| | Addressing violence in the emergency departmentAbstract Violent injury remains a major cause of death and disability for children and youth in this country, even with the dramatic declines in violent injury rates experienced in recent years. Most youth and adolescents with or who are at risk for violence-related injuries present in emergency department (ED) settings, although some come to the attention of the police. Similarly, many women present to EDs with injuries related to domestic violence, and it is well described that children exposed to such situations suffer both short- and long-term consequences from these exposures. Given the significance of these issues with respect to the health and well-being of children, it is important for emergency care and primary care professionals to consider the roles they can play in the acute management, assessment for future risk, screening for risk, and follow-up services involved in the response to violent injury.
WILLIAM FIRST PRESENTED TO THE emergency department (ED) at age 13 with a boxer’s fracture to his right hand. He reported that he had been in a fight after school and that his hand hurt and had swollen over the afternoon. After a physical exam and radiograph, his hand was placed in a cast and he was referred to orthopedic clinic for follow-up. No further history, evaluation, or follow-up arrangements were made at that time.
Over the next two years, William had three more ED visits for various injuries, including one for multiple lacerations from knife wounds. As with his first visit, his injuries were treated and follow-up was arranged as needed for rechecks of his wounds or suture removal. None of his injuries required hospital admission, and no additional information was noted in the record except for the presence of alcohol on his breath at one visit. There was no acknowledgement or recognition of his pattern of recurrent injuries.
Almost three years to the day of his first presentation to the ER, William was brought in by ambulance with several gunshot wounds to his chest and abdomen. Efforts to resuscitate him were unsuccessful and he was pronounced dead shortly after his arrival.
Had efforts been made to more extensively evaluate the circumstances of William’s injuries during his previous visits, it might have been discovered that he had a long history of fighting, weapon carrying (initially knives and then guns), poor school performance, and an extremely unsettling home situation with domestic violence and alcohol abuse. All of these factors were present and reported by family members. Sadly, this is not an uncommon scenario for youth who present with violent injuries to the health care system.
Case 2  Kevin first presented to the emergency department at age 14 with multiple bruises and lacerations. As part of his evaluation, he was asked about the circumstances of his injuries. He reported that he got into a fight after school with a classmate as a result of an argument that had started earlier in the day. Further probing revealed that he had been in a number of fights over the past several years and had been suspended from school because of one such fight. He denied substance abuse and carrying weapons but, when asked, did say he was “not done with the kid who beat him up.” He was planning on getting back at him the next day at school. He denied any violence at home. As a result of this information, Kevin was referred to a social worker in the ED. The social worker followed up by gathering further information from the school and talking with Kevin’s mother (who did report a history of domestic violence—no longer an issue, she said, since her husband had moved out a year before). The social worker had an additional phone conversation with Kevin the following day in an effort to prevent further fighting on his part and attempted a referral to a local Boys Club that ran a program for teenagers with similar problems. Kevin did not follow through with this referral. Approximately three months later, Kevin presented again with a superficial knife wound. His previous ED visit was noted and additional evaluation revealed that his history of fighting was continuing and that he was now regularly carrying a knife. He had also been suspended from school again and had not returned. The social worker was once again consulted and this time worked out an arrangement with the Boys Club program that they would start home visits to Kevin. This more aggressive follow-up resulted in Kevin’s engagement in the program and his eventual linkage to the Big Brother Program. In addition, the staff of the Boys Club was able to work with his school to arrange for his enrollment in a multidisciplinary special education program run by the school system. In a two-year follow up, Kevin was regularly attending school, had experienced no further significant violent injuries (although he had been in one additional fight early on in this period), was linked with a mentor from the Big Brother Program, and was talking about plans to attend community college upon completion of high school. While this case illustrates a somewhat optimal situation with respect to the availability of services, such resources are not that uncommon and have proven rates of successful outcomes.1 What this case also illustrates is the other end of the spectrum from that of William with respect to the evaluation and treatment provided in the ED. The