OR 2.53, 95% CI 2.03-3.15) and unintentional falls (OR 2.10, 95% CI 1.76-2.52). For both mechanisms, this increase was observed across the three years following the index encounter.

CONCLUSIONS

Our study found that patients with assault injuries have the highest odds of injury recidivism and assault-related recidivistic encounters. These results demonstrate the feasibility and utility of incorporating EMR data, and suggest that the development of targeted interventions focused on mitigating assault injuries, such as hospital-based violence intervention programs, should be considered in our region.

The impact of retained bullet fragments on outcomes in patients with gunshot wounds

BACKGROUND

Nationally, 115,000 non-fatal firearm injuries occurred in 2017, with many such victims possessing retained bullet fragments (RBFs); however, the impact of RBFs has not been well studied.

METHODS

An institutional trauma database from an urban, level one trauma center was queried for patients presenting with gunshot wounds (GSWs) to the ED in 2017. GSWs were stratified by the presence or absence of RBFs. Groups were compared using t-tests, chi-squared, and logistic regression.

RESULTS

Of 674 patients with GSWs who met inclusion criteria, 394 had RBFs versus 280 with no RBFs. Patients with RBFs were more likely admitted from the ED (57.4% vs. 41.8%, p < 0.001), had significantly higher rates of return to the ED within six months (30.7% vs. 18.6%, p < 0.001), and higher rates of subsequent GSW in the next year (5.1% vs. 1.8%, p = 0.03). On return to ED, 17.6% of those with a RBF had symptoms associated with their RBF.

CONCLUSION

RBFs may represent an unrecognized risk factor for both repeat ED visits and subsequent bullet injury.

Recidivism at the puerto rico trauma hospital

Purpose

Although trauma represents a leading cause of morbidity and mortality worldwide, there is limited and heterogeneous evidence regarding trauma recidivism and its outcomes. This analysis determined the rate and independent risk factors of trauma recidivism and compared the first and second injury episode among recidivists.

Methods

An IRB-approved retrospective cohort study was performed with data from the Puerto Rico Trauma Hospital Registry. Bivariate analyses were done using Pearson’s Chi squared, Wilcoxon rank-sum, McNemar, Stuart-Maxwell or Wilcoxon signed-rank tests, as appropriate. Independent predictors for recidivism were determined through a logistic regression model. Statistical significance was set at p < 0.05.

Results

24,650 patients were admitted to the hospital during 2000–2017. Recidivism rate was 14 per 1,000 patients discharged alive. Males and individuals aged 15–24 years old were 3.88 (95% CI: 2.21–6.80) and 3.80 (95% CI: 2.24–6.46) times more likely to be recidivists, respectively. Contrariwise, an ISS \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 25 [adjusted odds ratio (AOR) = 0.44; 95% CI: 0.28–0.68] and a GCS \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\le$$\end{document}≤ 8 (AOR = 0.56; 95% CI 0.34–0.92) were protective factors. Furthermore, recidivists exhibited less in-hospital mortality than their non-recidivist counterparts (7.2% vs. 10.7%; p = 0.045).

For recidivists, the median (interquartile range) time to reinjury was 42 (59) months; and the second injury episode was more severe than the first one, as the proportion of patients with ISS \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 25 increased (7.9% vs. 14.1%; p = 0.022).

Conclusion

The independent predictors of trauma recidivism and the median time to reinjury identified in this study provide valuable information to the development of prevention strategies aimed at reducing the burden of injury.

Characteristics of Injury Patients in the Emergency Department in Shanghai, China: A Retrospective Observational Study

Background

This study analyzed the epidemiological characteristics and trends of trauma injuries in Ruijin Hospital North, Shanghai, China, and the feasibility of methods to prevent trauma.

Material/Methods

In this retrospective cross-sectional study, the electronic databases of Ruijin Hospital North were searched for patients who experienced severe trauma from 2013 to 2016. Characteristics of severe trauma were analyzed, including trauma mechanism, gender, reasons for injury, and injury-associated causes of death.

