Michael R. Rand

BJS Statistician

During 1994 U.S. hospital emergency

department (ED) personnel treated an

estimated 1.4 million people for injuries from confirmed or suspected interpersonal violence. These patients

represented about 1.5% of all visits 

to hospital ED's and 3.6% of the injuryrelated ED visits in 1994.1 Of the total,

1.3 million were treated for injuries

from confirmed violence, while 82,000

sought care for injuries that had probably been  or were suspected of having been  sustained from acts of

violence.

Based on information from the patients

or knowledgeable persons accompanying the patients, 94% of the persons

treated for intentional or possibly intentional injuries sustained those injuries

in an assault. About 31% of those injured during an assault  or 29% of all

those injured  indicated being injured in a fight. Two percent were injured during a completed or attempted

robbery, and 5% were injured by an 

offender during a completed or 

attempted rape or sexual assault. 

Bureau of Justice Statistics

Special Report

 Among the estimated 1.4 million 

hospital emergency department (ED)

patients treated in 1994 for nonfatal

injuries sustained in intentional or

possibly intentional violence 

94% were injured during an assault.

2%, during a robbery. 

5%, by an offender in a rape

or sexual assault.

 Males were three-fifths of all persons treated in ED's for injuries sustained in violence. Persons under 

age 25 were about half.

 Blacks, who constitute about 13% 

of the population, represented 24% 

of those treated for violence-related

injuries.

 Of all persons treated for violence

related injuries 

7% had been injured by a spouse 

or ex-spouse.

10%, by a current or former boyfriend or girlfriend.

8%, by a parent, child, sibling, or

other relative.

23%, by a friend or acquaintance.

23%, by strangers.

In almost 30% of all cases in the

study, the relationship of the person

inflicting the injury to the patient

was not recorded for the study.

 A higher percentage of women than

men were treated for injuries inflicted

by an intimate  a current or former

spouse, boyfriend, or girlfriend. Men

were more likely than women to be

treated for injuries caused by nonrelatives: acquaintances and strangers.

 The estimated number of persons

treated in ED’s for injuries inflicted by

intimates was 4 times higher than estimates from the National Crime Victimization Survey, an ongoing

household survey.

 People injured in violence were

treated for a variety of injuries:

34% for bruises or similar injuries

31% for cuts, stab wounds, or 

 internal injuries

17% for fractures, sprains, disloca-

 tions, dental injuries, or other

 muscular/skeletal injuries

5% for gunshot injuries

5% for rapes/other sexual assaults

4% for concussions or other head 

 injuries

5% for other injuries.

 About 92% of violence victims

treated in ED's were released at once

after treatment; about 7% were hospitalized for further treatment. 

U.S. Department of Justice

Office of Justice Programs

Violence-Related

Injuries Treated in Hospital

Emergency Departments

Highlights

1

Centers for Disease Control, Hospital Ambulatory

Medical Care Survey: 1994 Emergency 

Department Summary Advance Data, 275, 

May 17, 1996. 

August 1997, NCJ-156921
Seventeen percent of those requiring

ED treatment for violence-related injuries, about 243,000 persons, had been

injured by someone with whom they

had an intimate relationship  a husband, ex-husband, boyfriend, girlfriend, ex-boyfriend, or ex-girlfriend.

These are some key findings of the 

Study of Injured Victims of Violence

(SIVV), conducted for the Bureau of

Justice Statistics (BJS) by the Consumer Product Safety Commission

(CPSC), to estimate the number of

persons treated in hospital emergency

departments for nonfatal injuries from

violence.2

Study of Injured Victims of Violence

The SIVV was undertaken to augment

available estimates of certain types of

more serious violence, such as domestic violence and sexual assault,

that have been shown to be difficult to

measure. (See the box on page 6 and

Understanding Violence Against

Women, National Research Council,

1996)

The study was conducted as a supplement to the National Electronic Injury

Surveillance System (NEISS), in a nationally representative, one-third sample of 31 hospitals having emergency

departments. CPSC conducts the

NEISS to measure injuries related to

consumer products. Because hospital

coders examine every ED record,

NEISS can be used for special studies

outside the normal scope of the CPSC

mission. (See the box on this page.) 

Relying on ED records, coders in each

sample hospital classified the cause of

injury for every person treated as intentional, possibly intentional, or

unintentional.

Intentional injuries were those deemed

to have been caused deliberately by

another person. These injuries, for example, resulted from assaults, fights,

family violence or abuse, and sexual

assault or rape.

Possibly intentional injuries were those

in which the injury sustained was characteristic of injury from violence, such

as extensive bruising with no explained cause, or those in which the

cause reported did not account for or

was inconsistent with the injury sustained. In the same category were

those injuries about which a knowledgeable person, such as a parent or

guardian of the ED patient, expressed

suspicions of violence. This category

included suspected family violence

and sexual assault. 

Unintentional injuries were injuries resulting from accidents such as motor

vehicle accidents, falls, occupational

injuries, and sports injuries. 

In this report violence-related injuries

refers to nonfatal injuries classified 

as either intentional or possibly intentional. The study excludes selfinflicted injury and uses violence and

interpersonal violence interchangeably.

2 Violence-Related Injuries Treated in Hospital Emergency Departments

2

This study was initiated with funding from the

Administration for Children and Families, U.S. 

Department of Health and Human Services.

The National Electronic Injury 

Surveillance System of the CPSC

The NEISS is an ongoing program to

identify and measure the number and

type of injuries associated with consumer products. The injuries are

those treated at hospital ED's in the

United States and its territories. 

The NEISS is conducted at a sample

of 91 hospitals. The stratified, probability sample of hospitals was constructed to be representative of all

U.S. hospitals that have at least 6

beds and provide 24-hour emergency

service. The collected data can be

weighted to produce national estimates of patients treated in hospital

ED's. (See page 8 for further discussion of the NEISS methodology.)