ED response to violence can make a difference. Background In spite of the recent decline in rates of violent death and injury in this country, the US continues to have one of the highest rates of youth homicide in the world. Homicide is the third leading cause of death for 10- to 14-year-olds and the second for 15- to 19-year-olds.2 Almost 40 children and adolescents are killed by violence each week in this country.3 Violent behavior peaks in mid-adolescence and a large majority (about 80%) of violent youth stop this behavior by their early 20s.4 Violence disproportionately affects African American female and male youth who experience 4 and 11 times the violent death rates of white youth respectively.5 Of greatest importance is that while violent death rates among youth have fallen, the presence of violence in the lives of teenagers has not. Surveys of teenagers report that between 13% and 15% of high school seniors committed an act of serious violence (1993-98), that such acts increased by over 50% in the past two decades, and that this rate has remained constant since l993 which was the peak year of the youth violence epidemic.6 While it is impossible to put a cost to the effects of youth violence given the huge emotional and social implications, there are some who have at least tried to quantify the costs with respect to the health care system. Approximately 3% of medical expenses in this country each year are related to interpersonal violence.7 Gun-related injuries alone may cost up to $4 billion a year in direct medical costs, with as much as another $19 billion annually in other costs such as lost earnings.8 With respect to domestic violence, more than $44 million is spent each year for related injuries in direct care cost alone9 and that is in the context of dramatic under-identification of domestic violence. There are a number of key risk factors that have been extensively discussed and studied with respect to violent behavior and violent crime. There is a significant relationship between alcohol use and violent behavior.10 A number of forms of violence in the family setting are major risk factors.2 Experiencing child abuse and neglect,11 witnessing violence especially in the form of battering,12, 13 and experiencing corporal punishment14 have all been associated with risk for violent behavior in adolescence and young adulthood. As a side note, there is considerable overlap in families between spousal battering and child maltreatment that may be as high as 60% to 75%, and more than 3 million children witness domestic violence each year in the US.15 Each of these findings has important implications for risk of violent behavior as well as ED clinical practice. Exposure to media violence, while still considered a controversial issue, has elicited great concern as a risk factor for violent behavior by many of the major medical professional associations in this country,16 and therefore should not be dismissed. Lastly, the issue of firearms cannot be ignored. The increase in youth homicide rates in this country from the mid-1980s through the late 1990s was entirely caused by increased firearm deaths.3 Were it not for the involvement of guns in episodes of violence, we would most likely be dealing with an epidemic of bloody noses and broken bones rather than deaths. Why the emergency department? It is not uncommon for many people to define the issue of violent injury as a problem for the criminal justice system. After all, have we not heavily funded and delegated the police and courts to deal with this issue? While the later statement is true, the former represents a serious misunderstanding of the situation. First, the criminal justice system is primarily organized to respond to and punish criminal behavior and violence with some limited attention to secondary prevention but little or no primary prevention of violence and violent injury. Second, four times more individuals with violent injuries present to the health care system (particularly to EDs) than to the police.17 In addition, every homicide in this country represents over 100 violent injuries seen in EDs in the US.17 Two percent of women (and this is likely a gross underestimate) who are seen in EDs are current victims of domestic violence.18 Most importantly, the recidivism rates and eventual mortality rates for individuals presenting to hospital EDs with violent injuries is extremely concerning and calls for serious action. Numerous studies have shown rates as high as 44% for individuals returning to EDs with violent injuries within 5 years of their initial presentation with a violent injury.19, 20, 21, 22, 23, 24, 25 As a comparison, individuals with violent trauma have significantly higher rates of recidivism than those with unintentional injury.26 Furthermore, children treated in an ED for a violence-related injury have a five-fold increased risk for repeat injury than those with unintentional injury.27 Of greatest concern is mortality. One study showed a 5-year mortality rate of 20% for individuals who had presented to an ED with a violent injury.20 Another study reported that 44% of fatal victims of domestic violence had an ED visit within the 2 year period before their death.25 EDs are clearly important settings for the identification, treatment, evaluation, and prevention of violent injuries. At least several reports from medical and related health care professional associations