GUEST EDITORIAL

Firearm Safety: Where We Are, Where We Needto Be

Patricia Kuntz Howard, RN, MSN, CEN, CCRN

Firearm injuries pose a risk to the safetyof Americans. It is estimated that eachday in the United States, 90 people die,and an additional 175 people are in-

jured by firearms.1 If the estimates are accurate,more than 30,000 deaths each year are directlyattributable to guns. This would give the UnitedStates a firearm-injury death rate 5 to 10 timesgreater than other industrialized countries. Fire-arms pose a serious threat to public health, yet theactual number of injuries and deaths is unknown.There is not a mechanism to accurately measurethe magnitude of the problem.2,3 The UnitedStates is unable to describe the extent and natureof firearm-related morbidity and mortality.4

Deaths do not reflect the number of nonfatal in-juries or other significant factors. To be successfulin reducing firearm-related deaths and injuries,more must be known about the problem.5

PAST ATTEMPTS TO MEASURE

A review of 13 federal data systems noted thatsome useful information could be found; however,each of the data systems was limited.6 None of thesystems reviewed utilized a consistent methodol-ogy to monitor and characterize firearm-relateddeaths or injuries.

MortalityThe National Mor-

tality File7 provideslimited information.For example, it doesnot identify type offirearm used in morethan two thirds of thedeaths that occurredin 1995. It lacks dataregarding the caliberor manufacturer ofthe gun used, the cir-cumstances of fire-arm-related deaths, or the relationship between thedeceased and the shooter.8

MorbidityAll firearm injuries are required to be reported

to law enforcement agencies; however, many non-fatal injuries are not. Patients with gunshotwounds are treated in many settings, such as pri-mary care clinics, physician offices, or at home,which may result in a failure to report the injuries.

Firearm-injury surveillance has been used at thecommunity level to locate “hotspots” of gun vio-lence and to allocate resources to decrease theincidence in firearm-related injuries.9

Unfortunately, previous attempts to track non-fatal injuries have created much consternation.10

In 1994, the Centers for Disease Control and Pre-vention (CDC) funded 7 states and 2 large metro-politan areas to develop and evaluate surveillancesystems for firearm-related injuries. The cohortcollaborated with the CDC to develop a list ofrecommended data elements (RDEs) for fatal andnonfatal firearm-related injuries. The project pilot-tested RDEs to develop a concise, complete datacollection tool to measure firearm-related inju-ries,11 and 21 items were found to be valid andreliable. The US Congress did not fund the sur-

Patricia Kuntz Howard is a Staff Development Specialist in theEmergency Department at the University of Kentucky Hospital.

Write Patricia Kuntz Howard at pkunzhoward@aol.com withcomments.

Int J Trauma Nurs 2002;8:33-5.

Copyright © 2002 by the Emergency Nurses Association.

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doi:10.1067/mtn.2002.123519

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veillance program beyond developing the initialdata set.

THE NEED FOR DATAInjuries of all types are the leading cause of

death in the United States for persons 1 to 34 yearsof age. Despite the numbers, limited resourceshave been dedicated to defining the scope of theproblem of firearm-related injuries. The relation-ship between injury events and firearm design andsafety features is unknown.12 A national surveil-lance system would assist in assessing changes inlethality of gun-related injuries over time and inassessing the effectiveness of prevention efforts.

If the estimates are accurate,more than 30,000 deaths eachyear are directly attributable toguns.

Surveillance has been used by public healthagencies to identify patterns of injuries anddeaths.13 A successful surveillance effort shouldbe focused on data collection and should avoidbecoming involved in political aspects. In theUnited States, the largest obstacle to a surveillancesystem might be the lack of consensus betweencurrent proponents and opponents of data collec-tion. Opponents of firearm-related surveillance ef-forts are fearful that data may be extrapolated andused in gun control measures. Although opponentsmay promote gun safety, they openly oppose anyinitiatives that may be construed as gun controland have had very visible effects on legislation.Health care providers who support surveillanceand other measures to control firearm-related in-juries may find grassroots activism by groups,such as the Million Mom March, who may enableconsensus to occur more quickly.14

A national database should include all types offirearm injuries to identify significant patterns ofinjury.13 The surveillance system could link datafrom law enforcement, medical examiners, 911calls, and emergency departments throughout thecountry.9 For example, the scope of the firearmproblem has been consistently misunderstood be-cause research efforts and public policy have fo-cused on the circumstances of the shooting, ratherthan the outcome. Data exists for violence-relatedgun injuries; however, other types of data, such asinjuries caused by paintball guns, air guns, and BB

guns, are not available.12 Parents, law enforce-ment, and health care professionals are not cogni-zant of the risk posed by guns that are intended fornonlethal recreation, and they tend not to reportthose injuries. A national database that includes alltypes of gun-related injuries, regardless of gun ormechanism of action, is essential to move forwardwith advocacy initiatives and injury preventionstrategies.

