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JAMA Surg. 2017 May 1;152(5):467-474. doi: 10.1001/jamasurg.2016.5049.

Undertriage of Firearm-Related Injuries in a Major Metropolitan Area.

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Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois at Chicago.



National anatomic triage criteria prescribe specific transport rules for injured patients. However, there is limited information about patients with firearm-related injuries undertriaged to nondesignated facilities (ie, hospitals without specialized trauma teams or units), including what clinical outcomes are achieved and how many are transferred to a higher level of care. Without these data, it is difficult to make informed regional or national policy decisions about triage practices. Undertriage of firearm-related injuries is a good model for evaluating the undertriage of patients with trauma because the anatomic triage criteria for patients with firearm-related injuries are simple.


To evaluate the prevalence, spatial distribution, and clinical outcomes of undertriage of firearm-related injuries.

Design, Setting, and Participants:

This study is a retrospective analysis of firearm-related injuries in residents of Cook County, Illinois, from January 1, 2009, to December 31, 2013. Outpatient and inpatient hospital databases were used. Participants included patients with International Classification of Diseases, Ninth Revision, Clinical Modification firearm-related cause-of-injury codes. Data were collected all at once in August 2014. Data analysis took place from March 12, 2015, to February 1, 2016.

Main Outcomes and Measures:

Undertriaged cases were defined as patients who met the national anatomic triage criteria for transfer to higher-level trauma center care. Spatial distribution, injury severity, and clinical outcomes, including death, were analyzed.


Of the 9886 patients included in this analysis, 8955 (90.6%) were male, 7474 (75.6%) were African American, and 5376 (54.4%) were aged 15 to 24 years.In Cook County, Illinois, where there are 19 trauma centers, 2842 of 9886 (28.7%) firearm-related injuries were initially treated in nondesignated facilities. Among the 4934 cases with firearm-related injury who met the anatomic triage criteria, 884 (17.9%) received initial treatment at a nondesignated facility and only 92 (10.4%) were transferred to a designated trauma center. Significant spatial clustering was identified on the west side of Chicago and in the southern parts of Chicago and Cook County. In the multivariable models, patients treated in nondesignated facilities were less likely to die than were patients treated in designated trauma centers.

Conclusions and Relevance:

Undertriage of firearm-related injuries was much more prevalent than expected. Although the likelihood of dying during hospitalization was greater among patients treated in designated trauma centers, these patients were substantially in worse condition across all measures of injury severity. A smaller proportion of patients treated in designated trauma centers died during the first 24 hours of hospitalization. This study highlights the need for better regional coordination, especially with interhospital transfers, as well as the importance of assessing the distribution of emergency medical services resources to make the trauma care system more effective and equitable.

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