have acknowledged this fact.2, 28, 29, 30, 31 What can be done? Evaluation Traditionally, and in many settings this is still the case, violent injuries are treated with the “stitch ‘em up and send ‘em out” approach.32 As in the first case, injuries are evaluated and treated from a pure physical management perspective. Whether injured individuals are admitted to the inpatient service or treated in the ED and discharged, their injuries are repaired and any follow-up is specifically related to the physical injury itself. Little if any attention is paid to the circumstances of the injury or the risk for recurrence. The studies on incidence, recidivism, and mortality have changed this in at least some ED settings, illustrating the importance of considering a dramatic change in practice in broader terms, particularly with the growing understanding and experience with success in primary and secondary prevention.1 In this context, individuals presenting with violent injuries should be evaluated in ways that parallel what has been standard practice with respect to self-inflicted injuries (suicide attempts) for many years. No one would discharge an individual who has attempted suicide without a careful evaluation of his/her immediate risk for further injury and the longer term management needs. Individuals with violent injuries should be offered the same level of service. At the bare minimum, an evaluation should include the following:
1.A full assessment of the circumstances of the injury event including relationship to the assailant, presence of a weapon, cause of the event, involvement of alcohol and other abuse substances.
2.Possible intent to seek revenge.
3.Possibility of being re-injured by the assailant or others.
Further assessment by the physician, social worker or other ancillary staff member should focus on the individual’s overall risk for violent injury. These risk factors include:
1.Past history of violent behavior and fighting.
2.Past history of exposure to violence.
3.Past and current practice of carrying weapons.
4.Past and present use of alcohol and/or other drugs.
5.Involvement with gangs.
6.History of mental disorders, head injury, behavior problems.
All of these relate to risk factors that require consideration with respect to acute treatment, further assessment, follow-up, and even whether it is safe to discharge the patient. One of the bigger dilemmas in this situation occurs if one determines an immediate risk for further injury. While reimbursement for hospitalization exists if an individual is determined to be at immediate risk for self-inflicted injury, no such funding exists if it is determined that an individual is at risk for injury from others except in the case of child maltreatment. This significantly limits the options available to clinicians in an ED setting. While this should not limit the extent of the evaluation, it does affect what one can do. Treatment While immediate stabilization of the patient and treatment of their physical injury must take priority, there are important considerations for additional services and interventions. For this, non-physician professionals such as social workers and nurses trained in mental health are an important resource. They can provide additional evaluation, share their knowledge of additional resources both within the hospital as well as in the community, and use their skills to elicit information and assess situations beyond the skills of many physicians. As many patients with violent injuries present on evenings, nights, and weekends, the availability of these support professionals must take into account such factors. Follow-up of these patients is not often easy; they are not necessarily the most cooperative or compliant. Therefore the window of opportunity for assessment, engagement, and referral is not necessarily large. The ability to offer services needs to be as closely linked to the injury event as possible. As above, reimbursement for these services is often unavailable. Given financial constraints in the health care system, this creates yet another dilemma. However, the data on recidivism and mortality must balance these constraints. Several grant-funded programs have modeled programs using trained outreach workers to see patients in the ED and then follow up with youth who experience violent injuries. One such program was in place for about four years at Boston City Hospital, the public municipal hospital in Boston, MA. Unfortunately, while these programs seem encouraging and anecdotally report positive results, none have been well evaluated and most are short-lived, with funding rarely lasting more than 3 to 5 years. Considerably more attention and work is required in this area, as it is essential that the understanding of how to best engage and follow-up with such a high risk group needs to be advanced. There are few conditions seen in EDs that have such significantly concerning long term consequences and costs. Data collection Another important function that the ED can play is in contributing to the understanding of violent injury. Internally tracking the rates and types of violent injuries seen in the ED can be useful. This provides an important feedback loop to the clinicians seeing and treating these injuries. One of the unexpected outcomes of ED weapon-related injury surveillance in Massachusetts was that the rates of violent injuries in many facilities were