The medical staffs at the selected

hospitals have been trained to include

information in patient records about

the cause and circumstances of any

treated injury. Coders at each

hospital examine the records of all

ED patients and identify cases involving injuries related to consumer products. For pertinent cases the coders

abstract information on a number of

variables. The coders enter the information into personal computers and

electronically transmit the data to

CPSC for processing and tabulation. 

Because the sample is nationally representative and the record of every

patient at selected ED's is evaluated,

the NEISS provides an efficient

means for collecting information 

about injuries resulting from violence.

In addition to SIVV, the NEISS sample has been used for studying the

following: firearm injuries (Centers

for Disease Control), injuries involving motor vehicles (National Highway

Traffic Safety Administration), and

work-related injuries (National Institutes for Occupational Safety and

Health). 

Table 1. Characteristics of persons

treated in hospital emergency 

departments for violence-related

injuries, 1994

Characteristic 

of emergency 

department 

patients injured

by violence

Number

treated Percent

Rate per

1,000 U.S.

residents

Total 1,417,600 100% 5.5

Sex

Male 862,000 60.8% 6.8

Female 554,700 39.1 4.2

Not specified 900 .1 --

Race

White 744,400 52.5% 3.4

Black 344,300 24.3 10.5

Other 161,600 11.4 14.4

Not recorded 167,200 11.8 --

Age

Under 12 75,600 5.3% 1.6

12-14 87,100 6.1 7.8

15-18 199,600 14.1 14.2

19-24 325,800 23.0 14.9

25-34 389,600 27.5 9.4

35-64 318,700 22.5 3.5

65+ 20,300 1.4 0.6

Not recorded 900 .1 -- 

--Not applicable.
For each intentional or possibly intentional injury identified, hospital coders

extracted from the ED records information about the patient and the nature of the violence related to the

injury. As explained in the Methodology section on page 8, unintentional

injuries were excluded from the study;

as were fatal injuries, self-inflicted injuries, those that law enforcement officers inflicted in the line of duty, injuries

such as broken hands incurred by persons while attacking others or committing other crimes, and those inflicted

by persons under age 13. 

Intentional injuries treated

About 1.4 million people were treated

in hospital ED's in 1994 for nonfatal injuries sustained in intentional or possibly intentional acts of violence (table

1). Injuries were categorized based on

the circumstances of their occurrence

rather than offenders' motives. 

While an offender may not have intended to cause the specific injuries

measured by the study, the injuries

were the outcomes of violent acts.

Thus, a nose broken in a fight, a gunshot wound of an innocent passerby to

a drive-by shooting, and a stab wound

inflicted during a robbery are examples

of intentional or possibly intentional injuries that the study measured.

In 1994 persons treated for intentional

or possibly intentional injuries accounted for 3.6% of all physical injuries treated in hospital ED's. The 1994

SIVV estimate of 1.4 million treated in

hospital ED's for injuries from interpersonal violence was virtually identical to

the estimate of violence-related injury

by the 1994 National Hospital Ambulatory Medical Care Survey (NHAMCS).3

Excluding homicides would not measurably affect the NHAMCS estimate of

1,456,000 ED visits related to "homicide and injury purposely inflicted by

other persons." Most of the 23,300

homicide victims in 1994 were not

brought to ED's. 

Characteristics of persons treated

for violence-related injuries 

Three-fifths of all persons treated in

hospital ED's during 1994 for injuries

sustained in violence were male.

About half were under age 25. Blacks,

who constitute about 13% of the Nation’s population, were 24% of those

treated for violence-related injuries.

These data on the characteristics of

persons in hospital ED's for violencerelated injuries corroborate data from

other sources on the characteristics of

victims of violent crime. The National

Crime Victimization Survey (NCVS)

has consistently found that blacks,

males, and persons age 15-24 are the

most vulnerable to become violent

crime victims.4

 Comparisons between

SIVV data and those from the NCVS

are discussed on page 7.

Characteristics of injuries

While a patient might have exhibited a

variety of injuries, using information in

ED records, CPSC’s coders at each

hospital in the study categorized the

most serious or significant of the injuries sustained.

About a third of all persons in the study

were treated for bruises or similar injuries, and another third were treated for

cuts, stab wounds, or internal injuries

(table 2). About a sixth of the injuries

treated were muscular/skeletal injuries,

such as fractures, sprains, dislocations, or dental injuries. Gunshot injuries and rapes or other sexual assaults

each represented about 5% of all

treated injuries. 

Among those injuries for which the

place of occurrence was obtained, almost half were inflicted in or around a

home, either the patient's or someone

else's. Public places, such as stores,

restaurants, or office buildings, were

the next most common (29%), followed by open areas such as on the

street (15%).

About three-fifths of the injuries were

inflicted without the use of a weapon.

Most such patients were injured after

being punched or kicked. Some were

injured in falls during assaults or by

being thrown to the ground, into part 

of a building like a wall or door, or 

into an object like a table. 

