Hospital-based Violence Intervention Programs Research Articles

States should use Medicaid to support violence intervention efforts.

In recent years, calls to address gun violence through public health approaches have increased. However, securing funding for health-based community violence intervention models has remained a challenge. New actions suggest that this may be shifting. Upon taking office, the Biden administration announced a series of funding opportunities for these programs, which ranged from competitive grant programs to a proposed 8-year, $5 billion plan. Less publicized, but just as important, is the administration's announcement that Medicaid can be used to reimburse this work, specifically noting the eligibility of hospital-based violence intervention and prevention programs. For these programs, this creates a predictable and reliable funding source that has not existed to date. This integration of violence prevention programming in the traditional health care and financing systems represents a critical inflection point in the United States' shifting response to community violence. However, the decision to use this optional benefit lies with each state. States should strongly consider harnessing Medicaid as a wise investment to address the United States' gun violence epidemic. Economic and value-based evaluation, level IV.

Shook Ones: Understanding the Intersection of Nonfatal Violent Firearm Injury, Incarceration, and Traumatic Stress Among Young Black Men

Violent injury is a leading cause of death and disability among young Black men, with the highest rates occurring in low-income urban populations. Hospital-based violence intervention programs (HVIPs) offer a promising opportunity to address the biopsychosocial factors that adversely affect this population. However, there are major gaps between the needs of young Black male survivors of violent injury and the forms of care provided by HVIPs. Patient-centered outcomes research provides a useful mode of inquiry to develop strategies to decrease these differences. Care for survivors, including treatment for traumatic stress disorders, must be reconceptualized to center the lived experiences of young Black men. This paper qualitatively explores how these survivors of gun violence express symptoms of traumatic stress and the ways in which their narratives can inform the implementation of the biopsychosocial model in HVIPs. A phenomenological variant ecological systems theory framework was used to analyze participant narratives to aid in understanding their symptoms of traumatic stress and post-injury affective changes as both psychologically and socially important experiences. Such insight may inform changes to HVIP practice to address persistent health disparities related to violence.

Integration of Civil Legal Services into Hospital-Based Violence Intervention Programs

Integration of Civil Legal Services into Hospital-Based Violence Intervention Programs

143EMF Acute and Recurrent Firearm Injury Rates Among Patients Presenting to St. Louis Level I Trauma Hospitals from 2010-2019

Firearm violence is the leading causes of homicide in the United States, and is the third leading cause of death for adults aged 15-34. Longitudinal, linked data on firearm injuries is needed to permit more nuanced research and interventions for survivors of a firearm injury. State-wide trauma registries do not reliably capture patients who are discharged directly from the ED without a trauma service evaluation. The St. Louis Hospital-based Violence Intervention Program Data Repository (STL-HVIP-DR) launched in 2018.

Assessing improvements in emergency department referrals to a hospital-based violence intervention program

BackgroundYouth violence is a major public health concern in the United States. Hospital-based Violence Intervention Programs (HVIPs) are integral in connecting youth sustaining interpersonal violence-related injuries to medical, mental health, and social services. At our pediatric emergency department, our baseline referral rate to the established HVIP was 32.5%. From November 2018–2019, we aimed to increase the percent of eligible patients referred to our HVIP from 32.5 to 70% for patients aged 7–18 years who present to our Level 1 emergency department/trauma center with a violent injury.MethodsFor this quality improvement project, we recorded key aspects of the referral process, such as patient eligibility, who placed referrals, and when referrals were placed in relation to the ED admission. Key stakeholders were interviewed to identify specific interventions. Our key interventions were: 1. Educating providers on eligibility requirements. 2. Encouraging nurses to enter consults at the time of admission. 3. Publishing information about program referrals in the weekly nursing newsletter. 4. Updating social workers on eligibility requirements for the HVIP. We used PDSA cycles to inform our project. Our primary outcome measure was the number of eligible patients referred to our HVIP and measures were analyzed using statistical process control charts.ResultsThe HVIP-eligible population had the following demographics: 31.1% female and a mean age 14.3 ± 2.7, 82.6% assaults and 17.4% gunshot wounds. From 11/2018 to 11/2019, there were 78 referrals to the HVIP, out of 167 eligible patients. The referral rate improved from 32.5% pre-interventions to 61.1% post-interventions, showing an 88% increase.Conclusion(s)We noted an increase in referrals to our HVIP following our interventions that centered on educating, advertising, and encouraging. Future studies will focus on analyzing other aspects of the enrollment process, such as obtaining patient consent.

Trauma-Informed Acute Care of Patients With Violence-Related Injury.

