The emergency department (ED) can play a crucial role in curbing violence, thereby reducing deaths and serious injuries, Christopher Colwell, MD, of the Department of Emergency Medicine, San Francisco General Hospital (SFGH) and Trauma Center, University of California, San Francisco (UCSF) School of Medicine, said in a presentation at the American College of Emergency Physicians (ACEP) 2021 Scientific Assembly.
“As emergency physicians, we have seen the benefits of early intervention in other conditions and how it can impact future health — we’ve done it with hypertension and vascular disease, and I would argue that we have set the standard for identifying nonaccidental trauma, child abuse, and domestic violence,” Colwell said.
These interventions recognize “that it’s not just what we’re doing in the ED to treat the injured patient in front of us but that we can intervene to prevent future issues in a meaningful way,” so “creating and implementing HVIPs [hospital-based violence intervention programs] [is] “absolutely in our lane,” Colwell said.
“Recurrent Disease”
Colwell cited statistics showing an alarming recent increase in violent crime, including an increase of nearly 30% in homicides since 2019.
Violence — especially firearm homicides — “disproportionately affect people of color.” Firearm homicides are the number one cause of death among young Black Americans (aged of 15–34 years) and is the number two cause of death among male Latinx of the same age, he said.
Victims of violence are more likely to sustain repeat firearm injury and die from firearm injuries, Colwell stated. He called violent injury a “recurrent disease” in which the mortality rate is higher with the second injury compared to the first.
“We talk about prevention issues about diabetes and hypertension, domestic violence, and child abuse, but this is one that I would argue is every bit as much of a problem and may even have a greater impact than hypertension and diabetes in terms of intervention, because we’re talking about young, healthy people of color who — if prevented from experiencing violence — will go on to have extraordinarily long, productive lives rather than experiencing violence and dying before they have even reached the prime of their lives,” Colwell told Medscape Medical News.
Seize the Teachable Moment
Colwell advised ED clinicians to recognize “that the injury in front of you represents a challenge for you right now, and you obviously have to treat that injury, but that’s not the greatest challenge. It’s the next injury that’s coming that we need to prevent so as to break the cycle — similar to domestic violence and pediatric abuse.”
He characterized violence as a public health issue. He noted that a public health approach is a “cornerstone” of an HVIP and involves “mitigating modifiable root causes,” which exist on multiple levels — individual, interpersonal, organizational, community, and policy — and being cognizant of social determinants of health.
“Victims who arrive at your hospital are coming from your communities, and so you need to reach out to culturally competent violence intervention specialists from those communities that really understand what they’re going through and what their experiences are,” he said.
He said that another cornerstone is “seizing the teachable moment.” Every visit to the ED is an opportunity for intervention in which “we can implement long-term, culturally competent case management and provide links to risk reduction resources.”
He likened the approach to identifying a patient with hypertension. “We implement a bedside assessment and refer the patient to appropriate resources, such as a primary care physician, for hypertension management,” he said.
Colwell explained that in the program at UCSF and SFGH, “after a patient receives initial care, one of our five culturally competent case managers meets the individual at the bedside during their initial hospitalization, taking advantage of the teachable moment.”
The case managers perform a risk assessment and offer persons at highest risk enrollment into the case management program. Enrolled clients spend 6 months to 1 year in the program. All individuals are provided with links to risk reduction sources.
Who Funds These Programs?
Funding comes from a variety of sources, including mayors and supervisors, departments of public health, foundations, and private donors.
Additionally, “the exciting new landscape that we’re looking at with Joe Biden’s $2.3 trillion infrastructure plan includes $5.3 billion that would be focused on community and evidence-based HVIPs — which is a big chunk of money that has never been available before, which could really help spearhead some of these programs,” he said.
Colwell noted that funders want to see data, and he cited several studies showing that HVIPs are evidence based.
Trauma-Informed Care
“Some victims can be perceived as difficult; they can be angry at us, not forthcoming with their history, and they can be — or appear to be — distracted, distant, and hard to relate to, and if we don’t understand this, our reactions further reinforce their trauma,” Colwell said. He emphasized the importance of providing trauma-informed care.
“We have to remember that if they are angry or lash out or are distrustful, it is not because they are difficult or bad people, but it’s part of the response to trauma,” he stated. He noted that the traumatic event is “far more than the injury in front of you.”
Trauma-informed care entails recognition “that there are psychological wounds and mental health issues that go well beyond the physical wounds in many of these cases, and they need to be addressed, recognized, and respected at the same time.”
This will pave the way of a “healthy recovery” because the patient will feel respected and will be more likely to listen to the next steps being recommended for them.
Working With Law Enforcement
The sense of safety that ED staff seek to create for victims can be compromised by the presence of law enforcement, which is often unavoidable when a patient has been the victim of gun violence.
Proactive discussions with law enforcement personnel can go a long way toward furthering trauma-informed care while “still allowing law enforcement to do their job,” Colwell said.
“After 25 years at urban-level trauma centers, I have never found law enforcement more open to engaging in these discussions than now, because they recognize that they need to be part of the solution, not part of the problem,” he said.
He recommended “sitting down and talking about processes that put the medical care of the patient first” while understanding and respecting “the needs of law enforcement.”
He noted that having the police leadership and the police union on board will increase the likelihood of a better response from law enforcement “in the heat of the moment” in the ED. Hospital and community leadership can be involved in building those relationships.
As an example, he said that in their program, the leadership reached out to the mayor, who was “excited about our program and wanted law enforcement involved in it.” Through the mayor, the police chief became involved.
Rolling Out the Program
Colwell advised determining peak hours and focusing staffing at those times, whenever possible. Staff should include violence prevention professionals — intervention specialists and advocates are credible and are ingrained in the community — as well as mental health support, housing advocates, and long-term case managers.
Other departments of the hospital in addition to the ED should be involved, he suggested, including surgery and mental health. Professional training should be provided for staff, and former patients should be brought back to recount their experiences, because their “stories have power.”
For creating an HVIP, he recommended a step-by-step primer that was developed by the American College of Surgeons.
Additional resources include the Health Alliance for Violence Intervention, the American Foundation for Firearm Injury Reduction in Medicine at the Aspen Institute, and the Social Emergency Medicine Section of the ACEP.
Colwell has disclosed no relevant financial relationships.
American College of Emergency Physicians (ACEP) 2021 Scientific Assembly: James D. Mills, Jr, Memorial Lecture. Presented October 27, 2021.
Batya Swift Yasgur MA, LSW, is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).
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