 Violence-Related Injuries Treated in Hospital Emergency Departments 3

 Number Percent

 Total 1,417,500 100.0%

Intentional 1,335,900 94.2

Possibly intentional 81,700 5.8

Table 2. Characteristics of violencerelated injuries treated at hospital

emergency departments, 1994

Characteristic of injury

and violent event Number Percent

Injury diagnosis

Total 1,417,500 100.0%

Shot 70,300 5.0

Concussion/head injury 50,900 3.6

Muscular/skeletal injury 234,800 16.6

Cut/stab wound/

internal injury 433,500 30.6

Bruise 477,600 33.7

Burns/chemical injury 13,300 .9

Poisoned 1,400 .1

Rape/sexual assault 63,800 4.5

Other 72,000 5.1

Weapon used

Total 1,417,500 100.0%

No weapon 827,700 58.4

Firearm 60,900 4.3

Hit with gun 15,300 1.1

Knife/sharp object 100,100 7.0

Other object 264,900 18.7

BB/pellet gun 9,400 .7

Not recorded 139,200 9.8

Place of occurrence

Total 1,417,500 100.0%

Home 410,300 28.9

Street 128,300 9.0

Store, office, factory 246,400 17.3

School 54,800 3.9

Recreational area 20,300 1.4

Not recorded 557,300 39.4

Month of occurrence

Total 1,417,500 100.0%

January 101,300 7.1

February 90,700 6.4

March 102,400 7.2

April 115,600 8.2

May 114,300 8.1

June 135,200 9.5

July 136,100 9.6

August 139,800 9.9

September 129,600 9.1

October 124,100 8.8

November 115,700 8.2

4 December 112,700 8.0 BJS, Criminal Victimization in the United States,

1994, NCJ-162126, May 1997.

3

Centers for Disease Control, Hospital Ambulatory

Medical Care Survey : 1994 Emergency Department Summary Advance Data, 275, May 17, 1996.
About 5% of the victims, representing

about 61,000 injured, were treated for

nonfatal gunshot wounds. These injuries exclude those inflicted by BB or

pellet guns, shown separately. The

firearm injury estimate was not significantly different from that of a previous

study conducted by the Centers for

Disease Control using a full sample of

91 NEISS hospitals. That study estimated 58,485 persons were treated in

hospital ED's for firearm injuries from

assault or legal intervention during the

year ending May 31, 1993.5 

About 100,000 people, or about 7% 

of all those treated for violence related

injuries, were treated for stabbing or

cutting wounds. Approximately 19% 

of the injuries were sustained by being

hit with an object like a rock or a stick

that an assailant held or threw. In

nearly 10% of the cases, the source 

of the injury was not recorded.

A slightly higher percentage of

violence-related injuries occurred 

during the warmer months  June,

July, and August  than during other

months. Altogether 29% of the intentional and possibly intentional injuries

occurred during the summer.

In 14% of the violence-related injuries

treated in ED's in 1994, the ED record

indicated that the victim or someone

else involved in the incident had been

drinking or using drugs (table 3). This

estimate should be considered a lower

bound of the percentage of injuries involving alcohol or drugs. Usually the

ED's did not test patients for intoxication but indicated alcohol or drug involvement if cited by patients or other

involved persons or if ER personnel

observed the patient under the influence of alcohol or drugs. 

In most cases the hospital record did

not specify whether the person who

had been drinking was the patient,

another person involved in the incident

surrounding the injury, or both. Almost

all of the alcohol/drug citations on the

hospital records reflected alcohol involvement. Drugs were cited on the

hospital record in less than 1% of all

violence-related injuries treated. 

The apparent difference between the

percentages of injuries associated with

alcohol and/or drugs for men (17%)

and women (10%) was not statistically

significant. About a fifth of the alcohol/

drug-related injuries to men were sustained in or near bars or restaurants,

many during what were characterized

on the hospital records as “bar fights.”

Male Female

 Total involving alcohol 100% 100%

At/near bar 18 9 

Other/unspecified place 82 91

Over 90% of all persons requiring ED

treatment for intentional or possibly 

intentional injuries were released after

treatment (table 4). About 8% were

hospitalized at least overnight. 

Persons suffering gunshot or knife

wounds were more likely than other

persons treated to require overnight

hospitalization. Sixty percent of persons treated in the ED for gunshot

wounds required overnight hospitalization, as did 24% of those suffering stab

wounds. While accounting for only 5%

of those treated, victims of gunshot

wounds represented a third of those

requiring hospitalization. (Firearms

were involved in about 70% of U.S.

murders in 1994. These fatal injuries

were outside the scope of this study.)

Similarly, stabbing victims, about 7%

of persons treated, represented a

fourth of those who were hospitalized

after treatment in the ED.

Characteristics of persons 

inflicting injuries

Although about a third of the cases

contained no information about the

person who inflicted the injury, in those

cases with such information, 5 in every

6 ED patients reported that a male had

injured them (table 5). Three of every

four patients providing information on

offender age reported that the person

4 Violence-Related Injuries Treated in Hospital Emergency Departments

Table 3. Involvement of alcohol or illegal drugs in violence-related injuries

treated in hospital emergency departments, 1994

Patients with violence-related injuries

Involvement of alcohol All Male Female

or illegal drugs Number Percent Number Percent Number Percent

Total 1,416,600 100.0% 862,000 100.0% 554,700 100.0%

Involvement 201,400 14.2 144,800 16.8 56,600 10.2

No involvement recorded 1,215,300 85.8 717,200 83.2 498,000 89.8

Note: Table excludes cases for which sex of patient was not ascertained.

Table 4. Disposition of emergency

department patients treated for

violence-related injuries, 

by type of weapon, 1994

Weapon 

identified with 

injuries treated Total

Treated

and

released

Hospitalized

Total 100% 92.4% 7.6%

No weapon 100 97.0 3.0

Gun 100 39.6 60.4

Hit with gun 100 93.9 6.1

Knife/sharp object 100 76.0 24.0

Other object 100 94.9 5.1

BB/pellet gun 100 92.3 7.7

Not recorded 100 95.1 4.9

Total 100.0% 100.0%

No weapon 61.3 23.1

Gun 1.8 34.2

Hit with gun 1.1 .9

Knife/sharp object 5.8 22.3

Other object 19.2 12.6

BB/pellet gun .7 .7

Not recorded 10.1 6.3

Table 5. Characteristics of persons

causing violence-related injuries

treated in hospital emergency 

departments, 1994

Characteristic of

the offender Number Percent

Sex

Total 1,417,500 100.0%

Male 763,400 53.9

Female 144,300 10.2

Not reported 509,800 36.0

Age

Teenager (12-19) 185,500 13.1%

Adult (20+) 726,700 51.3

Teen or adult 43,500 3.1

Not reported 461,900 32.6

5

Joseph L. Annest, James A. Mercy, Delinda R.