Results

Of the 17,093 patients who experienced trauma during the study period, 11,165 (65.3%) were male and 5,928 (34.7%) were female. Analysis by age showed that the highest incidence of traumatic injuries was in subjects aged 25–34 years, whereas analysis by occupation showed the highest incidence of injury in migrant workers without higher education. Classification by Injury Severity Score (ISS) showed that 12,563 (73.5%) subjects had minor injuries, 4,273 (25.0%) had serious injuries, and 256 (1.5%) had severe injuries. In addition, 256 (1.5%) subjects died, with traffic accidents and falling injuries being the main causes of death. The incidence of injury peaked at 9–11 am and 2–4 pm and was significantly higher in autumn and winter than in spring and summer.

Conclusions

Most trauma patients were young adults. Injuries due to traffic accidents and falling were the main causes of death, with disregard of driving regulations and other health and safety regulations being the main cause of trauma. Trauma injuries may be prevented by strengthening education and by obeying traffic laws and construction site safety regulations.

National Estimates and Factors Influencing Trauma Recidivism in Children Leading to Hospital Readmission

INTRODUCTION

Trauma is the leading cause of mortality in children. Factors influencing recidivism after major trauma have not been well documented in children. The objective of this study is to determine the burden of pediatric trauma recidivism and to identify predisposing factors in the United States.

METHODS

The 2010-2015 National Readmissions Database was queried for pediatric patients (≤18 years) with a diagnosis of major traumatic injuries. Patients readmitted for major trauma were subsequently identified. Patients that did not survive their index-hospitalization were excluded. Information on mechanism, intent, nature and injury severity including Abbreviated Injury Scale (AIS) and Injury Severity Scores (ISS) was obtained. Multivariable-regression analyses were performed adjusting for demographic, hospital-level and injury characteristics.

RESULTS

Of 286,508 pediatric trauma records analyzed, trauma recidivists represented 2.9% of the total population. Recidivists had a higher proportion of severe (AIS ≥ 3) head injury (11.3%). Recidivists were more likely to have public-insurance (OR [95% CI]:1.30[1.25-1.37]), and belong to lower income families (OR [95% CI]:1.22[1.15-1.31]). Recidivism was more common amongst patients with penetrating injuries (OR [95% CI]:2.12[1.96-2.28]). The risk adjusted cost of readmission for trauma was $8401[95% CI: 6748-10,053] higher compared to the index hospitalization with a total increased cost of 11.5 million USD annually.

CONCLUSION

Although not common, recidivism after major trauma remains a significant public-health concern. This study gauges the previously unquantified burden of recidivism amongst children and identifies factors predisposing to recurrent trauma.

LEVEL OF EVIDENCE

III TYPE OF EVIDENCE: Case control study.

Factors Influencing Nonadherence to Recommended Postdischarge Follow-Up After Trauma

INTRODUCTION

Historically, trauma patients have low adherence to recommended outpatient follow-up plans, which is crucial for improved long-term clinical outcomes. We sought to identify characteristics associated with nonadherence to recommended outpatient follow-up visits.

METHODS

This is a single-center retrospective examination of inpatient trauma survivors admitted to a level 1 trauma center (March 2017-March 2018). Patients with known alternative follow-up were excluded. All outpatient visits within 1 y from the index admission were identified. The primary outcome was nonadherence, which was noted if a patient failed to follow-up for any specialty recommended in the discharge instructions. Factors for nonadherence studied included age, injury severity score, mechanism, length of stay, number of referrals made, and involvement with a Trauma Recovery Services program. Bivariate and logistic regression analyses were performed.

RESULTS

A total of498 patients were identified (69% men, median age 43 y [range, 26-58 y], median injury severity score 14 [range, 9-19]). Among them, 240 (47%) were nonadherent. The most common specialties recommended were orthopedic surgery (56% referred, 19% nonadherent), trauma (54% referred, 35% nonadherent), and neurosurgery (127 referred, 35% nonadherent). Lowest levels of follow-up were seen for nonsurgical referrals. In adjusted analysis, a higher number of referrals made (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.95-3.05) and older age (OR, 1.01; 95% CI, 1.00-1.02) were associated with nonadherence. Trauma Recovery Service participants and penetrating trauma patients were more likely to be adherent (OR, 0.60; 95% CI, 0.37-0.97).

CONCLUSIONS

The largest contributor to nonadherence was the number of referrals made; patients who were referred to multiple specialists were more likely to be nonadherent. Peer support services may lower barriers to follow-up.

