Trauma among Adults Experiencing Primary Homelessness

Mr Jean-Philippe Miller1, Dr Biswadev  Mitra1,2,3, Dr Jessica Mackelprang4, Dr Gerard O’Reilly1,2,3
1Emergency and Trauma Centre, Alfred Hospital, Melbourne, Australia, 2School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia, 3National Trauma Research Institute, Alfred Hospital, Melbourne, Australia, 4Swinburne University of Technology, School of Health Sciences, Melbourne, Australia

Background: Injury is a major cause of morbidity and mortality worldwide. Homeless patients suffer a greater burden of health problems than the general population; however, there is a paucity of literature on aetiology and outcomes amongst homeless patients suffering physical injury.

  1. To describe the epidemiology of physical trauma among patients experiencing primary homelessness who present to a major trauma centre
  2. To determine whether there are differences in the nature of injury, injury severity and outcomes between homeless and domiciled patients.

Methods: A retrospective matched cohort study using data from the Hospital Information System and the Alfred Hospital Trauma Registry (AHTR) was performed. The primary outcome variable was the Injury Severity Score (ISS). Secondary outcomes were hospital length of stay (LOS), mortality at hospital discharge, disposition destination and trauma recidivism. Secondary analyses of differences between homeless and domiciled patients were conducted.
Results: Of 25,920 cases in the AHTR, 147(0.6%) were identified as homeless, comprising 131 primary presentations that were matched by age, sex, month and year of presentation to 262 domiciled trauma cases. The median (IQR) ISS among the homeless cases was 5(2-10), compared to 9(4-17) for the domiciled cases (p<0.001). Homeless patients had lower odds for sustaining ISS>12 (OR 0.5, 95% CI: 0.3-0.8, p=0.001). Homeless patients were admitted more often than domiciled patients for assault (32.1% vs 9.5%), intentional self-harm (10.7% vs 2.7%), and penetrating injury (16.0% vs 6.5%). There was no difference in LOS (p=0.51), mortality (p=0.19), ED disposition (p=0.64) or trauma recidivism (p=0.07). A higher proportion of homeless patients self-discharged (21.4% vs 11.5%, p<0.001) or were admitted under Psychiatry from the hospital (9.2% vs 0.8%, p<0.001).
Conclusion: Amongst injured patients, homelessness was associated with higher levels of assault, intentional self-harm, penetrating injury, self-discharge, psychiatry admissions and lower injury severity. This study adds to the sparse amount of literature investigating trauma and homelessness. Further research is required in order to understand injury epidemiology and trauma outcomes in homelessness. Definitions and standardised coding for homelessness needs to be urgently addressed. This will better inform targeted interventions for injury prevention and care amongst homeless people.

Jean-Philippe Miller is a Critical Care Nurse in the area of Emergency & Trauma nursing, with a background of eight years clinical experience at The Alfred Hospital’s Emergency & Trauma Centre.JPcompleted his post-graduate Critical Care qualification in 2010 and has recently completed his Master of Public Health (International Stream) at Monash University. JP has a strong passion for international healthcare, emergency preparedness and trauma reception and resuscitation. JPhas also been deployed as an Australian Red Cross Delegate on humanitarian missions.This has led him to work in remote locations, areas of armed conflicts and resource-poor settings with refugees and displaced populations.