Patterns of U.S. Firearm Injury Emergency Department Visits by Month, Day, and Time During 2018 to 2023FREE
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Visual Abstract. Patterns of U.S. Firearm Injury Emergency Department Visits by Month, Day, and Time During 2018 to 2023
This cross-sectional analysis uses Centers for Disease Control and Prevention data from 9 states to describe temporal patterns of emergency department visits for firearm injury from 1 January 2018 to 31 August 2023. Understanding these patterns can assist with resource allocation.
Abstract
Background:
Monitoring temporal trends in firearm injury–related emergency department (ED) visits is challenging because traditional surveillance systems lack detailed temporal information.
Objective:
To describe temporal patterns of ED visits for firearm injury using data from the Centers for Disease Control and Prevention’s (CDC) Firearm Injury Surveillance Through Emergency Rooms (FASTER) program.
Design:
Cross-sectional analysis of firearm injury–related ED visits.
Setting:
9 states (Florida, Georgia, New Mexico, North Carolina, Oregon, Utah, Virginia, Washington, and West Virginia) and the District of Columbia from 1 January 2018 to 31 August 2023.
Patients:
ED visits for firearm injury (n = 93 022) from CDC’s FASTER program.
Measurements:
ED visits for firearm injury per 100 000 ED visits, analyzed by time of day (in 30-minute intervals), day of the week, day of the year, and holidays.
Results:
From January 2018 through August 2023, there were 93 022 firearm injury ED visits (73.9 per 100 000 ED visits), or approximately 1 firearm injury every 30 minutes overall. Rates of firearm injury ED visits were highest between 2:30 and 3:00 a.m. and lowest between 10:00 and 10:30 a.m. Nighttime peaks and daily rates were highest on Friday and Saturday. Monthly rates were highest in July and lowest in February; daily rates were disproportionately high on most holidays, especially Independence Day and New Year’s Eve.
Limitations:
Data are limited to 9 states and the District of Columbia and are not nationally representative. The analysis of ED visits for firearm injury does not distinguish injury intent and is based on arrival time rather than actual injury time.
Conclusion:
Distinct temporal patterns in firearm injury ED visits highlight resource allocation considerations for prevention and response efforts.
Primary Funding Source:
Centers for Disease Control and Prevention.
Firearm-related deaths remain a pressing public health concern in the United States. In 2021, firearm homicides reached their highest level in approximately 3 decades (1). Although firearm homicides have since decreased nationwide, provisional estimates of 2023 deaths remain elevated relative to prepandemic levels. Concerningly, firearm suicides have continued to increase each year and currently are at their highest level in more than 50 years (1–4). Furthermore, firearm injuries are the leading cause of death among children and teens in the United States (5). Although the reasons for these long-term trends are complex, the large number of firearm injuries has prompted growing attention to the problem.
The infrastructure for firearm injury data in the United States is limited, particularly for nonfatal injuries; this constrains our understanding of temporal patterns (6), especially because most health care–based data sources on firearm injuries lack granular temporal information (7). For example, neither the administrative claims–based data sets of the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project (8) nor the National Electronic Injury Surveillance System (9) release information on the precise day or time of injury. Although this helps prevent the disclosure of protected information at the individual level, it precludes researchers from understanding when injuries are most likely to occur.
Prior research on the temporal dynamics of firearm injury and other violence outcomes has observed variation according to time of day (10–12), day of the week (10, 13–17), and holidays (10, 13), with higher rates of firearm injury occurring generally at night, on weekends, and on holidays. Other research in criminology has highlighted similar trends across multiple types of violent incidents and crime (18–20). However, definitions of the temporal variables (for example, “night”) have varied due to the lack of temporal granularity, limiting comparability across studies. These studies also have limitations in representativeness and timeliness. For example, several of these studies focused primarily on urban areas (10, 11, 15–17), perhaps because these areas may have greater public availability of firearm injury data provided by law enforcement or media sources. However, these results may not be generalizable to rural areas (21). Other studies utilizing health care–based data sources are limited by substantial lags in data availability and the potential for bias inherent in sampling-based methods (6, 13, 14). Emergency medical services data exclude patients who arrive to a hospital by other means, which would result in undercounting and may introduce other systemic biases (12).