Gibson, and George W. Ryan, "National Estimates

of Nonfatal Firearm-Related Injuries," Journal of

the American Medical Association, 273, 22, June

14, 1995, pp. 1749-1754.
who injured them was over age 19. To

facilitate obtaining information about

the person who inflicted the injury,

hospitals classified age into three categories: child (under age 13), teenager

(age 13-19), and adult (age 20 or

older). As explained on page 9, persons injured by children were excluded

from the analysis for this report.

These data substantiate findings from

the NCVS that adult males commit

most violence. Males committed more

than three-fourths of the violent crimes

that the NCVS measured in 1994.

Persons age 18 or older committed

about four-fifths of NCVS-measured

aggravated assaults. In about a third

of all cases in the SIVV, however, the

ED record did not contain information

about the characteristics of the person

inflicting the injury.

Adult men inflicted two-thirds of the

violence-related injuries about which

ED patients provided information.

Teenage males were responsible for

an additional 15%; adult women, 11%,

and teenage females, 4%.

Patient-offender relationship

The patient's spouse or ex-spouse inflicted about 7% of all violence-related

injuries treated in ED's (table 6). A

current or former boyfriend or girlfriend

caused injuries to an additional 10% of

persons seeking treatment. Parents,

children, siblings, and others related to

the patient were responsible for about

8% of all intentional or possibly intentional injuries; friends or acquaintances

caused about 23%; and persons who

were strangers to the patients, about

23% of the injuries. In almost 30% of

all cases, the relationship between the

patient and the injurer was unknown.

A higher percentage of women than

men were injured by someone with

whom they shared an intimate relationship: a spouse, ex-spouse, boyfriend,

girlfriend, ex-boyfriend, or ex-girlfriend

(table 7). Conversely, injured men

were more likely than women to have

been treated for injuries inflicted by

nonrelatives: acquaintances and

strangers. Because the patientoffender relationship was unknown 

 Violence-Related Injuries Treated in Hospital Emergency Departments 5

Table 7. Patient/offender relationship in violence-related 

injuries, by the sex of emergency department patient, 1994

Hospital ED patients injured by violence

Male Female

Number Percent Number Percent

Total 862,000 100.0% 554,700 100.0%

Spouse/exspouse 15,400 1.8 88,400 15.9

Other relative 56,900 6.6 52,600 9.5

Boy/girlfriend 23,600 2.7 116,000 20.9

Other friend 142,100 16.5 86,100 15.5

Other acquaintance 75,200 8.7 27,200 4.9

Stranger 248,800 28.9 77,500 14.0

Not reported 300,100 34.8 106,900 19.3

Child injuries from suspected 

rape and sexual assault

Virtually all of the older teenagers and

adults who visited the hospital ED's

as a result of sexual violence sought

treatment for a physical injury suffered during the attack. A substantial

number of the child patients, representing 39% of the rape and sexual

abuse cases of children under age 

12 treated at the ED's in 1994, were

brought by parents or guardians to

evaluate whether the child had been

a victim of a sexual assault or rape.

In many cases of suspected abuse,

there were physical signs or symptoms that could have resulted from

sexual abuse. In other cases the children had been alone with persons

suspected of committing such acts.

In almost all of these suspected child

abuse cases, the study records do not

include outcomes of the hospital examinations or of other investigations.

For this study these cases were classified as possibly intentional injuries,

and the data reflect suspected, rather

than confirmed sexual abuse of children. 

Recent studies of the validation of

claims of sexual abuse of children

have found that physical examinations alone are usually insufficient to

determine whether a child has been

the victim of such attacks.*

 The

American Academy of Pediatrics

"Guidelines for the Evaluation of Sexual Abuse of Children" states that the

diagnosis of child sexual abuse must

be made on the basis of a child’s history, of which the physical examination is one part.I

*

Joyce A. Adams, "Significance of Medical Findings in Suspected Sexual Abuse: Moving Towards Consensus," Journal of Child Sexual

Abuse, 1, 3, 1992, pp. 91-99.

I

American Academy of Pediatrics, "Committee on

Child Abuse and Neglect, Guidelines for the

Evaluation of Sexual Abuse of Children," Pediatrics, 87, 2, February 1991, pp. 254-260.

Offender

age

Offenders identified by ED patients

Male Female

Teenager (12-19) 14.7% 3.8%

Adult (20+) 66.9 10.8

Teen or adult 2.9 .8

Table 6. Relationship between the

emergency department patient injured by violence and the person

committing that violence, 1994

Relationship to

patient Number Percent

Total 1,417,500 100.0%

Spouse/ex-spouse 103,800 7.3

Parent 40,400 2.8

Child 11,500 .8

Other relative 57,700 4.1

Boy/girlfriend 139,600 9.8

Other friend 228,200 16.1

Other acquaintance 102,400 7.2

Stranger 326,400 23.0

Not reported 407,600 28.8
in about a third of all injuries of males,

compared to a fifth of injuries of females, this finding should be regarded

by some caution.

