Case Studies and Practice
The Youth Nonfatal Violent Injury Review Panel: An Innovative Model to Inform Policy and Systems Change
Jonathan Purtle, DrPH, MSca Linda J. Rich, MAb John A. Rich, MD, MPHa Jazzmin Cooper, MPHb Erica J. Harris, MDb Theodore J. Corbin, MD, MPHc
ABSTRACT Among young people in the United States, nonfatal violent injuries outnumber fatal violent injuries by 171 to 1. The Child Fatality Review Team (CFRT) is a well-established model for informing injury prevention planning. The CFRT’s restricted focus on fatal injuries, however, limits its ability to identify opportunities to prevent violent reinjury and address issues unique to nonfatal violent injuries. We adapted the CFRT model to develop and implement a Youth Nonfatal Violent Injury Review Panel. We convened representatives from 23 agencies (e.g., police, housing, and education) quarterly to share administrative information and confidentially discuss cases of nonfatal violent injury. In this article, we describe the panel model and present preliminary data on participants’ perceptions of the process. Although outcomes research is needed to evaluate its impacts, the Youth Nonfatal Violent Injury Review Panel offers an innovative, promising, and replicable model for interagency collaboration to prevent youth violence and its effects.
Drexel University School of Public Health, Department of Health Management and Policy, Philadelphia, PA
a
Drexel University College of Medicine, Center for Nonviolence and Social Justice, Philadelphia, PA
b
Drexel University College of Medicine, Department of Emergency Medicine, Philadelphia, PA
c
Address correspondence to: Jonathan Purtle, DrPH, MSc, Drexel University School of Public Health, Department of Health Management and Policy, 3215 Market St., 3rd Fl., Philadelphia, PA 19102; tel. 267-359-6167; fax 267-359-6001; e-mail . 2015 Association of Schools and Programs of Public Health
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Nonfatal violent injury is a common, but often underrecognized, problem among young people in the United States. In 2011, among those aged 0–18 years, 354,218 incidents of nonfatal hospital-treated violent injury occurred compared with 2,076 incidents of fatal violent injury (defined as nonsexual, intentional injury inflicted by another person)—a 171:1 ratio.1,2 In addition to the physical consequences of nonfatal violent injury, young people are at risk for psychological aftereffects, such as posttraumatic stress and depression.3–9 Many violently injured young people are reinjured after they leave the hospital.10 The estimated one-year violent reinjury rate among U.S. high school students is 9%,11 and a study of violently injured young people (mean age: 14.5 years) participating in a hospital-based violence intervention program (HVIP) found that 23% had previously sustained a violent injury resulting in medical care.12 Among adults, the five-year violent reinjury rate is estimated to be as high as 45%.13–18 Despite the high incidence of nonfatal violent injury, its consequences, and recurrent nature, little information exists about the issues that young people encounter after they sustain nonfatal violent injuries. Furthermore, the public health and medical literature provides little guidance about how public policies and systems might most effectively prevent violent reinjury and improve the health and social trajectories of violently injured young people. The Child Fatality Review Team (CFRT) is an established model that can potentially be adapted to facilitate a coordinated, systemslevel response to the problem of nonfatal violent injury. A CFRT is a multidisciplinary group of representatives from different sectors, such as education, health care, child welfare, law enforcement, and public health, who regularly convene to systematically discuss cases of child death and, occasionally, serious injuries.19,20 CFRT participants share data from their agencies about child decedents and the circumstances surrounding their deaths with the aim of identifying prevention opportunities.21–25 First established in Los Angeles, California, in 1978,26 the CFRT model has been widely adopted. As of 2012, a CFRT existed in every state in the United States27 and in many other countries.28–31 PURPOSE We adapted the CFRT model to develop and implement a Youth Nonfatal Violent Injury Review Panel in Philadelphia, Pennsylvania. By using the CFRT model to examine cases of nonfatal violent injury, the panel aimed to (1) identify issues encountered by violently injured young people during their recoveries and (2) generate empirically grounded recommendations
about how public policies and systems can more effectively meet the needs of violently injured young people and prevent violent reinjury. Furthermore, because the people meeting the case definition are still alive, we intended for the panel to produce tangible benefits for the violently injured young people who served as case subjects for panel discussions. The panel was funded as a practice-based, pilot initiative to promote interagency collaboration and systems solutions to address youth violence. We did not implement the panel as a research project, and the panel did not review a sufficient number of cases to attribute any outcomes (e.g., policy changes) to itself. As a result, we do not present evidence of effectiveness, but, rather, describe a novel and replicable model from the field and offer it as a blueprint for establishing Youth Nonfatal Violent Injury Review Panels—and a template for other interagency collaboration to address youth violence—in cities across the United States. METHODS Panel engagement and composition The staff of our organization—an academic center operating an HVIP that provides case management, behavioral health, and psychoeducational services to violently injured young people—designed and convened the panel. Informed by our knowledge of the CFRT model and local public systems and services, we developed a list of agencies to serve on the panel. We invited prospective panel participants via an e-mail that described the aims of the panel and included details about what