In this study, we analyzed granular temporal patterns of emergency department (ED) visits for firearm injuries using data from a novel and large-scale syndromic surveillance data source, covering both urban and rural areas, to improve resource allocation. Specifically, we utilized data on the date and time of firearm-related ED visits in 30-minute intervals to understand patterns of firearm injury and interactions between the precise time of day, day of the week, month, and holiday. This information expands on previous research (19) by including detailed data on arrival time as well as incorporating both urban and rural areas. The timeliness of syndromic surveillance data combined with the detail they contain on the timing of patient encounters may be valuable for informing resource allocation (such as health care facility staffing), prevention, and response efforts.
Methods
Data Source
Syndromic surveillance data from the Centers for Disease Control and Prevention’s (CDC) National Syndromic Surveillance Program (NSSP) (22) were analyzed to examine temporal trends in firearm injury–related ED visits. Approximately 80% of U.S. EDs contribute electronic health record data to NSSP, often within 24 hours of a patient’s visit. These data can be used to monitor trends in health conditions that typically present to EDs at the national and local levels. However, to access state-level data and ensure timely monitoring of specific conditions, CDC has developed state-specific data use agreements; this is sometimes achieved through CDC funding programs. For example, in 2020, CDC’s Division of Violence Prevention established the Firearm Injury Surveillance Through Emergency Rooms (FASTER) program (23, 24) to provide more timely and comprehensive data on firearm injuries at the state and local levels than were previously available through traditional data sources. FASTER utilizes and queries near-real-time data from visit-level electronic health records for the purposes of timely monitoring of firearm injury trends (23, 24). We analyzed data from 125 862 881 ED visits during the period from 1 January 2018 to 31 August 2023 in 9 FASTER-funded states (Florida, Georgia, New Mexico, North Carolina, Oregon, Utah, Virginia, Washington, and West Virginia) and the District of Columbia. Visits to the ED for initial firearm injury encounters (including those classified as unintentional, intentional self-harm, assault, legal intervention, terrorism, and undetermined intent but not those representing follow-up care or other sequelae, and including all patients regardless of age, sex, or other demographic characteristics) were identified using a syndrome definition that queried diagnosis codes and presenting problem text fields (24–27). This syndrome definition was developed and validated by CDC in partnership with state, tribal, local, and territorial health departments (27). Each of the 10 participating jurisdictions collects and accesses data from a minimum of 75% of EDs in the jurisdiction, including visits from at least 90% of level 1 to 3 trauma centers. To reduce the effect from changes in reporting patterns, which can vary among jurisdictions and across time, analyses were restricted to facilities with a coefficient of variation less than 40% for total visit volume and facilities with more than 75% complete information on discharge diagnoses throughout 2018 to 2023.
Statistical Analysis
Rates of firearm injury were calculated as the proportion of all ED visits that were related to firearm injury per 100 000 ED visits, with 95% CIs calculated using the Wilson score interval method. Temporal variation by time of day, day of the week, and date and across holidays was descriptively assessed. Individual ED visits were coded according to the patient’s arrival time in 30-minute intervals and analyzed in relation to 24-hour periods beginning at 7:00 a.m. When information was analyzed by day, visits that occurred between midnight and 6:59 a.m. were reported for the previous day (for example, an arrival time of 2:30 a.m. on 1 January would be included in the total for 31 December); this was done because such analysis can inform health care staffing and clinical preparedness, and overnight clinician shifts routinely begin at 11:00 p.m. on the preceding day. Furthermore, firearm injuries that occur late in the evening or in the early morning hours typically follow and relate to events of the previous day rather than being associated with risk the following day (for example, firearm violence occurring after events on Saturday evening and resulting in ED visits in the early morning hours of Sunday). Temporal variation in ED visits for firearm injury was analyzed according to select U.S. public holidays and other days of interest (hereafter referred to as “holidays”): Independence Day, Labor Day, Memorial Day, the weekend preceding Monday holidays (Labor Day and Memorial Day), Christmas, Super Bowl Sunday, Halloween, New Year’s Eve, days with a full moon, and the first day of each month. These holidays were chosen a priori on the basis of previous research (10, 13, 28, 29). Annual variations in calendar dates for holidays (such as Memorial Day) were accounted for where appropriate. The Mondays of Labor Day and Memorial Day were analyzed separately from the preceding weekends. Temporal variation in ED visits for firearm injury was analyzed using χ2 and Kruskal–Wallis tests (for example, rates were calculated individually for each day of the week and then compared across days) using Holm–Bonferroni adjusted P values where appropriate (considering the number of tests conducted in each subanalysis [for example, 7 for the subanalysis for days of the week]). In a sensitivity analysis, calculations were repeated using raw counts of firearm injuries in place of rates. All statistical analysis was done using R, version 4.4.0 (30).