Violently-injured individuals presenting to the emergency department (ED) have an elevated risk of repeat injury after being discharged from acute care settings and a high rate of unaddressed mental health and social needs. While there is a growing body of programmatic interventions to address these needs, including hospital-based violence intervention programs, there is a lack of data regarding physician perspectives of current practice for this patient population. Understanding current practice is critical for integrating new programs into workflow and developing evidence-based medical education to improve care. The aim of this study is to elucidate current trauma-informed care practices of emergency medicine and general surgery trainee physicians to inform future curriculum development surrounding care of violently injured patients. In this study, emergency medicine and surgical trainees with at least one year of residency experience participated in simulation-primed interviews in pairs or small groups. Interviews garnered perspectives on the physician role in treating violently injured youth, using simulation as a priming event focused on previously known patient concerns. Qualitative themes that emerged were participants (1) perceived their role as managing medical/surgical concerns and seek others to build trust and manage psychosocial and legal concerns, (2) had a high level of knowledge of ED stressors and de-escalation strategies, (3) perceived that patient distrust can negatively impact their ability to provide care, and (4) perceived that law enforcement can negatively impact care and are sometimes uncertain about how to interact with law enforcement. These findings support that medical education for providers should focus on medicolegal issues, particularly managing law enforcement presence in the ED, structural and interpersonal causes of distrust of medical providers and the medical system, and addressing postdischarge mental health and social needs.

Understanding the makeup of a growing field: A committee on trauma survey of the national network of hospital-based violence intervention programs

BackgroundAmong Hospital Based Violence Intervention programs (HVIPs), little is known about variation in services provided, funding sources, or populations served. Study designTwenty-eight member programs of Health Alliance for Violence Intervention participated in a survey administered by the American College of Surgeons Committee on Trauma. Questions were quantitative and qualitative. For qualitative analysis, questions pertaining to the domains were assessed for common themes and assessed across all subject domains. ResultsAll programs enroll patients injured by community violence, some by intimate partner violence (IPV), trafficking, and rarely by child or elder abuse. Programs with more funding (≥$300,000 per year) were more likely federally, state, or city funded. Lower funded programs (≤$300,000 per year) were funded by foundations or philanthropy. In both qualitative and quantitative analysis, barriers to starting or sustaining HVIPs included funding, and lack of risk reduction and mental health resources. Successful programs had stable funding, adequate staffing, and buy in from hospitals and staff. ConclusionHVIPs serve diverse populations in variable models. There is opportunity to expand the reach of HVIPs, and the experience if existing programs is an invaluable resource.

Mechanism of penetrating injury mediates the risk of long-term adverse outcomes for survivors of violent trauma.

While hospital-based violence intervention programs are primarily designed to aid youth victims of gun violence at high risk for reinjury, the root causes and complex outcomes of community violence are varied. In this study, we examined the risk factors for violent penetrating injury and how the risk of adverse outcomes for survivors differs by injury type (stabbing vs. gunshot wound). This retrospective study was performed using a cohort of patients presenting to the Boston Medical Center emergency department for a penetrating injury due to community violence between 2006 and 2016. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the risk of all-cause mortality and violent reinjury within 3 years after surviving a penetrating injury. Of the 4,280 survivors of the initial violent penetrating injury, there were 88 deaths (2.1%) and 568 violent reinjuries (13.3%) within 3 years. Compared with gunshot wound victims, stab wound victims were 31% less likely to be reinjured with a gunshot wound (HR, 0.69; 95% CI, 0.51-0.93), 72% more likely to be reinjured with a stab wound (HR, 1.72; 95% CI, 1.21-2.43), and 49% more likely to be reinjured by assault (HR, 1.49; 95% CI, 1.14-1.94). While survivors of stabbing and firearm injuries were equally at risk for 3-year all-cause mortality, stab wound victims were 3.75 times more likely to die by a drug/alcohol overdose (HR, 3.75; 95% CI, 1.11-20.65). Patients surviving a stab wound have a significantly higher risk of violent reinjury by stabbing or assault, and risk of death by drug/alcohol overdose. Hospital-based violence intervention programs with similar patient populations should explore options to expand partnerships with drug treatment programs. These results illustrate two distinct populations of victims of violence-gunshot victims and stabbing/assault victims-with separate risk factors and outcomes, mediated by substance use disorder. Prognostic and Epidemiologic; level III.

A Prospective US National Trauma Center Study of Firearm Injury Survivors Weapon Carriage and Posttraumatic Stress Disorder Symptoms.