When cases without a recorded

patient-offender relationship areas are

excluded, patients under age 12 were

more likely to have been injured by a

relative or acquaintance than by a

stranger. Over half of the teenagers

requiring ED treatment for violencerelated injuries were injured by an acquaintance. Adults were about equally

likely to be injured by an acquaintance

or a stranger 

Crime classification of incidents

surrounding injuries

To measure the number of incidents 

in which ED patient injuries were sustained from criminal actions and to enable comparisons with estimates from

the National Crime Victimization Survey (NCVS), each SIVV case was assigned a type-of-crime code. BJS

applied the code by reviewing the written descriptions of the incidents on the

NEISS record. The coding protocol is

described in Type-of-crime coding of

injuries in the SIVV on page 9.

In many cases the written descriptions,

which were based on information that

the patient or another knowledgeable

person provided, contained minimal

6 Violence-Related Injuries Treated in Hospital Emergency Departments

Accounting for differences in

measures of violent crime

The Federal Government and research organizations currently conduct several programs to measure the

prevalence, characteristics, and consequences of violent crime. The Department of Justice administers two

such ongoing programs. The FBI's

Uniform Crime Reporting (UCR) program provides a measure of the number of crimes that come to the

attention of law enforcement agencies

across the Nation, and the BJS National Crime Victimization Survey

(NCVS) provides a detailed picture of

crime incidents, victims, and trends

from the victim's perspective. 

The estimates from the various studies of violent crime have often varied

dramatically. Such differences are

expected, given the differences in the

nature and content of differing statistical programs. Discussing differences

in estimates of violence against

women from various studies, the National Academy of Sciences found

that "as with all research, a variety of

methodological factors can be linked

to the differences in study findings.

Sample composition and locale, data

collection method and question construction and context are among the

most important methodological differences in U.S. studies."*

It is therefore not surprising that the

SIVV estimates of the persons treated

in hospital ED's for violence-related

injuries differ from those of the

NCVS, even when, to enhance comparisons with the NCVS, injuries sustained by persons under age 12 were

excluded from the SIVV. The differing methodologies and contexts of the

two studies can explain much of the

differences between the SIVV and

NCVS estimates.

The SIVV is based on identification by

a patient, hospital staffer, or other

knowledgeable person of the cause of

injuries sustained by people treated in

the ED. The context of the study is

nonaccidental injury, regardless of

whether the victim perceived the

event to have been criminal in nature.

The context of the NCVS is crime,

some of which resulted in injury requiring treatment in a hospital ED.

Any injuries sustained in violence that

a victim did not perceive to be criminal in nature might not be recounted

by the victimization survey.

There are also other information filters operating in each program that

can help to explain differences in resulting estimates. The SIVV data are

collected at the time the injury is

treated; therefore, error cannot be introduced by forgetting or misremembering aspects of the incident.

However, some people treated in hospital ED's may choose not to relate

the cause of injury or may provide inaccurate or incomplete information

about the source of injury. The NCVS

data are collected up to 6 months after the incident. Responding to personal situations at the time of the

interview, victims may choose not to

recount incidents or may feel unable

to recount incidents that happened to

them earlier.

Moreover, the SIVV includes persons

who live outside usual household settings, such as the homeless and persons in institutions, not included in the

NCVS.

The appropriateness of a particular

measure must depend on the context

in which the estimate is used. As an

example, the NCVS estimate of persons treated in ED's could be more

appropriate in discussions of the extent to which crime victims seek treatment for their injuries, while the SIVV

measure could be more appropriate

for examination of the more encompassing impact of violence on health

services. *National Research Council (NRC) Understanding Violence Against Women, Washington D.C.,

1996.

Relationship to the patient of the 

person who inflicted the injury

Age of ED patient Total Relative Acquaintance Stranger

Child (younger than 12) 100% 56.3% 34.1% 9.7%

Teenager (age 12-19) 100% 11.9 58.2 29.9

Adult (age 20 or older) 100% 20.9 43.9 35.2
detail of circumstances of the injury.

These cases were, for lack of other information, categorized for the study as

assaults, as were cases in which the

assaultive behavior was fully described. About 94% of the injuries in

the SIVV were sustained during incidents that were classified for the study

as assaults (table 8). Of these a third

were sustained in what were described

as altercations or fights. About 2% of

the people treated for intentional injuries were victims of robbery, and 5%

were victims of rape, sexual assault, or

suspected sexual assault. 

While the percentages of treated injuries from assaults were generally similar among age groups, young children

differed from others in the percentages

of treated injuries that resulted from

fights and sexual assaults. Among 

patients treated for a violence-related

injury, about 29% of the children under

age 12 were treated for suspected or

confirmed rape or sexual assault, compared to 5% of teens and 3% of adults

(table 9). See the box Child injuries

from suspected rape and sexual 

assault on page 5.

Children treated in ED’s for intentional

or possibly intentional injuries were

less likely than teenagers or adults to

have sustained their injuries in incidents characterized as fights or altercations (9% versus 33% and 30%,

respectively.) Part of these differences between children and others injured in fights may have come from

NEISS excluding injuries inflicted by

persons age 12 or younger.

Among children under age 12 brought

to hospital ED's, half of those who

were examined or treated for sexual

abuse were age 4 or younger; half

those treated for injuries from other

types of violence were age 5 or

younger.

Comparisons with other 

data on violence

The SIVV was implemented to improve estimates of certain types of

more serious violence, especially

those difficult to measure  violence

between people known or related to

each other, rape and sexual assaults,

and violence against children.6

 These

crimes typically occur in nonpublic settings. Many of the victims, including

those of long-term abuse, are unable

or unwilling, because of fear or embarrassment, to report such abuse to

authorities or to programs that measure these victimizations.

The NEISS collection effort may help

clarify the variations in current estimates of such crimes. The estimates

often vary because of differences in

collection methods and because there

is lack of agreement on the behaviors

defined by "domestic violence," "sexual assault," and "child abuse." 