Ethical Considerations
This activity was reviewed by CDC, was deemed not to be research, and was conducted in accordance with applicable federal law and CDC policy (for example, 45 CFR §46.102(l)(2), 21 CFR §56, 42 USC §241(d), 5 USC §552a, and 44 USC §3501 et seq.).
Role of the Funding Source
This study was conducted as part of the authors’ normal duties as employees of CDC.
Results
From 1 January 2018 to 31 August 2023, a total of 93 022 firearm injury ED visits were identified out of a total of 125 862 881 ED visits. The overall rate of firearm injury ED visits was 73.9 per 100 000 ED visits (95% CI, 73.9 to 73.9).
Time-of-Day Patterns
Firearm injury ED visit rates were not evenly distributed throughout the day (P < 0.001). When aggregated across the entire study period, firearm injury ED visit rates were consistently highest between 2:30 and 3:00 a.m. (224.7 firearm injury ED visits per 100 000 ED visits [CI, 223.9 to 225.5]) and were lowest between 10:00 and 10:30 a.m. (31.3 per 100 000 [CI, 31.3 to 31.4]). Rates gradually increased during the afternoon to 74.8 (CI, 72.0 to 77.7) firearm injury ED visits per 100 000 ED visits between 8:00 and 8:30 p.m. and then consistently increased toward the average nightly peak rate between 2:30 and 3:00 a.m.
Day-of-Week Patterns and Overall Daily Differences
Throughout the week, visit rates were highest between approximately 11:00 p.m. and 4:00 a.m. and lowest between approximately 7:00 a.m. and 3:00 p.m. (Figure 1 [left panel]). Rates were heterogeneous throughout the week (P < 0.001) (Figure 1 [right panel]). The daily mean rates on Friday (83.8 firearm injury ED visits per 100 000 ED visits [CI, 82.4 to 85.1]), Saturday (103.0 per 100 000 [CI, 101.5 to 104.6]), and Sunday (81.4 per 100 000 [CI, 80.0 to 82.7]) were higher than the overall mean (73.9 per 100 000 [CI, 73.9 to 73.9]); the daily mean rates on Monday (61.2 per 100 000 [CI, 60.2 to 62.4]), Tuesday (63.2 per 100 000 [CI, 62.1 to 64.4]), Wednesday (63.2 per 100 000 [CI, 62.1 to 64.4]), and Thursday (65.6 per 100 000 [CI, 64.4 to 66.8]) were lower than the overall mean. Nighttime peaks were most pronounced on Friday and Saturday nights (that is, early Saturday and Sunday mornings).
Figure 1. Rate of firearm injuries treated in EDs by time of day and day of the week (left panel) and differences in daily total rate (right panel), January 2018 to August 2023.
The rate of firearm injury ED visits was calculated as the proportion of all ED visits involving firearm injuries per 100 000 ED visits. Visits that occurred between midnight and 6:59 a.m. were reported for the previous day. Data source: Centers for Disease Control and Prevention’s Firearm Injury Surveillance Through Emergency Rooms (FASTER) program, 9 states (Florida, Georgia, New Mexico, North Carolina, Oregon, Utah, Virginia, Washington, and West Virginia) and the District of Columbia. ED = emergency department.
