PURPOSE: Homelessness increases the risk of cold-related injuries. We examined emergency department visits for cold-related injuries in Toronto over a 4-year period, comparing visits for patients identified as homeless to visits for patients not identified as homeless. METHODS: This descriptive analysis of visits to emergency departments in Toronto between July 2018 and June 2022 used linked health administrative data. We measured emergency department visits with cold-related injury diagnoses among patients experiencing homelessness and those not identified as homeless. Rates were expressed as a number of visits for cold-related injury per 100,000 visits overall. Rate ratios were used to compare rates between homeless vs. not homeless groups. RESULTS: We identified 333 visits for cold-related injuries among patients experiencing homelessness and 1126 visits among non-homeless patients. In each of the 4 years of observation, rate ratios ranged between 13.6 and 17.6 for cold-related injuries overall, 13.7 and 17.8 for hypothermia, and 10.3 and 18.3 for frostbite. Rates per 100,000 visits in the fourth year (July 2021 to June 2022) were significantly higher than in the pre-pandemic period. Male patients had higher rates, regardless of homelessness status; female patients experiencing homelessness had higher rate ratios than male patients experiencing homelessness. CONCLUSION: Patients experiencing homelessness visiting the emergency department are much more likely to be seen for cold-related injuries than non-homeless patients. Additional efforts are needed to prevent cold-related exposure and consequent injury among people experiencing homelessness.
Vohra N, Paudyal V, Price MJ. Homelessness and the use of emergency department as a source of healthcare: a systematic review. Int J Emerg Med. 2022;15(1):1–22. https://doi.org/10.1186/s12245-022-00435-3 .
[DOI: 10.1186/s12245-022-00435-3]
Zhang P, Bassil B, Gower S, et al. Cold-related injuries in a cohort of homeless adults. J Soc Distress Homeless. 2019;28(1):85–9. https://doi.org/10.1080/10530789.2018.1523103 .
[DOI: 10.1080/10530789.2018.1523103]
Rouquette A, Mandereau-Bruno L, Baffert E, et al. Winter surveillance of cold exposure effects on health among the homeless population in the Paris area: data from the coordinated health surveillance of emergency department network (organisation de la surveillance coordonnée des urgences [Oscour(®)]). Revue d’Épidémiologie et de Santé Publique. 2011;59(6):359–68.
[DOI: 10.1016/j.respe.2011.05.006]
Frencher SK, Benedicto CMB, Kendig TD, et al. A comparative analysis of serious injury and illness among homeless and housed low income residents of New York City. J Trauma Acute Care Surg. 2010;69(4):S191–9. https://doi.org/10.1097/TA.0b013e3181f1d31e .
[DOI: 10.1097/TA.0b013e3181f1d31e]
Romaszko J, Cymes I, Draganska E, et al. Mortality among the homeless : causes and meteorological relationships. PLoS ONE. 2017;12(12):e0189938. https://doi.org/10.1371/journal.pone.0189938 .
[DOI: 10.1371/journal.pone.0189938]
Vuillermoz C, Aouba A, Grout L, et al. Mortality among homeless people in France, 2008–10. Eur J Pub Health. 2016;26(6):1028–33. https://doi.org/10.1093/eurpub/ckw083 .
[DOI: 10.1093/eurpub/ckw083]
Zhang P, Wiens K, Wang R, et al. Cold weather conditions and risk of hypothermia among people experiencing homelessness: implications for prevention strategies. Int J Environ Res Pub Health. 2019;16:3259. https://doi.org/10.3390/ijerph16183259 .
[DOI: 10.3390/ijerph16183259]
City of Toronto. Extreme Cold Weather. 2023 [cited 2023 Feb 28]. Available from: https://www.toronto.ca/community-people/health-wellness-care/health-programs-advice/extreme-cold-weather/.
Unity Health Toronto. A statement from Unity Health Toronto on winter, homelessness and the care we all deserve. 2023 [cited 2023 Feb 28]. Available from: https://unityhealth.to/2023/01/statement-on-homelessness/.
