American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Violence Intervention Programs: A Primer for Developing a Comprehensive Program within Trauma Centers

Injuries resulting from interpersonal violence in the U.S. are all too common. In 2015, homicide was the sixth leading cause of death for all age groups. Nearly 1.5 million nonfatal injuries occur amongst 15 to 34 year olds, and the direct and indirect cost of these injuries is approximately $12 billion.

Trauma centers stand on the front lines of the interpersonal violence epidemic. With injury recidivism rates as high as 55 percent, injury prevention advocates are exploring ways to close this revolving door to decrease violent injury, similar to the methods that have been used effectively to reduce the incidence of cardiovascular disease and cancer.

To begin a program to reduce risk factors associated with violent injury, a comprehensive approach that addresses mental health and social determinants of health is critical. Hospital-based violence intervention programs (HVIPs) are multidisciplinary programs that identify patients at risk of repeat violent injury and link them with hospital and community-based resources aimed to address underlying risk factors for violence. Data indicate the HVIPs can reduce violent injury recidivism and hospital costs.

A group from the American College of Surgeons Committee on Trauma’s (ACS COT) Injury Prevention and Control Committee was tasked with outlining a comprehensive approach to institute a sustainable HVIP.  Below is a step-wise guide to establishing a working HVIP. It describes what is necessary to run a program at minimum, and is followed by an additional piece on resources for a “dream” program. It is intended to guide fledgling programs and perhaps save new programs from the pitfalls that often accompany this difficult work.

In an effort to provide a more comprehensive approach to treating victims of interpersonal violence, over 30 programs have developed nationwide with a similar approach to hospital-based violence intervention. Although programs have regional adaptations, the fidelity is in the main principles:

  1. A public health approach to violence prevention, which acknowledges that there are modifiable risk factors associated with violent injury. These factors include but are not limited to poor education, lack of job opportunities, injury and criminal recidivism, socioeconomically deprived neighborhoods, substance abuse, complex PTSD, and lack of positive role models.
    1. The notion of violence as a public health issue with modifiable risk factors was first acknowledged by Surgeon General C. Everett Koop in the 1980s.
  2. HVIPs work with the target population by approaching victims in the hospital, in the “teachable moment”, using culturally competent case managers.
  3. Case managers develop an almost instant rapport with victims and begin identifying and addressing individual needs with the commitment of long-term case management.
  4. Case managers shepherd clients through risk reduction resources grounded in strong community and city ties and a working knowledge of the landscape of options.

HVIP Timeline