Date Patterns and Overall Monthly Differences
Rates of firearm injury ED visits were not evenly distributed throughout the year on either a daily basis (P < 0.001 [Figure 2 [left panel]) or a monthly basis (P < 0.001 [Figure 2 [right panel]). Daily rates were lowest on 1 March (50.8 firearm injury ED visits per 100 000 ED visits [CI, 44.0 to 58.6]) and highest on 31 December (New Year’s Eve; 141.1 per 100 000 [CI, 128.5 to 154.9]) and 4 July (Independence Day; 158.7 per 100 000 [CI, 145.7 to 172.8]). Monthly rates of firearm injury ED visits were highest in July (82.1 firearm injury ED visits per 100 000 ED visits [CI, 80.5 to 83.8]) and lowest in February (63.6 per 100 000 [CI, 62.1 to 65.1]).
Figure 2. Rate of firearm injuries treated in EDs by day of the month (left panel) and monthly total rate (right panel), January 2018 to August 2023.
The rate of firearm injury ED visits was calculated as the proportion of all ED visits involving firearm injuries per 100 000 ED visits. Visits that occurred between midnight and 6:59 a.m. were reported for the previous day. Data source: Centers for Disease Control and Prevention’s Firearm Injury Surveillance Through Emergency Rooms (FASTER) program, 9 states (Florida, Georgia, New Mexico, North Carolina, Oregon, Utah, Virginia, Washington, and West Virginia) and the District of Columbia. ED = emergency department.
Holiday Patterns
Holidays defined by a specific date (such as Independence Day on 4 July) and those that always fall on the same day of the week (such as Memorial Day) both showed deviations from the daily mean rate for nonholidays (73.0 firearm injury ED visits per 100 000 ED visits [CI, 72.5 to 73.5]) (Table). Holidays with rates that were significantly higher than the nonholiday mean rate (P < 0.001 for all) included Independence Day (158.7 per 100 000 [CI, 145.7 to 172.8]), New Year’s Eve (141.1 per 100 000 [CI, 128.5 to 154.9]), Christmas (112.8 per 100 000 [CI, 100.8 to 126.2]), Memorial Day weekend (the Saturday and Sunday preceding Memorial Day; 106.7 per 100 000 [CI, 99.3 to 114.6]), Halloween (105.2 per 100 000 [CI, 94.0 to 117.8]), and Labor Day weekend (the Saturday and Sunday preceding Labor Day; 105.0 per 100 000 [CI, 96.9 to 113.6]). Daily rates on Labor Day (Monday), Memorial Day (Monday), Super Bowl Sunday, full moon days, and the first day of each month did not differ significantly from nonholiday rates. Analysis of the 4 date-specific holidays with the highest daily rates (Independence Day, New Year’s Eve, Christmas, and Halloween), stratified by time of day and day of the week, demonstrated consistently higher rates of firearm injury ED visits on holidays than on nonholidays during the nighttime hours (approximately 7:00 p.m. to 7:00 a.m.) (Figure 3).
Figure 3. Rate of firearm injuries treated in EDs by time of day and holiday, January 2018 to August 2023.
The rate of firearm injury ED visits was calculated as the proportion of all ED visits involving firearm injuries per 100 000 ED visits. For this analysis, holidays include the 4 date-specific holidays with the highest daily rates (Independence Day, New Year’s Eve, Christmas, and Halloween). All other days are reported as nonholidays. Data source: Centers for Disease Control and Prevention’s Firearm Injury Surveillance Through Emergency Rooms (FASTER) program, 9 states (Florida, Georgia, New Mexico, North Carolina, Oregon, Utah, Virginia, Washington, and West Virginia) and the District of Columbia. ED = emergency department.
| Day of Interest | Firearm Injury ED Visits per 100 000 ED Visits (95% CI) |
|---|---|
| Independence Day | 158.7 (145.7–172.8) |
| New Year's Eve | 141.1 (128.5–154.9) |
| Christmas | 112.8 (100.8–126.2) |
| Memorial Day weekend (Saturday/Sunday) | 106.7 (99.3–114.6) |
| Halloween | 105.2 (94.0–117.8) |
| Labor Day weekend (Saturday/Sunday) | 105.0 (96.9–113.6) |
| Labor Day (Monday) | 89.1 (79.1–100.3) |
| First day of the month | 74.2 (71.4–77.0) |
| All other days | 73.0 (72.5–73.5) |
| Days with full moon | 72.6 (70.8–74.5) |
| Super Bowl Sunday | 71.1 (62.6–80.6) |
| Memorial Day (Monday) | 65.3 (57.6–74.0) |
ED = emergency department.