substantially higher than the ED personnel had thought. In some cases, this resulted in additional training efforts on the part of the ED staff and in a few cases even resulted in the commitment of hospital resources to the development of better back-up/follow-up services for the physicians and nurses in the ED. At the larger level, there is great need for better data on the incidence and characteristics of violent injury in this country. Such information would not only help to advance the field of violence prevention but would also provide more opportunities to evaluate the outcomes of violence prevention programs at the community as well as health care system level. While there has been ongoing discussion on the implementation of a national violent injury surveillance system, this has yet to come to fruition. Improved and consistent E-coding of ED visits would greatly advance this effort. Screening One area that has been getting considerable attention in recent years is the implementation of screening for domestic violence in EDs. The importance of this issue in ED settings has already been discussed but the implementation experience in this area, as important as it may be, has been mixed.33, 34, 35, 36 These and other studies speak to the great importance of screening but also acknowledge the difficulties in implementation, quality, response, and effectiveness. It is clear that such efforts require training and support as clinicians will not ask questions if they are not comfortable doing so or do not have a reasonable response when the situation requires something be done. It is important to note, however, that merely asking is better than not as, at the very least, it acknowledges concern and gives the message that domestic violence is not right or acceptable or normal. Furthermore, if nothing else, women can be offered access to several 1-800 hotlines that offer information about shelters, legal resources, support groups, and other key services. One does not have to provide such services on site to be able to respond. Some have gone further than screening in the ED. One program37 conducted a trial of phone follow-up to women who used their ED for the purpose of additional screening. The case finding return on this program was quite low and very labor intensive, suggesting that on-site screening may be more cost effective. In addition, studies38 have shown that training alone does not assure implementation or maintenance of violence screening or protocol use. There is need for ongoing review, oversight, and support for these efforts. Prevention While there is little experience with prevention of violence and violent injury through ED efforts, there are some important glimmers of hope and optimism that the ED is a place for prevention. From a primary prevention perspective, there is one study that found that parental education in the ED about the risks of access to firearms resulted in a significant number of parents reporting a change in their behavior with respect to gun storage and ownership.39 From a secondary prevention perspective, an ED intervention has demonstrated significant reduction in self-reported victimization compared to a group without the intervention.40 What is particularly interesting about this effort is that it was a collaboration between a hospital ED and a local Boys and Girls Club involving social service involvement and community-based follow-up and outreach. This limited experience makes it hard to draw conclusions about the most effective ways for EDs to become involved in prevention. However, they at least begin to provide some possibilities for consideration and further study. As a major site for the presentation of violent injuries, EDs should begin to define and enhance their role in the violence prevention movement. Advocacy Last, but certainly not least, is the role emergency care professionals can play in efforts to enhance services and resources for violence prevention. Among all who work in addressing violence, it is those who work in EDs who can best put the human face on the problem of violent injury. It is in EDs where much of the horror of the consequences of violent injury is seen. It is the ED staff and trauma surgeons who work to patch people up, keep them alive, see the victims appear and reappear for their services, and have to tell families about the death or severe disabilities suffered by their sons, daughters, and other loved ones. It is this human face that can move policy makers, politicians, and community leaders as well as better inform the general public about this issue. There is great need for more resources for services, surveillance, research and understanding, prevention, changing stereotypes, and misassumptions. While all of us need to do our best for the individual patients we see, we must never lose sight of the bigger picture that can create change for the larger population and lessen the load of the system working on one person at a time. References 1.
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a Division of General Pediatrics and Adolescent Medicine, Tufts University School of Medicine, Tufts New England Medical Center, Boston, MA,, USA b Harvard School of Public Health, Boston, MA, USA  Address reprint requests to Howard R. Spivak, MD, Tufts New England Medical Center, 750 Washington Street, Box 351, Boston, MA 02111 USA
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