participation would entail. We sent these e-mails to 44 agency leaders (e.g., commissioners and deputy directors), and all of the invited agency leaders agreed to participate. Although we did not explicitly limit the number of representatives who could attend from each agency, we requested at least one highlevel employee with policy-making authority and one employee who provides direct services (e.g., a dyad of a deputy police commissioner and patrol officer). The panel convened four times during the course of one year, and 44 individuals from 23 different agencies attended (Table 1). Case subject identification and interagency information sharing Violently injured young people participating in our HVIP served as case subjects for the panel discussions. The study subjects, aged 15–24 years, had received hospital care for nonfatal violent injuries resulting from blunt, knife, and firearm assaults. HVIP social workers identified these young people through daily reviews of
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Table 1. Organizations participating in a Youth Nonfatal Violent Injury Review Panel, Philadelphia, Pennsylvania, 2013–2014 Sector
Organization
Public
Department of Public Health Court System Department of Behavioral Health Department of Child Welfare Division of Juvenile Justice Office of Supportive Housing District Attorney’s Office Police Department Probation/Parole Department State Safe Schools Advocacy Office U.S. Congressperson’s Office U.S. Attorney’s Office
Community-based organizations
Violence Prevention Program Crime Prevention Program Grief Counseling Program Youth Enrichment Program
Health care
Family Medicine Psychology/Psychiatry Internal Medicine Emergency Medicine
Academia
College of Medicine School of Public Health
Other
Youth-Focused Philanthropy Public Defender’s Association
hospital electronic health record systems and recruited them to participate in the program after they had been medically cleared. A total of 66 violently injured young people completed intake and were fully enrolled in our program during the one-year panel period. To ensure that panel participants from different sectors were engaged in the meetings, we deliberately selected HVIP clients who were interacting with multiple public systems to serve as potential case subjects. After identifying these case subjects, we described to them (and their primary caregiver, if the young person was a minor) the purpose of the panel and what serving as a case subject would entail. We emphasized that agreeing to serve as a case subject was not required for continued HVIP services and that their real names would not be disclosed at the panel meetings. If interested in serving as a case subject, the young person or his/her primary caregiver signed a consent form granting our center permission to request information about the person from the participating panel agencies. Of the 66 violently injured young people who were fully enrolled in the HVIP during the panel period, six were invited to serve as case subjects. All six consented.
After the HVIP participants consented to serve as case subjects, we sent their names and other personal identifiers to a designated employee at each panel agency. We requested that this employee search agency records for information about the case subjects and their interactions with the agency before and after the nonfatal violent injury that was the focus of the case presentation. The employee sent this information to the center via secure e-mail. Panel agencies provided information, such as histories of involvement with child protective services, school records, and police reports. We typically received this information in a timely manner, but there were instances when the information provided was incomplete, an issue attributed to the transition from paper to electronic records within the agency. We used pseudonyms for all case subjects in the presentations. The designated employee who searched agency records for information about a case subject was not the same agency representative who attended the panel meetings. Thus, the agency representatives who attended the panel meetings were blind to the true identity of the case subjects, despite the fact that their agency provided information about the case subjects to the center. Case presentation format Each panel meeting lasted two hours and began with a 20-minute presentation about traumatic stress. Center staff provided these presentations, which covered topics about the epidemiology of traumatic stress; its physiological, social, emotional, and cognitive effects; and principles of trauma-informed care.32 We chose to integrate these presentations into panel meetings because all case subjects experienced violent injury trauma, and most had experienced multiple traumas in their lifetime. Following a 10-minute discussion about the content of the trauma presentation, HVIP social workers who were providing direct services to the case subjects presented cases. Using information obtained from panel agencies and collected through HVIP assessments (e.g., Survey of Children’s Exposure to Community Violence33 and Child Trauma Screening Questionnaire34), social workers presented subjects’ life histories using a series of slides. They placed emphasis on pre-injury circumstances and events related to violent injury risk (e.g., school and family environment, arrest history, and behavioral health issues),35–37 systems and services with which the case subject was currently involved, and specific challenges that the case subject was encountering post-injury. Social workers presented one or two cases at each panel meeting and each presentation lasted