To describe the demographic, injury-related, and mental health characteristics of firearm injury patients and trace firearm weapon carriage and PTSD symptoms over the year after injury. Based on the increasing incidence of firearm injury and need for novel injury prevention strategies, hospital-based violence intervention programs are being implemented in US trauma centers. There is limited data on the long-term outcomes and risk behaviors of firearm injury survivors to guide this work. We conducted a secondary analysis of a pragmatic 25-trauma center randomized trial (N = 635). Baseline characteristics of firearm-injured patients (N = 128) were compared with other trauma patients. Mixed model regression was used to identify risk factors for postinjury firearm weapon carriage and PTSD symptoms. Firearm injury patients were younger and more likely to be black, male and of lower socioeconomic status, and more likely to carry a firearm in the year before injury. Relative to preinjury, there was a significant drop in firearm weapon carriage at 3- and 6-months postinjury, followed by a return to preinjury levels at 12-months. Firearm injury was significantly and independently associated with an increased risk of postinjury firearm weapon carriage [relative risk = 2.08, 95% confidence interval (1.34, 3.22), P < 0.01] and higher PTSD symptom levels [Beta = 3.82, 95% confidence interval (1.29, 6.35), P < 0.01]. Firearm injury survivors are at risk for firearm carriage and high PTSD symptom levels postinjury. The significant decrease in the high-risk behavior of firearm weapon carriage at 3-6 months postinjury suggests that there is an important postinjury "teachable moment" that should be targeted with preventive interventions. ClinicalTrials.gov NCT02655354.

Evaluation of Injury Recidivism Using the Electronic Medical Record

BackgroundTraumatic injuries remain one of the leading causes of death in the United States. Patients who survive traumatic injuries but return to the emergency department with repeat injuries are said to suffer from injury recidivism. Numerous studies have described trends in injury recidivism using trauma registry and survey data. To our knowledge, no prior study has leveraged electronic medical record (EMR) data to characterize injury recidivism. The EMR is potentially more comprehensive as it contains details of patients who visited the emergency department after injury but did not meet the criteria for inclusion in the trauma registry. Such injuries could be predictive of future recidivism. We therefore aimed to describe patterns of injury recidivism seen at a Level 1 trauma center using the EMR. MethodsA retrospective review was conducted of all injury-related encounters between January 2016 and December 2019. Manual review was conducted of all recidivistic encounters with < 11 months between encounters to ensure the recidivistic encounter was not a sequela of the index visit. A general estimating equation logistic regression adjusted for age, race, sex, and insurance payor, estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between injury mechanism and odds of recidivistic encounter. ResultsA total of 20,566 index encounters was included during the study period. Of the 20,566 encounters, 7.6% (n = 1570) had a recidivistic encounter during the study period, half of which (n = 781) occurred within the first year of the index encounter. An over two-fold increased odds of recidivism was observed for blunt assault encounters (OR 2.53, 95% CI 2.03-3.15) and unintentional falls (OR 2.10, 95% CI 1.76-2.52). For both mechanisms, this increase was observed across the three years following the index encounter. ConclusionsOur study found that patients with assault injuries have the highest odds of injury recidivism and assault-related recidivistic encounters. These results demonstrate the feasibility and utility of incorporating EMR data, and suggest that the development of targeted interventions focused on mitigating assault injuries, such as hospital-based violence intervention programs, should be considered in our region.

Not All Survivors Are the Same: Qualitative Assessment of Prior Violence, Risks, Recovery and Perceptions of Firearms and Violence Among Victims of Firearm Injury

Qualitative exploration into the risk, experiences, and outcomes of victims of firearm injury is imperative to informing not only further research, but prevention and intervention strategies. The purpose of this study was to explore prior violent exposures, risks, recovery, supportive services, outcomes, and views of firearms and violence among survivors of firearm assaults and unintentional injuries. Adults treated at a level 1 trauma center in Seattle, WA, for assault and unintentional firearm injuries were interviewed utilizing a semistructured instrument. Interview responses were coded to identify common themes and representative quotes are reported. Sixteen participants were interviewed. Notable themes included the following: (a) prior violent exposures were experienced by half of survivors, mostly through community violence; (b) risk for firearm injury was felt to be related to general societal violence, unsafe communities, and firearm practices; (c) important aspects of recovery included family/social support, mental health care and financial support services; (d) notable outcomes included psychological problems such as PTSD and anxiety, changes in relationships, and developing a new sense of purpose or mission in life; (e) generally negative views toward firearms, supporting restricted access and firearm safety practices; (f) acknowledgement of the complexity of firearm violence in society with prevention geared toward equitable education, economic opportunities and safety net programs to reduce community violence; and (g) disappointment in the criminal justice system. These findings demonstrate the varied experiences, needs, and outcomes after injury, but highlight the significance of community and societal violence, and need for improved mental health services. Integration of mental health services and victim assistance programs into trauma centers and hospital-based violence intervention programs is imperative for all survivors. Encouraging survivors to engage in new aspirations after injury can be empowering, and there is an unmet need for victim support and advocacy within the criminal justice system.