 Violence-Related Injuries Treated in Hospital Emergency Departments 7

 Median age of children

under age 12 treated

in hospital ED's for

violence-related injury

Any injury 5 years

Rape/sexual assault* 4

Fights, assault 6

*Includes suspected rape/sexual assault.

6

National Research Council (NRC), Understanding

Violence Against Women, Washington D.C.,

1996.

Table 9. Offense type in violence-related injuries treated in hospital

emergency departments, by age of patient, 1994

Total

Child (under 

age 12)

Teen 

(age 12-19)

Adult

(age 20 or older)

Number

Total 1,416,700 75,600 341,000 1,000,000

Rape/sexual assault 65,100 22,100 15,500 27,500

Robbery 22,000 100 2,300 19,600

Assault 1,329,600 53,500 323,200 952,900

Fight/altercation 416,500 7,100 113,200 296,200

Assault 913,100 46,400 210,000 656,700

Percent

Total 100.0% 100.0% 100.0% 100.0%

Rape/sexual assault 4.6 29.2 4.5 2.8

Robbery 1.6 .1 .7 2.0

Assault 93.9 70.7 94.8 95.3

Fight/altercation 29.4 9.4 33.2 29.6

Assault 64.5 61.3 61.6 65.7

Note: The table excludes cases for which the age of the patient was not ascertained.

Table 8. Offense type in violencerelated injuries treated in hospital

emergency departments, 1994

Number Percent

Total 1,417,500 100.0%

Rape/sexual assault 65,100 4.6

Robbery 22,000 1.5

Assault 1,330,400 93.8

Fight/altercation 416,600 29.4

Assault 913,800 64.5
In 1992 BJS redesigned the NCVS

questionnaire to “produce more accurate estimates of rape and sexual assault and of any kind of crimes

committed by intimates or family

members.”7

 At the time it was redesigning the victimization survey, BJS

began exploring alternative means for

measuring the extent and characteristics of these difficult-to-measure forms

of violence. The fielding of the SIVV

in 1993 came from this effort. 

SIVV estimates of persons seeking

treatment at hospital emergency departments in 1994 for violence-related

injuries are substantially higher than

NCVS estimates for the same category

of persons (1.3 million versus 540,000)

(table 10). For these comparisons,

SIVV patients under 12 years old were

excluded to allow comparability with

the NCVS.

The differences between the SIVV and

the NCVS estimates were greatest for

those types of violence thought to be

most undercounted in studies of violence, that is, rapes/sexual assaults

and crimes by intimates or other relatives. The number of rapes/sexual assaults measured by the SIVV was

about double that of the NCVS. The

SIVV estimate of ED treated injuries

inflicted by a spouse or ex-spouse was

many times that of estimates from the

NCVS. The differences between the

SIVV and NCVS were not evenly distributed across types of crimes or

patient-offender relationships. 

The percentages of ED treated injuries

inflicted by intimates, and by relatives,

were substantially higher in the SIVV

than in the NCVS, despite a larger

number of SIVV cases with missing

data for victim-offender relationship.

An intimate  a current or former

spouse, boyfriend, or girlfriend  inflicted 18% of all injuries recorded in

the SIVV, compared to 12% of injuries

treated in ED's and recorded in the

NCVS. The NCVS estimate of the

proportion of injuries inflicted by a

stranger was about double that of the

SIVV (54% versus 24%).

The two programs also differed in the

nature of the offenses surrounding the

injuries. While the percentage of all

injuries treated in ED's that were rapes

or sexual assaults were almost identical in the two programs, the percentage of injuries sustained in robberies

was almost negligible in the SIVV but

represented about 20% of the EDtreated injuries in the NCVS. When

the patients were treated at the hospital, some SIVV robbery cases were

likely classified as assaults. It is not

possible to determine from these data

the extent of such misclassification,

however.

A principal reason for differences between estimates from this study and

the NCVS are the differences in study

contexts and victim perspectives.

Some of these methodological differences in the two programs are discussed in the box on page 6. 

SIVV data provide evidence that the

crimes believed to be most liable to

undercounting are actually more frequent than the NCVS has estimated.

The fresh perspective of the hospital

ED enables a formulation of a broader

measure. 

Methodology

Data collection for the SIVV began in

October 1993 at a one-third sample

(31 ED's) of the current NEISS sample. The data described in this report

cover injuries treated in hospitals in

the NEISS sample during calendar

year 1994. 

Sample design

The 91 hospitals in the NEISS sample

were selected from 4 strata based

upon hospital size (small, medium,

large, and very large) as determined

by the number of annual visits to the

ED’s. The NEISS sample includes

hospitals in urban, suburban, and rural

settings, and was designed to enable

national estimates. Because the sample is representative of all hospitals

with ED's in the Nation, the NEISS can

be used to estimate the number and

characteristics of all injuries, including

injuries derived in acts of violence,

treated in hospital ED's.

For the SIVV, a third of the hospitals 

in each strata, for a total of 31, were

randomly selected for inclusion in the

study. To obtain national estimates 

of intentional and possibly intentional

injuries, each injury was assigned a

weight based on the inverse of the

8 Violence-Related Injuries Treated in Hospital Emergency Departments

7

BJS, Violence against Women: Estimates from

the Redesigned Survey, BJS Special Report,

August 1995, NCJ-154348.