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approximately 30 minutes. We did not invite the case subjects to attend panel meetings because we were concerned that the experience could be emotionally distressing for them. Discussion format After case presentation, center staff joined the HVIP social worker and co-facilitated a discussion about the case. Two center staff members captured panel discussions by writing notes on large notepads while a third staff member typed detailed notes. A list of questions that were informed by the Milwaukee Homicide Review Commission process,38 literature on interagency collaboration,39 and research about the experiences of HVIP participants40,41 helped structure the discussion. These questions included: • In what ways were agencies effective in responding to this injury? • How could your agency have more effectively served the case subject? • What strengths/assets does the case subject possess? • What systems/services currently exist to address the needs of the case subjects and prevent reinjury/other adverse outcomes? • Based on this case, what policy and systems-level change might need to be made? OUTCOMES: PERSPECTIVES OF PANEL PARTICIPANTS Two center staff members conducted semi-structured interviews with 13 panel participants in three weeks following the panel meeting. The interviews were conducted with a mix of high-level employees and direct service providers and explored their perceptions of the panel process. The aim of these interviews was not to evaluate the panel’s impact but to obtain preliminary feedback, identify opportunities to improve the panel process, and collect information to inform the selection of variables in a future outcome evaluation. Two center staff conducted the interviews in the three weeks following the final panel meeting. Interviews were audio recorded, transcribed, and analyzed using thematic content analysis. The interviews highlighted panel strengths, weaknesses, and areas for improvement (Table 2). Many participants emphasized the value of case subjects being living people—not deceased individuals as per the typical CFRT model—and expressed appreciation for the opportunity to hear different agencies’ perspectives on issues related to youth violence. The panel thought
the trauma presentations were beneficial, as they conveyed complex information in an accessible format and created a framework in which to guide productive interagency discussions. The interviews also identified panel weaknesses, and feedback offered suggestions for improvement. Interview respondents expressed a desire to ensure that panel recommendations translated into actual policy change and offered suggestions to improve the logistics of the panel, such as holding meetings more frequently and discussing a greater number of cases. Based on the interview findings, we identified interagency collaboration and knowledge about the recovery needs of violently injured young people as candidates for proximal outcome measures. LESSONS LEARNED We learned that it is possible to adapt the CFRT model for the purpose of reviewing cases of nonfatal violent injury in a confidential manner. We believe that using living individuals rather than decedents as case subjects can potentially illuminate challenges unique to the needs of young people who sustain nonfatal injuries and identify priorities for policy and systems-level change. We also propose that it is possible for this process to generate real-time suggestions and actions to address the immediate needs of violently injured young people. Although outcomes research is needed to test the empirical validity of these assumptions, the Youth Nonfatal Violent Injury Review Panel might offer an innovative, promising, and replicable model for interagency collaboration to prevent youth violence and its effects. All panel participants signed a confidentiality agreement when they entered the panel meetings. The Drexel University Institutional Review Board approved all aspects of the panel process.
REFERENCES 1. Centers for Disease Control and Prevention (US). Injury prevention and control: data and statistics (WISQARS™). Nonfatal injury data [cited 2015 Feb 6]. Available from: URL: http://www.cdc.gov /injury/wisqars/nonfatal.html 2. Centers for Disease Control and Prevention (US). Injury prevention and control: data and statistics (WISQARS™). Fatal injury data [cited 2015 Feb 6]. Available from: URL: http://www.cdc .gov/injury/wisqars/fatal_injury_reports.html 3. Kassam-Adams N, Marsac ML, Hildenbrand A, Winston F. Posttraumatic stress following pediatric injury: update on diagnosis, risk factors, and intervention. JAMA Pediatr 2013;167:1158-65. 4. Langeland W, Olff M. Psychobiology of posttraumatic stress disorder in pediatric injury patients: a review of the literature. Neurosci Biobehav Rev 2008;32:161-74. 5. Fein JA, Kassam-Adams N, Vu T, Datner EM. Emergency department evaluation of acute stress disorder symptoms in violently injured youths. Ann Emerg Med 2001;38:391-6. 6. Fein JA, Kassam-Adams N, Gavin M, Huang R, Blanchard D, Datner EM. Persistence of posttraumatic stress in violently injured youth
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Table 2. Participants’ perceptions of the Youth Nonfatal Violent Injury Review Panel process, Philadelphia, Pennsylvania, 2013–2014 Domain Strengths of the panel
Theme
Illustrative quotes
Having living people “I had to keep reminding myself—because I’ve sat through enough fatality serve as case subjects for reviews—that we were thinking about and talking about an active, living, thriving panel discussions person, and that there was an opportunity to intervene and change the course of his life.” “We’re at least working with living individuals . . . we can still make a difference in their lives. That’s really powerful to me, the fact that we’re reviewing it in real time and talking together about what our respective systems can do to support that young person . . . with the injury review panel, it’s real time.” Hearing multidisciplinary perspectives about youth violence
“I’m so glad that finally something like this has come together . . . everyone in the same room [having] some thoughtful discussion about the subject of traumainformed care and how each various entity is actually dealing with the same child and how they can work better to really help a child and their family.” “Hearing from people who [speak] a different language than what I’m used to and thinking about these problems from other perspectives has been really useful. It helps us come back to our work and think about things a little more broadly.”
