International and Domestic Health Equity and Leadership (IDHEAL) UCLA Emergency Medicine

VIOLENCE INTERVENTION
Module 14
Shamsher Samra, MD, MPhil

Objectives

1. Understand the scope of interpersonal violence and injury recidivism.

2. Understand how the acute care setting can be a unique setting to interrupt the downstream
impacts of violent injury and re-injury.

3. Discuss what resources can be made available in the acute care setting for victims of violence.

Case

MF is 23-year-old male presenting to the emergency department with a gun-shot wound to his left upper extremity. He has a past medical history significant for splenectomy in the setting of a previous gun-shot wound three years prior and a substance use disorder. He has a history of incarceration and has had a difficult time finding work since release from jail. While he is not affiliated with a gang, several of his friends and family members are. Today, his injury is determined to only involve superficial soft tissue. A plan is made to discharge him with supplies for wound care.

He tells you that he is scared to go home, because his neighborhood is not safe. The last time after he was shot, he had nightmares for a long time. You recently heard about a program at your institution aimed at preventing violence recidivism while providing support for the patient. Given the patient’s concerns, you contact the new hospital-based violence intervention advocate to see him before he is discharged. The advocate educates him about the Victims of Crime program and arranges to follow up with him in the community.

Discussion Questions

1. What can be done to break the cycle of violence?

2. What factors increase this patient's risk of recidivism?

3. What is a hospital-based violence intervention program?

4. What is the Victims of Crime program and what benefits does it provide?

Teaching Points

1. Every year over fifty thousand deaths and 2.2 million injuries requiring medical attention are attributable to acts of violence between two individuals. The average non-fatal violent injury costs $24,000 for medical care and $1.3 million in lost productivity. This financial burden disproportionately affects already underserved communities.

2. For surviving victims, violence has long lasting psychological impact and a negative impact on life trajectory. Estimates of PTSD in urban victims of violence approach 40%.

3. Sustaining a violent injury increases one’s risk for both committing violent acts and re- victimization. Exposure to firearm violence doubles a youth’s likelihood of committing a violent act within two years. Estimates on re-injury suggest that between 5 and 45% of victims of violence will experience re-injury in five years.

4. Hospital-based violence intervention programs (HBVIP) can mitigate the downstream impact of interpersonal violence.

Practical Questions

1. What services and support are offered to victims of trauma at your hospital?

2. Who are local community-based organizations that could be partners in assisting victims
of violence?

Recommended Screening Question(s)

The LA County SBDOH workgroup has not recommended screening questions to specifically identify those patients at risk for future violence after intentional injury, however, the paired reading below recommends the use of the Children’s Hospital of Philadelphia Screening tool which includes the questions:

• 1. Do you know the person who hurt you?
• 2. Do you think the conflict that caused this incident is over?
• 3. Do you plan to hurt anyone because of what happened today?
• 4. Do you think that any of your friends or family members will hurt anyone because of what
• happened today?
• 5. Have you reported the incident to the police or any authority?

Paired Reading

Cunningham R, Knox L, Fein J, et al. Before and after the trauma bay: the prevention of violent injury among youth. Ann Emerg Med 2009;53:490-500.

Discussion Points from the Reading

1. Effective hospital-based violence prevention programs are based on strategies such as social skills training, positive youth development, mentoring, parent and family training and home visitation. Effective programs work to build resilience and help youth to face environmental and social stressors.

2. Preventing future violent injury is possible through HBVIP programs. When treating a youth after violent injury, consider whether the patient is at risk for retaliatory violence and potential re-injury. If so, consider counseling the patient briefly and referring to a local HBVIP. Initial contact post-discharge is much more difficult than an initial brief introduction face to face in the Emergency Department.

Additional Readings

1. Medical Costs and Productivity Losses Due to Interpersonal and Self-Directed Violence in the United States. American Journal of Preventive Medicine Volume 32, Issue 6, June 2007, Pages 474-482.e2

2. Dicker, Rochelle. “V iolence intervention programs: A primer for developing a comprehensive program for trauma centers.” The Bulletin, American College of Surgeons, 4 Oct. 2017. Available at: bulletin.facs.org/2017/10/violence-intervention-programs-a- primer-for-developing-a-comprehensive-program-for-trauma-centers/#.WqSli-jwaM8.

3. James TL, Bibi S, Langlois BK, Dugan E, Mitchell PM. Boston Violence Intervention Advocacy Program: a qualitative study of client experiences and perceived effect. Acad Emerg Med 2014;21:742-51.