* The rate of firearm injury ED visits was calculated as the proportion of all ED visits involving firearm injuries per 100 000 ED visits. Visits that occurred between midnight and 6:59 a.m. were reported for the previous day. Data source: Centers for Disease Control and Prevention’s Firearm Injury Surveillance Through Emergency Rooms (FASTER) program, 9 states (Florida, Georgia, New Mexico, North Carolina, Oregon, Utah, Virginia, Washington, and West Virginia) and the District of Columbia.
Sensitivity Analysis
The results of sensitivity analyses using raw counts (data not shown) were equivalent, with the exception that the time of the nightly peak in ED visits for firearm injury was slightly earlier (around 12:00 a.m. rather than 2:30 a.m.).
Discussion
Our findings highlight significant temporal clustering of firearm injury ED visits, emphasizing the importance of evidence-based resource allocation and the need for targeted interventions during peak times. Specifically, firearm injury ED visit rates were highest during evenings, weekends, summer months, and holidays, with important interactions between temporal patterns (for example, time of day and holiday status).
This study is the largest analysis to date of temporal patterns in firearm injury using ED data and the first to utilize a data source that is simultaneously timely, granular, and inclusive of data from both urban and rural areas. These findings support and expand on previous research demonstrating differences in firearm injury incidence according to time of day (10–12), day of the week (10, 14, 15), holiday status (10, 13, 15), and time of year (10). Because the FASTER program captures data from throughout each included state, this study is unique in its inclusion of areas other than major metropolitan centers. Rural areas of the United States have been relatively understudied in recent work (10); although the current analysis did not stratify by urbanicity, the inclusion of data from rural areas improves generalizability and suggests opportunities for future research.
These insights can inform health care staffing and emergency preparedness, potentially reducing mortality rates associated with firearm injuries. Identifying high-burden times when firearm injuries present in ED settings is important for informing prevention and response efforts, particularly in the form of resource allocation in treatment settings, as delays in care are associated with increased mortality rates after severe gunshot wounds (31). Given that a delay between an injury and accessing advanced trauma care is associated with increased mortality (31, 32), our findings provide detailed information that can help inform staffing for trauma centers and the surrounding infrastructure (for example, prehospital emergency services). Furthermore, because a large proportion of firearm injuries are assaults (33), services such as community violence intervention (CVI) programs or hospital-based violence intervention programs (HVIPs), which provide rapid intervention by a violence prevention specialist, could help deescalate conflicts and prevent retaliatory violence that may occur in a community in a subset of the injuries studied here (34). The implementation of these and other CVI programs could also benefit from the detailed understanding of temporal patterns provided by this study by allocating prevention and response resources when they are most likely to be needed (35).
Other research has also suggested the role of climate (36–38) and weather (15–17) in firearm injury specifically and interpersonal violence in general as modifiers of underlying temporal patterns. Higher rates of firearm injury have been observed in association with higher daily temperatures and long-term warming trends (15, 37), and lower rates have been observed in association with precipitation (16, 17). Increases in interpersonal violence have also been observed in association with deviations from historical climate patterns (37). Together, the interplay of local factors such as weather, urbanicity, variations in holiday observances, and potentially other unmeasured confounders highlights the need for further research using data that offer both temporal and spatial granularity. Furthermore, the period that was examined included the onset of the COVID-19 pandemic. Previous research using both ED and emergency medical services data (39, 40) has documented significant increases in firearm injuries during this period. Additional research is needed to fully understand how the temporal patterns described here may shift over time.