Perspectives on trauma Providing a framework to presentations discuss cases of nonfatal violent injury in trauma presentations Shedding new light on post-injury trajectories in trauma presentations
“I think [the trauma presentations] really laid the foundation and really helped people appreciate why it was that we were coming together.” “[The trauma presentations] brought everyone back to the same central idea that this is how we think about things and this is sort of our mission . . . and gets everyone back to the idea that they’re speaking the same language.” “[The trauma presentations] simplified [trauma] so that everybody could appreciate what it is, what the effects are, [and] what it really means, and you can look at anyone in the community and look through a different lens and [say] ‘Oh, that’s what it was, that maladaptive personality or that maladaptive behavior . . .’” “[Trauma-informed practice] is like trigonometry. You know, to this day, I don’t know what to do with a cosine because I learned it in a vacuum. But here we are, sitting with the trauma before us, learning about it, and it made it more powerful.”
Weaknesses and recommendations to improve the panel
Ensuring that panel discussions move from the case subject level to the systems level
“We haven’t gotten yet to the point where people are talking really openly about ‘What are we going do to change our systems?’ There’s conversation about ‘What could we do for this particular kid? Where could you send him?’ but that’s kind of the frustration that I have so often, that you can help one kid at a time and that’s really important, but we haven’t gotten to conversations about system change . . .” “I don’t know that we’re as deliberate as we could be . . . [we need to] come together and really start to talk about which policies we need to look at.”
Requiring each agency to “I think it would be better to compel people to contribute rather than to leave it to comment on every case their own volition.” Establishing small working groups within the panel
“Have small working groups—people who do speak the same language—to say, ‘What part of this can we take?’ Where is it that we’re seeing a pattern of failure to serve kids? What can we do to address this pattern?’”
Convening the panel more frequently
“I think you lose something in keeping [the frequency of the panel meetings] spaced so far apart [the panel met every three months]. I think probably having them more frequently would be useful.”
Limiting panel “Some of the people at the table are the right people, but some aren’t . . . you participation to agency need to identify the decision makers.” representatives with decision-making authority
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7. 8. 9.
10. 11. 12. 13. 14. 15. 16. 17. 18.
19.
20. 21. 22. 23.
seen in the emergency department. Arch Pediatr Adolesc Med 2002;156:836-40. Hamrin V, Jonker B, Scahill L. Acute stress disorder symptoms in gunshot-injured youth. J Child Adolesc Psychiatr Nurs 2004;17:161-72. Pailler ME, Kassam-Adams N, Datner EM, Fein JA. Depression, acute stress, and behavioral risk factors in violently injured adolescents. Gen Hosp Psychiatry 2007;29:357-63. Kelly VG, Merrill GS, Shumway M, Alvidrez J, Boccellari A. Outreach, engagement, and practical assistance: essential aspects of PTSD care for urban victims of violent crime. Trauma Violence Abuse 2010;11:144-56. Caputo ND, Shields CP, Ochoa C, Matarlo J, Leber M, Madlinger R, et al. Violent and fatal youth trauma: is there a missed opportunity? West J Emerg Med 2012;13:146-50. Chang JJ, Chen JJ, Brownson RC. The role of repeat victimization in adolescent delinquent behaviors and recidivism. J Adolesc Health 2003;32:272-80. Purtle J, Harris E, Compton R, Baccare R, Morris A, Dibartolo D, et al. The psychological sequelae of violent injury in a pediatric intervention. J Pediatr Surg 2014;49:1668-72. Sims DW, Bivins BA, Obeid FN, Horst HM, Sorensen VJ, Fath JJ. Urban trauma: a chronic recurrent disease. J Trauma 1989;29:940-6. Morrissey TB, Byrd CR, Deitch EA. The incidence of recurrent penetrating trauma in an urban trauma center. J Trauma 