USE OF NATIONAL DATAThe design of the surveillance system should be

driven by the information that is desired.15 A fed-erally funded, firearm-related surveillance pro-gram that includes RDEs (as defined from the1994 CDC pilots) would include gun-related de-vices, not just firearms.11 Facts obtained from thisdatabase could provide information about local,state, and national trends.

Injury prevention programs have been success-ful when conducted using concrete, scientific ra-tionale.4 Pilot firearm surveillance programs im-plemented in 3 urban areas allowed local agenciesto target certain areas and resulted in dramaticchanges in the characteristics of firearm injury andfatality in those communities.8 Data obtained froma national surveillance system could be used totarget or expand new and existing initiatives foreducation, engineering, and enactment and en-forcement of legislation related to firearm-relatedinjuries and deaths.

After the shootings thatoccurred at Columbine HighSchool in Littleton, Colorado,many people in the UnitedStates believed that schoolshootings were isolatedincidents.

CONCLUSIONSAfter the shootings that occurred at Columbine

High School in Littleton, Colorado, many peoplein the United States believed that school shootingswere isolated incidents and not a risk for theircommunity. Subsequent similar shooting incidentshave demonstrated that this belief is false. Thetruth is that the issues related to firearm injuriesand deaths in the United States are still unknown.Unfortunately, the politics of guns reach into the

34 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Guest Editorial VOLUME 8, NUMBER 2

science of injury prevention.16 It is imperative tosee the problem clearly: firearm-related injuriesare not an inevitable fact of life; they can beprevented. To effectively prevent firearm injuries,it is crucial to know what needs to be prevented.Surveillance is the answer.

REFERENCES

1. Centers for Disease Control and Prevention. Non-fatal and

fatal firearm-related injuries-United States. MMWR Mor

Mortal Wkly Rep 1999;48:1029-34.

2. Barber C, Hemenway D, Hargarten S, Kellerman A, Azrael

D, Wilt S. A “call to arms” for a national reporting system

on firearm injuries. Am J Public Health 2000;90:1191-3.

3. Christoffel K. Pediatric firearm injuries: time to target a

growing population. Pediatr Ann 1992;21:430-6.

4. Christoffel T, Gallagher S. Injury prevention and public

health. Gaithersburg (MD): Aspen; 1999.

5. Public Health Approach to Firearm Injury Prevention. Chi-

cago: The Help Network; 1999. Available at http://www.

helpnetwork.org/pubheal.htm. Accessed November 15,

2001.

6. Annest JL, Mercy JA. Use of the national data systems for

firearm-related injury surveillance. Am J Prev Med 1998;

15(Suppl 3):17-30.

7. Gotsch KE, Annest JL, Mercy JA, Ryan GW. Surveillance

for fatal and nonfatal firearm-related injury. MMWR Mor

Mortal Wkly Rep 2001;50:1-32.

8. Frattaroli S. Teret SP. Why firearm injury surveillance?

Am J Prev Med 1998;15(Suppl 3):2-4.

9. Kellerman AL, Bartolomeos KK. Firearm injury surveillance

at the local level. Am J Prev Med 1998;15(Suppl 3):109-12.

10. Powell EC, Sheehan KM, Christoffel KK. Firearm violence

among youth: public health strategies for prevention. Ann

Emerg Med 1996;28:204-11.

11. Saltzman LE, Ikeda RM. Recommended data elements for

firearm-related injury surveillance. Am J Prev Med 1998;

15(Suppl 3):113-9.

12. Hootman JM, Annest JL, Mercy JA, Ryan GW, Hargarten

SW. National estimates of non-fatal firearm related injuries

other than gunshot wounds. Inj Prev 2000;6:268-74.

13. Rosenberg ML, Hammond WR. The key to firearm injury

prevention. Am J Prev Med 1998;15(Suppl 3):1.

14. Tanner C. On grassroots activism and health policy: a case

study. . . Million Mom March. J Nurs Ed 2000;39:148.

15. Mercy JA, Ikeda RA, Powell KE. Firearm-related injury

surveillance, an overview of progress and challenges

ahead. Am J Prev Med 1998;15(Suppl 3):6-16.

16. Christoffel KK. Forests and trees in firearms injury re-

search. Inj Prev 2000;6:275-6.

FIREARM INJURIES AND FATALITIESThe Centers for Disease Control and Prevention (CDC) provides fact sheets that listinformation about various types of injuries. The fact sheet on firearm injuriescontains descriptions of the problem in the United States, various aspects of theinjuries, and the CDC’s program to prevent firearm-related injuries. To access theCDC’s fact sheet on firearm injuries and hyperlinks to many other resources, visithttp://www.cdc.gov/ncipc/factsheets/fafacts.htm.

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