Table 10. Comparison of the Study of Injured Victims of Violence (SIVV) 

and the National Crime Victimization Survey (NCVS), by offense, 1994

SIVV patients* 

NCVS victims reporting

treatment at a hospital

emergency department

Type of offense Number Percent Number Percent

Ratio of 

SIVV/NCVS

Total 1,341,900 100.0% 539,300 100.0% 2.5

Rape/sexual assault 43,000 3.2 24,300 4.5 1.8

Robbery 21,900 1.6 109,900 20.4 0.2

Assault 1,277,000 95.2 405,000 75.1 3.2

Total 1,341,900 100.0% 539,300 100.0% 2.5

Spouse/ex-spouse 103,800 7.8 25,100 4.7 4.1

Other relative 75,200 5.5 8,200 1.5 9.2

Boy/girlfriend (current

or former) 139,600 10.5 37,700 7.0 3.7

Other acquaintance 313,400 23.2 143,900 26.7 2.2

Stranger 322,000 24.1 289,800 53.7 1.1

Unknown or unreported 388,000 29.0 34,500 6.4 11.2

*Age 12 or older.
probability of selection of the hospitals

within each of the four strata of hospital size. Adjustments to the weights

were made when necessary to account

for changes in the NEISS sample and

non response by hospitals in any given

month. Because the SIVV sample was

a third the size of the NEISS sample,

the SIVV weights were 3 times the

NEISS weights. To produce national

estimates, study weights were

summed across all hospitals for 

cases of interest. 

Study procedures

Prior to the start of the Study of Injured

Victims of Violence in 1993, medical

staffs and NEISS coders at each insample hospital were trained to identify injuries sustained during acts of

violence. At each hospital in the sample, on an ongoing basis, NEISS coders examined the ED records to

determine the nature and source of

every injury for which people sought

treatment. 

Based on information provided by ED

doctors and nurses the coders classified all injuries into one of three

categories:

 intentional injury

 possible or suggestive 

of intentional injury

 nonintentional injury.

For all cases classified as intentional

or possibly intentional, the coders recorded additional information about

the case, including information about

the person inflicting the injury and type

of weapon used, (if any), to inflict the

injury.

Only those injuries coded as intentional or possibly intentional were included in the study. Nonintentional

injuries were those determined to be

accidental in nature. In addition, selfinflicted injuries, such as suicide attempts, were excluded as out of scope

for the study.

In all, 13,161 unweighted cases were

coded by sample hospitals as intentional or possibly intentional injuries

treated in 1994. Upon review in BJS,

some cases were reclassified based

on the written and coded entries of the

cases. Twenty-four cases were reclassified as non-intentional injuries; in

most of these, the written entries indicated injuries consistent with accidents. Three of the recoded cases

were statutory rapes, outside the

scope of this study. (Statutory rape

was excluded to maintain comparability with NCVS and UCR measures of

violent crime. These programs exclude statutory rape from their violent

crime estimates.)

A number of persons injured by 

violence were excluded from the

analyses for this report: 

Persons who died en route to 

or in ED's

Persons injured by children 

age 13 or under

Criminal suspects and prison 

or jail inmates injured by 

law enforcement officials

Persons hurting themselves in 

suicide attempts or other

circumstances

Persons injured while committing 

a crime or assaulting others 

in a fight.

Some of these exclusions were made

because there was not enough information to classify them correctly. Most

were made to focus on the issue of

crime more closely; children younger

than 13, for example, would seldom be

charged with a crime. In all, the cases

excluded from analysis represented

about 12% of all intentional or possibly

intentional injuries treated at the hospitals ( table 11). Three-fourths of the

excluded cases were injuries inflicted

by children age 12 or younger.

The NEISS sample does have some

limitations that should be taken into

account then interpreting the results

from this study. The Centers for Disease Control, as part of their NEISSbased study of firearm injuries, identified four major factors associated with

the NEISS sample design that could

influence the accuracy of national estimates of gunshot wounds.8

 Violence-Related Injuries Treated in Hospital Emergency Departments 9

Appendix table. Estimates of intentional and possibly 

intentional injuries treated at hospital emergency 

departments, by various characteristics: standard errors, 

confidence intervals, and coefficients of variation, 1994

Number

Standard 

error (SE)

95-percent 

confidence interval

Coefficient of

variation (CV)

Total 1,417,535 131,248 1,160,289 1,674,781 0.093

Intentional 1,335,864 126,417 1,088,086 1,583,642 0.095

Possibly intentional 81,671 19,299 43,845 119,496 0.236

Male 861,993 86,829 691,809 1,032,177 0.101

Female 554,653 49,894 456,860 652,446 0.090

White 744,377 68,968 609,199 879,555 0.093

Black 344,332 67,286 212,450 476,213 0.195

Other 161,645 61,247 41,601 281,688 0.379

Table 11. Patients treated in hospital

emergency departments, by type 

of injury, 1994

Unweighted

number Percent

Total 13,161 100.0%

Intentional/possibly intentional 11,549 87.8

Recoded as unintentional 24 .2

Dead on arrival 55 .4

Injured by law enforcement 227 1.7

Injured by child under age 12 1,167 8.9

Offender injured 98 .7

Self-inflicted 31 .2

8

For a comprehensive discussion of these factors

see Yvette Davis, Joseph L. Annest, Kenneth E.

Powell, and James A. Mercy, "An Evaluation of the

National Electronic Injury Surveillance System for

Use in Monitoring Nonfatal Firearm Injuries and

Obtaining National Estimates," Journal of Safety

Research, 27, 2, 1996, pp. 83-91.
These factors, which may apply to

violence-related injuries as well, are

the following:

 The NEISS sample does not account for hospitals with an ED that

came into existence after 1985.

 Hospitals were assigned to different strata based on the number of annual visits for treatment. The current

NEISS sample design does not account for annual changes in the number of ED visits when assigning

hospitals to different strata.

 Most of the large and very large

hospital in the NEISS sample are located in the northeastern United

States. While the overall sample is

statistically valid, the uneven distribution of the larger hospitals may influence national estimates based on

NEISS data.