Burn recidivism: a 10-year retrospective study characterizing patients with repeated burn injuries at a large tertiary referral burn center in the United States

Background

Psychiatric and substance use disorders are common among trauma and burn patients and are known risk factors for repeat episodes of trauma, known as trauma recidivism. The epidemiology of burn recidivism, specifically, has not been described. This study aimed to characterize cases of burn recidivism at a large US tertiary care burn center and compare burn recidivists (RCs) with non-recidivists (NRCs).

Methods

A 10-year retrospective descriptive cohort study of adult burn patients admitted to the North Carolina Jaycee Burn Center was conducted using data from an electronic burn registry and the medical record. Continuous variables were reported using medians and interquartile ranges (IQR). Chi-square and Wilcoxon-Mann-Whitney tests were used to compare demographic, burn, and hospitalization characteristics between NRCs and RCs.

Results

A total of 7134 burn patients were admitted, among which 51 (0.7%) were RCs and accounted for 129 (1.8%) admissions. Of the 51 RCs, 37 had two burn injuries each, totaling 74 admissions as a group, while the remaining 14 RCs had between three and eight burn injuries each, totaling 55 admissions as a group. Compared to NRCs, RCs were younger (median age 36 years vs. 42 years, p = 0.02) and more likely to be white (75% vs. 60%, p = 0.03), uninsured (45% vs. 30%, p = 0.02), have chemical burns (16% vs. 5%, p <  0.0001), and have burns that were ≤ 10% total body surface area (89% vs. 76%, p = 0.001). The mortality rate for RCs vs. NRCs did not differ (0% vs. 1.2%, p = 0.41). Psychiatric and substance use disorders were approximately five times greater among RCs compared to NRCs (75% vs. 15%, p <  0.001). Median total hospital charges per patient were nearly three times higher for RCs vs. NRCs ($85,736 vs. $32,023, p <  0.0001).

Conclusions

Distinct from trauma recidivism, burn recidivism is not associated with more severe injury or increased mortality. Similar to trauma recidivists, but to a greater extent, burn RCs have high rates of comorbid psychiatric and medical conditions that contribute to increased health care utilization and costs. Studies involving larger samples from multiple centers can further clarify whether these findings are generalizable to national burn and trauma populations.

Lasting impression of violence: Retained bullets and depressive symptoms

BACKGROUND

Over 70,000 nonfatal firearm injuries occur in the US annually, frequently leaving victims injured with retained bullets. The long-term psychological risks associated with retained bullets remains unstudied. By serving as a constant reminder of injury, we hypothesized that the presence of retained bullets after firearm injury is associated with increased PTSD and depression symptom severity.

METHODS

We conducted a prospective cohort study (2013-2015) of Black male survivors of firearm injury at an urban Level I trauma center. Interviews, questionnaires and validated survey tools for PTSD (PCL-5) and depression (QIDS-SR₁₆) to assess severity of symptoms were administered 3 months post-injury. Clinical characteristics and symptom severity scores were compared with respect to retained bullets using Wilcoxon Rank Sum tests and linear regression.

RESULTS

Of 139 participants, 101(73%) had retained bullets. The cohort was young (mean age 26 years), educated (82% high school or greater) yet unemployed (53%) and with multiple injuries (median [IQR] no. of GSWs 2 [1-3]). There was no difference in age, education, employment status, number of gunshot wounds, operative procedures, pain, hospital or ICU LOS between groups (p>0.05). Patients with retained bullets less often rated their health as "very good" or "excellent" (10% vs 29%, p=0.046). Of those working prior to injury (n=47), 61% with retained bullets had not returned to work compared to 33% without retained bullets (p=0.027). No difference in PCL-5 scores [30.9 (SD 18.9) vs 27.9 (SD 18.6), p=0.470] was observed, but patients with retained bullets had greater mean QIDS-SR₁₆ scores [10.7 (SD 6.2) vs 7.8 (SD 6.1), p=0.038] than those without. After controlling for injury severity, number of wounds, marital status and education level, multiple linear regression analysis determined that retained bullets (β=3.52; p=0.017) were associated with more severe depressive symptoms.

CONCLUSION

Retained bullets are associated with adverse psychological consequences after firearm injury. To improve recovery and to aid in clinical management decisions, clinicians should consider both the psychological and physical effects of retained bullets in survivors of firearm injury.