Zaheer J., Snider C., von Vopelius-Feldt J., et al. [Letter to Mayor John Tory and Toronto City Council encouraging them to vote in favour of the motion allocating funds for expanding the number of 24-hour, accessible and low-barrier warming centres during winter months]. Retrieved from CAMH. 2023 [cited 2023 Feb 28]; Available from: https://www.camh.ca/-/media/files/pdfs---public-policy-submissions/eds-letter-to-mayor-and-councillors---final2-pdf.pdf.
Inner City Health Associates. Statement by Inner City Health Associates: Toronto Homeless Encampments and the Right to Housing. 2021 [cited 2023 Feb 28]. Available from: https://www.icha-toronto.ca/statement-by-inner-city-health-associates-toronto-homeless-encampments-and-the-right-to-housing.
Hayes M. Winter closing of Toronto shelter hotel presents impossible decision for residents. 2022 [cited 2023 Feb 28]. Globe and Mail. Available from: https://www.theglobeandmail.com/canada/article-winter-closing-of-toronto-shelter-hotel-will-be-a-big-change-for/.
City of Toronto. Temporary Shelter Transition & Relocation Plan. 2022 [cited 2023 Feb 28]. Available from: https://www.toronto.ca/community-people/community-partners/emergency-shelter-operators/about-torontos-shelter-system/new-shelter-locations/temporary-covid-19-shelter-sites/shelter-transition-relocation-plan/.
City of Toronto. City of Toronto’s 2022/23 Winter Services Plan for people experiencing homelessness. 2022 [cited 2023 Feb 28]. Available from: https://www.toronto.ca/news/city-of-torontos-2022-23-winter-services-plan-for-people-experiencing-homelessness/.
City of Toronto. 2023 Operating Budget & 2023–2032 Capital Budget & Plan: Shelter, Support and Housing Administration. 2023 [cited 2023 Feb 28]. Available from: https://www.toronto.ca/legdocs/mmis/2023/bu/bgrd/backgroundfile-230766.pdf.
ICES Ontario. www.ices.on.ca/About-ICES.
Richard L, Hwang SW, Forchuk C, et al. Validation study of health administrative data algorithms to identify individuals experiencing homelessness and estimate population prevalence of homelessness in Ontario, Canada. BMJ Open. 2019;9(10):e030221. https://doi.org/10.1136/bmjopen-2019-030221 .
[DOI: 10.1136/bmjopen-2019-030221]
Canadian Institute for Health Information. COVID-19’s impact on emergency departments [story]. 2021 [cited 2023 Feb 28]. Available online: https://www.cihi.ca/en/covid-19-resources/impact-of-covid-19-on-canadas-health-care-systems/emergency-departments.
SAS Institute Inc., SAS Enterprise Guide, v7.1. Cary, NC
Toronto Weather Statistics Dashboard. Toronto Historical Number of Days with a Temperature < 0°C. [cited 2023 May 3]. Available from: https://toronto.weatherstats.ca/metrics/count_temp_0.html.
Lavoie, J. Toronto’s homeless community shares stories of struggles experienced during COVID-19 pandemic. CTV News Toronto. 2022 [cited 2023 Feb 28]. Available online: https://toronto.ctvnews.ca/toronto-s-homeless-community-shares-stories-of-struggles-experienced-during-covid-19-pandemic-1.6147721.
Gibson, V. On the front lines of the homelessness crisis, a downtown ER tries a novel new approach. Toronto Star. 2023 [cited 2023 Mar 21]. Available online: https://www.thestar.com/news/gta/2023/01/30/on-the-front-lines-of-the-homelessness-crisis-a-downtown-er-tries-a-novel-new-approach.html.
Rider D, Hasham A. Open warming centres 24–7, Toronto board of health urges. Toronto Star. 2023 [cited 2023 Feb 28]. Available online: https://www.thestar.com/news/city_hall/2023/01/16/open-warming-centres-24-7-toronto-board-of-health-urges-calling-lack-of-cold-weather-services-a-crisis.html?rf.
Reilly J, Ho I, Williamson A. A systematic review of the effect of stigma on the health of people experiencing homelessness. Health Soc Care Community. 2022;30(6):2128–41. https://doi.org/10.1111/hsc.13884 .
[DOI: 10.1111/hsc.13884]