A Novel Pediatric Hospital-Based Violence Intervention Program – Lessons Learned From the First Year

A Novel Pediatric Hospital-Based Violence Intervention Program – Lessons Learned From the First Year

Pediatric Emergency Department Referrals to a Hospital-Based Violence Intervention Program

Pediatric Emergency Department Referrals to a Hospital-Based Violence Intervention Program

Boston Violence Intervention Advocacy Program: Challenges and Opportunities for Client Engagement and Goal Achievement.

A better understanding of the factors affecting client engagement in hospital-based violence intervention programs (HVIPs), and which types of client needs prove most challenging to achieve, may be of key importance in developing novel, targeted strategies to violence intervention. In this study, we examined the demographics and injury characteristics of violently injured patients by their level of engagement with the Boston Violence Intervention Advocacy Program (VIAP) and determined the degree of client goal achievement through VIAP client services. This retrospective study was performed using a cohort of patients presenting to the Boston Medical Center emergency department for a violent penetrating injury due to community violence between 2013 and 2018. Data on client demographics, injury characteristics, and client needs were collected from the VIAP data repository. Cox proportional hazard regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals to assess the difference in hazards of client goal achievement by need type. Of the 2,243 victims of violent injury, 839 (37.4%) patients engaged with VIAP. Significant predictors of client engagement include younger age, Black race, permanent home, existing mental health diagnosis, gunshot wound, and more severe injuries. Conversely, older age, homelessness, substance use, stab wound, and less severe injuries predicted refusal of VIAP services. For clients who chose to engage with VIAP, needs related to education (HR=0.47, 95% CI= 0.38 to 0.58), employment (HR=0.66, 95% CI= 0.57 to 0.77), and housing (HR=0.76, 95% CI= 0.68 to 0.86) were significantly less likely to be achieved compared to basic needs. This study demonstrates that VIAP is effectively engaging the client population that HVIPs have been designed to support. HVIPs should consider novel strategies to engage vulnerable populations not typically targeted by intervention programs. These results speak to the difficulties of program attrition and the complexities of altering the life course for victims of violence.

Positioning public health surveillance for observational studies and clinical trials: The St. Louis region-wide hospital-based violence intervention program data repository

IntroductionFirearm injuries are a public health epidemic in the United States, yet a comprehensive national database for patients with firearm injuries does not exist. Here we describe the methods for a study to develop and query a new regional database of all patients who present to a St. Louis level I trauma hospital with a violent injury, the St. Louis Hospital-Based Violence Intervention Program Data Repository (STL-HVIP-DR). We hypothesize that the STL-HVIP-DR will facilitate identification of patients at risk for violent injury and serve as a comparison population for participants enrolled in clinical trials. MethodsThe STL-HVIP-DR includes all visits made for violent injury to four level I trauma hospitals in St. Louis, Missouri between January 1, 2010 and December 31, 2019. Two health systems representing the four participating hospitals executed a data sharing agreement to aggregate clinical data on firearm injuries, stabbings, and blunt assaults. Dataset variables include demographic hospital and timestamp, medical, and insurance information. ResultsA preliminary cross-sectional query of the STL-HVIP-DR reveals 121,955 patient visits among the four partner level I trauma hospitals for a violent injury between 2010 and 2019. This includes over 18,000 patient visits for firearm injury. DiscussionThe STL-HVIP-DR repository fills a critical gap regarding identification and outcomes among individuals who are violently injured, especially those with non-lethal firearm injuries. It is our hope that the methods presented in this paper will serve as a primer to develop repositories to help target violence prevention services in other regions.

Compassion Satisfaction and Compassion Fatigue among Violence Intervention Caseworkers

Violence intervention programs aim to help clients overcome trauma, but, due to the demands of their profession, caseworkers are at risk for experiencing low compassion satisfaction and high compassion fatigue. This cross-sectional study sought to describe the prevalence of compassion satisfaction and compassion fatigue (burnout and secondary traumatic stress [STS]) among 93 caseworkers. Participants completed the Professional Quality of Life Survey at a conference for a national network of hospital-based violence intervention programs in September 2018. Results displayed high compassion satisfaction across demographic groups, while participants significantly differed in compassion fatigue by years of experience and workplace setting. Caseworkers who had been working in their profession for 6–10 years experienced higher levels of burnout than those working fewer years (p = 0.02). Further, caseworkers employed in a single program setting experienced significantly lower levels of STS than those who work in both a community and hospital setting (p = 0.01). This analysis stands in contrast to previous studies showing higher levels of compassion fatigue in younger, and less experienced healthcare workers. Further studies are warranted to determine how the prevalence of compassion fatigue in victim advocates compares to those of other healthcare providers and which interventions can best promote compassion satisfaction.

