Integrate Youth Violence Prevention into Busy ED Workflow
Frontline providers are all too familiar with the consequences of youth violence. The CDC reports that every day, more than 1,000 youth are treated in EDs for injuries sustained from physical assaults.
Furthermore, the agency says the toll from nonfatal physical assault-related injuries is more than $20 billion a year — and that accounts for only medical-related expenses and costs associated with lost productivity. There are other, longer-range psychological and social consequences that affect the victims of violence, their families, and society.1
It is important to recognize the cyclical nature of violence, too. For example, researchers report that not only does violence adversely affect youth development, it also heightens the risk for other health problems and raises the risk for future violent incidents.2
There is an opportunity to intervene with young patients when they present to the ED for treatment of violence-related injuries. However, much less is known about how facilities can effectively seize this opportunity, considering the often-frantic pace of a busy department.
Researchers from the University of Michigan Injury Prevention Center studied whether leaders can effectively integrate an evidence-based behavioral intervention, dubbed SafERteens, into the workflow of a busy ED. The results of this work highlight some key challenges, but also provide a roadmap for bustling facilities looking for manageable solutions. Under SafERteens, a trained therapist works with a teen for roughly 30 minutes over the course of an ED encounter. The therapist and patient identify positive life goals and how the patient can reduce his or her involvement in violence. They also discuss behaviors that may exacerbate the risk of violence, such as drug or alcohol use.
Since the program was developed in 2006, it has been tested in multiple clinical trials, demonstrating the solution can reduce violence among patients who receive the intervention.3
More recently, researchers tested SafERteens at Hurley Medical Center in Flint, MI.4 Teens presenting to the ED were split between groups that received the intervention by an in-person therapist or a remote therapist. There also were two parallel control groups. The first step involves using a screen to identify youth who are most at risk for violence and could benefit from the intervention. “The screen includes questions about recent fights within the past three months,” says Patrick Carter, MD, director of the University of Michigan Injury Prevention Center. “The screening survey is built into the program website so that youth are able to privately answer the questions without anyone else knowing their answers.”
Upon completion of the screening survey, staff can see whether the patient is eligible for the intervention. Notably, clinical sites using the program can bypass the survey for cases in which they believe a patient would benefit from the program (e.g., if a teen presents with a clearly violence-related injury).
Once teens are identified for intervention, staff can customize how they fit the program into workflows. For example, in the pilot, Carter shares the initial screen was integrated into the standard nurse triage process upon patient arrival. “When a nurse identified a positive screen, she or he entered this information into the electronic medical record and triggered a notification to the intervention specialists,” he says.
The intervention specialists included clinical social workers or child life specialists who were trained to deliver the SafERteens intervention between the other types of clinical care the teens were receiving. “We also piloted a remotely delivered version where the notification of a positive screen was sent to a remotely located therapist,” Carter says. “The therapist then delivered the SafERteens intervention via an iPad, a HIPAA-compliant video program, mirroring a telehealth hub model of care.”
In the pilot, more teens received the intervention from a remote therapist than from an in-person social worker or child-life specialist because of the time constraints and other demands on the clinicians working on site. “The sample size of the pilot study was small, limiting conclusions about differences between the two types of delivery,” Carter says. “However, we did find that the remote therapist delivery [model] led to reductions in aggression, fighting behaviors, and violence-[related] consequences.”
Both the remote and in-person models resulted in better self-efficacy to prevent further fighting and to ease pro-violence attitudes. “Taken together, the telehealth hub model may be one solution to the limited time/availability of onsite staff to deliver the program,” Carter says.
Meanwhile, clinical staff identified the SafERteens as both necessary and critical to the health and well-being of their patients. However, staff also found it was difficult to deliver this program along with all the other competing demands. Thus, delivery of the intervention declined once the support of the research team was no longer available. “Staff and ED leadership identified that if the service was reimbursable, it would be easier for them to either hire dedicated staff to provide the service or allocate resources to provide the service to this patient population,” Carter explains. “Thus, the most needed resource to ensure program success is the availability of reimbursable billing codes that will allow hospitals to bill for providing this service.”
Carter reports such codes exist for other types of counseling, such as for smoking cessation and alcohol misuse, but not for violence prevention. Nonetheless, Carter and colleagues are examining ways to expand and implement the intervention across multiple EDs and other healthcare settings.
In particular, as part of a larger CDC-funded study, such work is taking place in Muskegon and Grand Rapids, MI, where the SafERteens program is undergoing implementation in EDs, primary care settings, and behavioral health settings. “We are examining whether widespread deployment of the program in this way can have a cumulative effect on preventing violence,” Carter says.
Whatever the outcomes, Carter still believes full integration is possible. “As medical providers, we need to focus not just on the treatment of physical wounds, but also on the things we can do to prevent youth from ending up in the trauma bay in the first place,” he says.
“With greater reimbursement/funding of such services, this program has the potential for widespread impact on addressing this important public health problem.”
Carter notes the training and program resources needed to implement the program in a clinical setting are assembled into a web-based SaferERteens toolkit (www.safERteens.org). The toolkit includes training manuals and videos to show clinicians how to screen patients and conduct the intervention to reduce youth violence. There is implementation support, including screening questions, as well as clinical therapy decision-support tools staff can use to deliver the intervention. Program brochures can be adapted for use in different types of clinical settings. Finally, a text message booster program is available to interested sites for a fee.
REFERENCES
- CDC. Preventing youth violence. Page last reviewed Sept. 10, 2021.
- David-Ferdon C, Clayton HB, Dahlberg LL, et al. Vital Signs: Prevalence of multiple forms of violence and increased health risk behaviors and conditions among youths — United States, 2019. MMWR Morb Mortal Wkly Rep 2021;70:167-173.
- Cunningham RM, Chermack ST, Zimmerman MA, et al. Brief motivational interviewing intervention for peer violence and alcohol use in teens: One-year follow-up. Pediatrics 2012;129:1083-1090.
- Carter PM, Cunningham RM, Eisman A, et al. Translating violence prevention programs from research to practice: SafERteens implementation in an urban emergency department. J Emerg Med 2022;62:109-124.
There is an opportunity to intervene with young patients when they present to the ED for treatment of violence-related injuries. However, much less is known about how facilities can effectively seize this opportunity, considering the often-frantic pace of a busy department.
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