How can healthcare providers, on a daily and case-by-case basis, interrupt and intervene to address youth exposure to violence? Increasing time pressures, financial pressures, and upside down incentives are real barriers. The most recent efforts I have seen in emergency departments (ED) focus on adapting and overlaying initiatives on top of existing healthcare structures rather than forcing clinicians to do more and more.
Research has shown that healthcare providers want to address violence and trauma in their daily practice. The key is to make it simple, evidence-based and time-efficient – which is not always easy to accomplish. I have spent a good part of my career designing, testing, and collaborating on clinician-based initiatives that can help front-line providers address safety and security in their patients' lives. I’d like to offer specific examples in the areas of gun exposure, assault injury, self-harm, and domestic violence.
- Gun Exposure -- Nothing is more maddening than taking care of a 3-year-old who was shot by her 5-year-old brother, with a gun that was for some reason left out or thought to be hidden. Quite a few years ago a landmark randomized controlled trial (RCT) of 137 pediatric practices found that an intervention called Safety Check, which combined screening for firearms with brief parent counseling and gunlock distribution, resulted in safer gun storage assessed at the next primary care visit. The intervention itself, designed by Dr. Shari Barkin, took less than a few minutes. My colleagues Dr. Rinad Beidas at the University of Penn is the Principal Investigator on a study to learn how we can best implement Safety Check more widely in primary care practices throughout the U.S. Other efforts, such as the community-based gun lock and gun safe distribution program at Seattle Children’s Hospital, have demonstrated significant uptake by gun-owning families and show how medical providers can become engaged in these efforts. Our own efforts to establish a similar program are currently underway here at Children's Hospital of Philadelphia.
- Assault Injury -- Drs. Rebecca Cunningham, Pat Carter and Maureen Walton at the University of Michigan have developed the SafERteens, a computer-assisted in-person therapist model of delivery demonstrated in a large RCT a decrease in violent aggression among ED youth (14-18 y/o) who reported past 3-month fighting and alcohol use, with findings that persisted up to a year. This team is currently testing a remote therapy version of the intervention as well as booster mechanisms to achieve longer term sustainability of the results.
- Self-Harm -- Our own work in the ED at CHOP utilizes technology to assess adolescent mental health and safety. We have developed and validated the Behavioral Health Screen ED Version (BHS-ED), a computerized, self-administered screening tool for depression, suicidality, substance use and violence exposure that screens more than 350 teenagers per month in our ED, with almost a third reporting moderate or severe depression and 8 percent with current suicidal ideation, the vast majority of whom did not come to the ER due to a mental health complaint.
- Intimate Partner Violence -- With colleagues Ashlee Murray and Joseph Zorc and our partners at Lutheran Settlement House, we have devised a way of safely screening for intimate partner violence (IPV) in the parents and caretakers of kids in our ED and connecting them with resources in real time, using external electronic communication techniques that avoid the potential danger of documenting the abuse in the child’s medical record. With the help of this technology, our IPV screening rates have risen from 2% to between 35% and 40% and we are moving toward disseminating this process to the CHOP inpatient teams.
Practicing clinicians in the healthcare system understand the impact of violence and trauma on the long-term health and wellness of their patients. Some take it on as a mission and work independently to expand their reach and impact. However, it is important to recognize the limitations of our clinical environments and adapt processes and procedures that overcome these barriers.
The systems that we design must have three ingredients: They do not increase the burden of work on already-beleaguered clinicians, they provide access to evidence-based processes and interventions, and they can be replicated across diverse settings. It is encouraging that the use of technology, combined with rigorous stakeholder input, allows us to incorporate social, emotional and environmental health into the healthcare provider’s daily work.
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