 For gunshot wounds there was substantial variation in the number of

cases within and among hospital size

strata. This variation yielded coefficients of variation of about 22%, which

are high compared to the coefficients

of variation for annual estimates of

product-related injuries (10%).

Despite these limitations, CDC concluded that the NEISS was a useful

tool for conducting research into firearm injury.

Type-of-crime coding of injuries 

in the SIVV

A hierarchy based on that used for the

NCVS was used to code type of crime:

rape, attempted rape, sexual assault,

robbery, assault. Thus, a case was

classified as a rape or attempted rape

if the written description mentioned

“rape” or “attempted rape” or described

such acts. Absent these, if the description described other sexual assaults, it was so classified. This

category included children brought to

the emergency department for evaluation of possible sexual abuse. (See

the box on page 5.) 

Cases not involving rape or sexual assault that included aspects of theft or

which were described as “mugging”

were coded as robberies. Cases not

classified above that were described

on the records as “fights,” “arguments,”

and “altercations” were classified as

fights and cases not coded as described above were classified as assaults. Typically, these last described

cases had summaries that included

such descriptions as “beaten,” “struck,”

“shot,” “hit,” “hit with,” “assaulted,”

“punched,” and “kicked.” For comparison with the NCVS, fights and assaults

in the SIVV were combined into a

composite assault category. 

For a number of reasons, the limited

amount of available information constrained the type-of-crime coding for

this study. For each SIVV case, the 

code was based primarily on a summary within two lines of writing describing the reason for the ED visit and

on the description of the injury gleaned

from the medical record. 

Three conditions especially restricted

the coding. First, the coding depended

on information provided by the patient

or someone with the patient, and does

not represent a legal finding about the

case. It is possible that some robbery,

rape, and sexual assault injuries were

classified as assaults because the injured person during treatment did not

provide the information. Second,

some patients were unwilling or unable

to provide information about the incident in which the injuries were received. Third, medical staffs varied

widely in the amount of information

about causes of injury that they elicited

and recorded on hospital forms. 

A good example of the limits imposed

on the coding occurred in trying to

separate injured offenders from injured

victims. Except for those cases in

which the hospital record contained information that the person treated had

been injured while committing a crime,

the study could not distinguish between the two types of patients. Cases

in which the record clearly indicated

that the patient suffered injury in the

course of committing a crime were removed from analysis. 

However, since many injuries in the

study resulted from events recorded as

altercations, fights, and arguments, the

records did not contain enough information to differentiate those injuries

suffered by "innocent" victims from 

injuries inflicted upon aggressors or 

instigators of violence. It is likely that

investigation of many of these cases,

like those of persons injured in bar

fights, would not have been able to 

establish who were offenders and who

were victims. 

The extent of information entered in

this text area varied considerably from

case to case. For the sake of consistency, it was decided not to attempt to

interpret the information available, but

to rely upon what was entered in the

text. 

Standard errors of estimates

Variance estimates were calculated for

each estimate presented in this report

using formulas provided by the CPSC.

These variance estimates were used

to calculate standard errors (SE’s) and

coefficients of variation (CV’s) for each

estimate. 

The national estimate of 1.4 million 

intentional and possibly intentional 

injuries had an SE of 132,000 and a

CV of 9.3%. 

All comparisons presented in this 

report met statistical tests of significance at the 90-percent or 95-percent

confidence levels. Most differences

presented were significant at the 95-

percent confidence level (about 2.0

standard errors). Differences significant at the 90-percent confidence level

(about 1.6 SE’s) were qualified by the

phrase “some evidence.” 

The SE’s, 95-percent confidence levels, and CV’s for some of the major

variables are presented in the appendix table on page 9.

10 Violence-Related Injuries Treated in Hospital Emergency Departments
Sources

Adams, Joyce A. "Significance of

Medical Findings in Suspected Sexual

Abuse: Moving Towards Consensus."

Journal of Child Sexual Abuse, 1, 3,

1992.

American Academy of Pediatrics.

"Committee on Child Abuse and Neglect, Guidelines for the Evaluation of

Sexual Abuse of Children." Pediatrics,

87, 2, February 1991.

BJS. Violence against Women: Estimates from the Redesigned Survey.

NCJ-154348, August 1995.

BJS. Criminal Victimization in the

United States, 1994. NCJ-162126,

May 1997.

Centers for Disease Control. Hospital

Ambulatory Medical Care Survey:

1994 Emergency Department Summary Advance Data. 275, May 17,

1996. 

National Research Council. Understanding Violence Against Women.

Washington, DC, 1996.

 Violence-Related Injuries Treated in Hospital Emergency Departments 11

The Bureau of Justice Statistics 

is the statistical agency of the 

U.S. Department of Justice. 

Jan M. Chaiken, Ph.D., is director.

BJS Special Reports address a specific topic in depth from one or more

datasets that cover many topics.

Michael Rand wrote this report.

Kevin Strom constructed and extensively edited the data files. Tom

Hester, assisted by Rhonda Keith,

edited and produced the report.

Marilyn Marbrook, assisted by Jayne

Robinson and Yvonne Boston, 

administered the final production.

The Intentional Injury Study was 

undertaken with funding from the

Administration for Children and

Families, U.S. Department of Health

and Human Services. At the Consumer Product Safety Commission,

under the direction of Art McDonald,

Eileen Kessler oversaw the collection and processing of the data.

August 1997, NCJ-156921

This report and many of its data, as

well as other reports and statistics,

may be found at the Bureau of 

Justice Statistics Internet World

Wide Web site:

http://www.ojp.usdoj.gov/bjs/

Data presented in this report may 

be obtained from the National 

Archive of Criminal Justice Data 

at the University of Michigan,

1-800-999-0960. The archive may

also be accessed through the BJS

Web site.