The Potential Impact of Hospital Violence Intervention Programs

Community violence disproportionately affects Black and Hispanic communities, and higher rates of poverty are associated with higher violent trauma mortality.1 From 2018 to 2021, children were disproportionately affected by the post-COVID-19 increase in community violence, with a 41.6% increase in the pediatrics firearm death rate resulting in firearm related injury becoming the leading cause of childhood mortality in the United States.1–3 The majority of pediatric firearm deaths (82.6%) during this period occurred in patients 15–19 years old, with an increase also observed in patients younger than 12 years old.1,2 At NYC Health + Hospitals/Jacobi, a pediatric and adult trauma center in the Bronx, our pediatric violent trauma trends mirrored national trends and were met by the efforts of our Hospital Violence Intervention Program (HVIP) called Stand Up to Violence (SUV). The SUV program encompasses a joint hospital and community effort at violence intervention/prevention and incorporates a network of community outreach and hospital-based teams to engage high-risk violent trauma patients and community participants. The SUV program sits within the department of social work and uses a multidisciplinary approach of social workers, community outreach workers, hospital responders, and physicians. All components of the SUV program work collaboratively to connect high-risk patients and community participants to conflict mediation strategies, mentorship, job-training/education services, housing relocation, mental health services, and other supportive resources. The SUV team also incorporates unifying community events to decrease community violence such as basketball tournaments, block parties, and marches.One such event was the SUV annual peace walk in June of last year, which was born out of the idea that people from different neighborhoods can safely march up a community corridor commonly plagued by violence. On that early summer afternoon, a collection of community members, SUV staff, hospital staff, and political/religious leaders gathered on a street corner in the northeastern part of the Bronx and began to march in synchrony chanting, “We walk for peace! In our streets!” The chants were accompanied by the rhythm of a djembe drum intermixed with the sound of the number 2 train treading on the train tracks above White Plains Road. The collection of individuals from different cultural, religious, and professional backgrounds all walked in unison promoting a summer of peace in a community otherwise devastated by violence. The summer months are typically associated with an increased incidence of violent trauma in many neighborhoods similar to those in the Bronx. But for that brief less than 2-hour peace walk, there was a disruption to the constant washing ashore of violent trauma patients to our hospital’s trauma bays. Perhaps, the most memorable image of SUV’s peace walk was the emergence of people from store fronts and building stoops as we marched by. The witnessed appreciative fist bumps, joyful chants, and exchanged handshakes, served as symbol of hope in a community subject to chronic community violence exposure.A couple of days after the peace walk, a 14-year-old male arrived with a gunshot wound to the head in cardiac arrest to our trauma bay. According the New York Police Department officer accompanying the patient, the alleged assailant was a 13-year-old male. The alleged assailant presented the following day to our same pediatrics emergency department under police custody, to be evaluated for reported pain to his right arm. The characteristic painful scream by the parents notified the day prior of their 14-year-old son’s death in the trauma bay was replaced by the silent scream on the desolate 13-year-old face of the accused that I saw the following day in the same emergency department. Both instances displayed a pain that was not capable of being understood, let alone described. There are always at least 2 victims when community violence incidents like these occur. It serves as a tragic representation of a societal failure to the 2 impacted children, their families, and their respective communities. The deleterious effects of pediatric violent trauma extend far beyond individual victimization, with community violence exposure now categorized as a distinct adverse childhood experience that may contribute to poor psychologic and neurocognitive outcomes later on in life.4 Adverse childhood experiences, along with lifetime income lost and lifetime quality-adjusted life years lost, contribute to the overall estimated lifetime financial cost of violent trauma of $614 billion.5Despite what we as physicians tell the victim’s families, there is always more that we can do to minimize the societal and economic cost of violent trauma. The circumstances and environment that resulted in a 13-year-old feeling that his only option was to take the life of a 14-year-old should lead us all to reflect. Simply because we have well documented the clear association of higher levels of poverty and of being a Black or Hispanic male with violent trauma mortality does not mean that we should accept it as an unavoidable reality that is not amenable to other documented effective forms of injury prevention.1 Risk factor identification should result in directed efforts to address modifiable variables to improve outcomes in vulnerable populations. Perhaps the multifactorial factors that resulted in the act of 1 child taking the life of another, are too daunting to consider, let alone begin to address. But the complexity of issues influencing patient outcomes with challenging diseases has never before deterred the medical and public health community from implementing and evaluating innovative interventions.Events such as the peace walk and HVIPs such as SUV are not going to unilaterally solve the problem of community violence that resulted in 1 child taking the life of another by violent means.But HVIPs such as SUV can be part of the solution in communities disproportionately affected by the violent trauma epidemic in this country. The Centers for Disease Control and Prevention recommends a systematic multilevel approach to violence intervention/prevention by communities and hospitals.6 The Centers for Disease Control and Prevention encourages advocacy for policies to enhance economic and household stability, improvement of physical and social characteristics of communities, and efforts to protect those at highest risk through street outreach programs and HVIPs.6 We should work collectively to eliminate preventable causes of childhood injury mortality. Hospital systems are uniquely positioned to intervene at the patient and community level through HVIP implementation to curtail the immediate and downstream effects of community violence. HVIP sites vary in their approach and resource allocation, but all share the common goal to treat and heal violent trauma patients and their communities. Most HVIPs use a multidisciplinary approach of physicians, social workers, other mental health providers, and community outreach workers. The growing interest in HVIP implementation has resulted in the formation of the Health Alliance for Violence Intervention, which works to promote best practices to medical providers seeking to optimize violent trauma patient outcomes.8 Outcome data for HVIPs are limited, but there is evidence to suggest that HVIPs can decrease rates of recidivism and reinjury and improve violent trauma patient morbidity/mortality.7Recently, Governor Hochul of New York followed the lead of other states and signed a bill allowing Medicaid reimbursement for HVIP services.9 This is a critical step in the potential implementation of sustainable hospital-based violence intervention services to optimize outcomes in both individual patients and communities. The recent trend in Medicaid reimbursement approved by states for HVIPs, along with the American College of Surgeons recommendations to include injury prevention as a requirement for American College of Surgeons pediatric trauma certification, provides a unique opportunity to better establish HVIP networks in other states that are evidence based and potentially self-sustaining.10A collective call to action and multidisciplinary evidence-based approach is needed to present a united front in the effort to decrease and eliminate the socioemotional, financial, and human cost to communities disproportionately affected by violent trauma. The SUV HVIP has now been implemented for 10 years in the Bronx and is beginning to see its positive impact on both community and individual violent trauma patient outcomes. There is a plan by the SUV programs’ primary funder, the New York State Department of Criminal Justice Services, to expand hospital-based violence intervention programming to other state trauma centers following the success of the SUV program in the Bronx. The hope is that the slow walk toward formidable change and sustainable peace will continue to march forward. The fact remains that children in our country are disproportionately dying from the preventable cause of firearm-related injury. In addition to securing sustainable sources for HVIP funding, evidence-based approaches to HVIPs need to be implemented and evaluated to establish replicable best practices that hold allocated funding accountable in other hospital systems. Perhaps, with enough collective investment, children in neighborhoods throughout the country will find choosing to go for a peaceful walk with others a more viable alternative to violent means of conflict resolution.