Shook Ones: Understanding the Intersection of Nonfatal Violent Firearm Injury, Incarceration, and Traumatic Stress Among Young Black Men.

Violent injury is a leading cause of death and disability among young Black men, with the highest rates occurring in low-income urban populations. Hospital-based violence intervention programs (HVIPs) offer a promising opportunity to address the biopsychosocial factors that adversely affect this population. However, there are major gaps between the needs of young Black male survivors of violent injury and the forms of care provided by HVIPs. Patient-centered outcomes research provides a useful mode of inquiry to develop strategies to decrease these differences. Care for survivors, including treatment for traumatic stress disorders, must be reconceptualized to center the lived experiences of young Black men. This paper qualitatively explores how these survivors of gun violence express symptoms of traumatic stress and the ways in which their narratives can inform the implementation of the biopsychosocial model in HVIPs. A phenomenological variant ecological systems theory framework was used to analyze participant narratives to aid in understanding their symptoms of traumatic stress and post-injury affective changes as both psychologically and socially important experiences. Such insight may inform changes to HVIP practice to address persistent health disparities related to violence.

A Case for Risk Stratification in Survivors of Firearm and Interpersonal Violence in the Urban Environment.

The emergency department (ED) serves as the main source of care for patients who are victims of interpersonal violence. As a result, emergency physicians across the nation are at the forefront of delivering care and determining dispositions for many at-risk patients in a dynamic healthcare environment. In the majority of cases, survivors of interpersonal violence are treated and discharged based on the physical implications of the injury without consideration for risk of reinjury and the structural drivers that may be at play. Some exceptions may exist at institutions with hospital-based violence intervention programs (HVIPs). At these institutions, disposition decisions often include consideration of a patient’s risk for repeat exposure to violence. Ideally, HVIP services would be available to all survivors of interpersonal violence, but a variety of current constraints limit availability. Here we offer a scoping review of HVIPs and our perspective on how risk-stratification could help emergency physicians determine which patients will benefit most from HVIP services and potentially reduce re-injury secondary to interpersonal violence.

Staying Out of the Way: Perceptions of Digital Non-Emergency Medical Transportation Services, Barriers, and Access to Care Among Young Black Male Survivors of Firearm Violence.

With a reduction in primary barriers to healthcare access as a result of the Affordable Care Act, there is an increased need to address secondary barriers faced by low-income young Black male survivors of violent injury. While transportation is often characterized as a barrier for individuals with chronic disease and disability, it also acts as a significant barrier in accessing cognitive behavioral therapy and mentoring services through hospital-based violence intervention programs (HVIPs). These services address the traumatic stress associated with surviving gun violence. Although there are many challenges associated with the current practices of non-emergency medical transportation, participants in HVIPs face additional risk factors. We highlight the application of a digital transportation intervention to increase the use of psychosocial services among low-income young Black male survivors of violent injury participating in an HVIP. Digital non-emergency medical transportation services (DNEMT) address issues concerning financial barriers, personal safety, program credibility, and program participation. We conducted qualitative interviews and a focus group with this population to assess the impact of Uber Health, a DNEMT service, on their participation in an HVIP located in a suburban Maryland hospital immediately outside of Washington, D.C. Survivors identified the use of Uber Health as essential to addressing the multifaceted and interconnected barriers to treatment. These barriers included reluctance to use alternative forms of transportation services (i.e., bus or subway) due to potential encounters with rivals, increased risk of repeat violent victimization, the need to carry a weapon for protection, stigmatization, and symptoms associated with traumatic stress. We found that integrating digital transportation services into the standard practices of HVIPs, as a part of a patient-centered outcomes framework, contributes to a reduction in violent injury and re-traumatization by addressing the multi-layered risks experienced by survivors of gun violence.

Characteristics of Violently Injured Patients Who Decline Services of a Hospital-Based Violence Intervention Program

Presser, Maxwell J. BA; Nwabuo, Adaobi MBBS, MPH; Decker, Hannah MD; Texada, Michael Social Work Associate; Jackson, Vanessa Social Work Associate; Henderson, Terrell Social Work Associate; Orellana, Julia Social Work Associate; Marquez, Ruben Social Work Associate; Dicker, Rochelle A. MD, FACS; Plevin, Rebecca E. MD Author Information