This study has several limitations. First, the data were limited to FASTER-funded jurisdictions, including 9 states and the District of Columbia, and are not nationally representative. Second, the syndrome definition used in this analysis might underestimate or overestimate ED visits related to firearm injuries because of variation in coding, reporting, and availability of visit-level data between facilities or over time. The syndrome definition also does not distinguish firearm injury intent, making it impossible to know the proportions of visits related to assaults, unintentional injuries, and self-directed injuries. Further research should explore intent-specific patterns of firearm injuries to refine prevention strategies. Third, temporal analysis of trends in ED visits for firearm injury offers only an approximation of temporal trends in the injuries themselves, as the time between injury and arrival to an ED may vary and could be influenced by unmeasured confounders, including community conditions (41–43). Fourth, the period examined in the current study (approximately 5 years and 8 months) results in relatively few data points for holidays (for example, 6 instances of Independence Day) compared with nonholidays. This may distort patterns observed for individual holidays as well as comparisons among holidays. Fifth, some individual patient–level and facility-level information was incomplete or not available (for example, discharge disposition) and thus could not be analyzed for this study. In addition, FASTER data that are available to CDC do not currently contain identifiers denoting multivictim incidents, a particular type of incident that merits additional research. Finally, temporal patterns in health care utilization for other conditions could distort the measurement of firearm injury rates as a proportion of total ED visits. A sensitivity analysis using raw counts of ED visits for firearm injury yielded largely equivalent results, and examining data as rates can still help inform the relative need for certain types of clinical services among all ED care being sought.
Understanding the factors contributing to the temporal patterns of firearm injury presents a valuable opportunity for future prevention efforts, and implementation of policies, programs, and practices grounded in the best available evidence can bolster states’ and communities’ prevention efforts. For example, some prevention programs account for temporal variation in demand for services, and these data could be used to support such programs by identifying high-risk periods, monitoring progress or evaluating program effectiveness, or facilitating information sharing among programs and partners. CDC’s Community Violence Prevention Resource for Action (44) highlights a number of strategies and approaches for preventing community violence, including firearm injury. Strategies like creating protective environments involve approaches such as safe and secure storage of firearms and remediation of vacant lots to reduce opportunities for violence. Strengthening youths’ and young adults’ skills through school-based skill building and job training and employment programs can reinforce positive interpersonal, emotional, and behavioral skills from a young age and promote healthy relationships and economic stability. Furthermore, strategies to intervene and lessen future harms include approaches like HVIPs and street outreach with changes in community norms. Specifically, implementing and staffing CVI programs or HVIPs, particularly during high-risk periods, such as those elucidated in this study, are concrete actions that hospitals can take that could help reduce firearm injury and mortality rates.
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Published In
Annals of Internal Medicine
Volume 178 • Number 5 • May 2025
Pages: 663 - 670
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Published online: 15 April 2025
Published in issue: May 2025
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Patterns of U.S. Firearm Injury Emergency Department Visits by Month, Day, and Time During 2018 to 2023. Ann Intern Med.2025;178:663-670. [Epub 15 April 2025]. doi:10.7326/ANNALS-24-02874
Patterns of U.S. Firearm Injury Emergency Department Visits by Month, Day, and Time During 2018 to 2023. Ann Intern Med.2025;178:663-670. [Epub 15 April 2025]. doi:10.7326/ANNALS-24-02874
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Temporal Relationships of Firearm Injury Emergency Department Visits
I read article by Rowh, et.al., with interest. Their article provides solid evidence of temporal relationships in firearm injury emergency department visits including certain days of the week such as Fridays and Saturdays, some holidays such as the Independence Day and New Year’s Eve, some months of the year such as June and July, and the time of day. This evidence could be of great use in developing preventive measures, emergency department and trauma staffing, and policing measures. Additional insight might be found with additional analyses such as age and gender demographics. For example, do those who identify as women who suffer firearm injury have different temporal patterns, or do those over the age of 60 have different temporal patterns? While this study was limited to jurisdictions who participate in the FASTER program, there are markedly different demographics within some of these jurisdictions. In Oregon, for example, one could analyze the data based on county population which has seven counties with populations over 200,000, three from 100,000 to 200,000 and 26 with less than 100,000. These additional insights might also prove to be quite helpful and point to differences that could help tailor programs to address these differences.