Increasing a Hospital-based Violence Intervention Program's Services for Pediatric Patients and Their Families Who Come to the Emergency Department for Interpersonal Violence

Narmeen Khan, MD
Michael Levas, MD, MS
Marlene Melzer-Lange, MD

Thousands of children are treated for firearm-related injuries in emergency departments (EDs) in the United States (US) annually, with mortality rates as high as 20%. Our children’s hospital resides in an urban county within the Midwest that has one of the highest rates of firearm injuries in the US. Our hospital-based violence intervention program (HVIP) is a collaborative support network that assists pediatric victims of violence and their families during and after hospitalization. The program provides resources including housing, mental health, job security, and legal support as these individuals attempt to recover from their trauma and navigate societal stressors. Our global aim is to increase HVIP services (through increasing referral and acceptance rates) at our pediatric ED. Our specific aim is to increase HVIP referral rates in our ED by 20% over a 12-month period. We highlight the needs assessment and quality improvement strategies utilized to reach our goals.

Inclusion criteria for our HVIP are children up to 18 years of age residing within our county who have faced interpersonal violence. Injuries include firearm injuries, stab wounds, and hit-and-runs. Exclusions include being under police and/or child protective services custodies, out-of-home placement, and sexual assaults. We looked at 974 ED encounters who presented to the ED from 2020 to 2023 and met the above inclusion criteria to perform a retrospective chart review. Thirty-two of these encounters were excluded as the patient was deceased or transferred to another facility. We created p-charts from the raw data and conducted focused interviews with and surveys to stakeholders, including nurses, providers, crime victim advocates (CVAs who discuss the HVIP to patients and families), and social workers. We retrospectively reviewed de-identified patient data including chief complaint and ED disposition to create the p-charts and review HVIP-eligible patients who were missed.

Six hundred and eighty-four out of the 942 HVIP-eligible encounters (73%) were not admitted to the hospital for their injuries, whereas 27% were. From the children who were discharged home (73%), 44% had HVIP consults placed, with 99% placed in the ED. Sixty-nine percent of patients who had a consult placed accepted enrollment into the program. From the children (27%) admitted to the hospital (including general floor, intensive care unit, or operating room), 75% had an HVIP consult placed, with only 43% placed in the ED. Seventy-six percent of these patients were ultimately enrolled in the HVIP.

From our needs assessment and chart reviews, we learned that we are missing large volumes of HVIP-eligible referrals. As next steps, we will be implementing plan-do-study-act cycles to test whether two of many possible interventions can help us achieve our specific aim. The two interventions will be to make modifications to our ED’s electronic medical record software as well as increase the visibility of and provide more resources to our HVIP’s CVAs.

1. Discuss the importance of hospital-based violence intervention programs (HVIPs), particularly in the pediatric emergency department setting.
2. Highlight a needs assessment to critically appraise an HVIP using a quality improvement approach.
3. Gather tools for next steps, including possible interventions, to improve the HVIP.