1991;31:1536-8. Tellez MG, Mackersie RC, Morabito D, Shagoury C, Heye C. Risks, costs, and the expected complication of re-injury. Am J Surg 1995;170:660-3. Kennedy F, Brown JR, Brown KA, Fleming AW. Geographic and temporal patterns of recurrent intentional injury in south-central Los Angeles. J Natl Med Assoc 1996;88:570-2. Worrell, SS, Koepsell TD, Sabath DR, Gentilello LM, Mock CN, Nathens AB. The risk of reinjury in relation to time since first injury: a retrospective population-based study. J Trauma 2006;60:379-84. Gomez G, Simons C, St John W, Creasser D, Hackworth J, Gupta P, et al. Project Prescription for Hope (RxH): trauma surgeons and community aligned to reduce injury recidivism caused by violence. Am Surg 2012;78:1000-4. Committee on Child Abuse and Neglect; Committee on Injury, Violence, and Poison Prevention; Council on Community Pediatrics. American Academy of Pediatrics. Policy statement—child fatality review. Pediatrics 2010;126:592-6. Johnston BD, Covington, TM. Injury prevention in child death review. Inj Prev 2011;17 Suppl 1:1-3. Johnston BD, Bennett E, Pilkey D, Wirtz SJ, Quan L. Collaborative process improvement to enhance injury prevention in child death review. Inj Prev 2011;17 Suppl 1:71-6. Onwuachi-Saunders C, Forjuoh SN, West P, Brooks C. Child death reviews: a gold mine for injury prevention and control. Inj Prev 1999;5:276-9. Douglas EM, Cunningham JM. Recommendations from child fatality review teams: results of a US nationwide exploratory study concerning maltreatment fatalities and social service delivery. Child Abuse Rev 2008;17:331-51.
24. Rimsza ME, Schackner RA, Bowen KA, Marshall W. Can child deaths be prevented? The Arizona Child Fatality Review Program experience. Pediatrics 2002;110:11. 25. Quan L, Pilkey D, Gomez A, Bennett E. Analysis of paediatric drowning deaths in Washington State using the child death review (CDR) for surveillance: what CDR does and does not tell us about lethal drowning injury. Inj Prev 2011;17 Suppl 1:28-33. 26. Durfee MJ, Gellert GA, Tilton-Durfee D. Origins and clinical relevance of child death review teams. JAMA 1992;267:3172-5. 27. Palusci VJ, Covington TM. Child maltreatment deaths in the U.S. national child death review case reporting system. Child Abuse Negl 2014;38:25-36. 28. Durfee M, Durfee DT, West MP. Child fatality review: an international movement. Child Abuse Negl 2002;26:619-36. 29. Sidebotham P, Fox J, Horwath J, Powell C. Developing effective child death review: a study of “early starter” child death overview panels in England. Inj Prev 2011;17 Suppl 1:55-63. 30. Browne KD, Lynch, MA. The nature and extent of child homicide and fatal abuse. Child Abuse Rev 1995;4:309-16. 31. National Center for the Review & Prevention of Child Deaths. U.S. CDR programs [cited 2015 Feb 6]. Available from: URL: https:// www.childdeathreview.org/cdr-programs/u-s-cdr-programs 32. Elliott DE, Bjelajac P, Fallot RD, Markoff LS, Reed BG. Traumainformed or trauma-denied: principles and implementation of trauma-informed services for women. J Community Psychol 2005;33:461-77. 33. Richters JE, Martinez P. The NIMH community violence project: I. Children as victims of and witnesses to violence. Psychiatry 1993;56:7-21. 34. Kenardy JA, Spence SH, Macleod AC. Screening for posttraumatic stress disorder in children after accidental injury. Pediatrics 2006;118:1002-9. 35. Dahlberg L. Youth violence in the United States. Major trends, risk factors, and prevention approaches. Am J Prev Med 1998;14:259-72. 36. Borum R. Assessing violence risk among youth. J Clin Psychol 2000;56:1263-88. 37. Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Lancet 2002;360:1083-8. 38. City of Milwaukee. Milwaukee Homicide Review Commission [cited 2015 Feb 10]. Available from: URL: http://city.milwaukee.gov/hrc 39. Bryson JM, Crosby BC, Stone MM. The design and implementation of cross-sector collaborations: propositions from the literature. Public Adm Rev 2006;66 Suppl 1:44-55. 40. Purtle J, Rich L, Rich J, Cooper J, Corbin T. “A positive clubhouse:” exploring the experience of participating in a trauma-informed, hospital-based violence intervention program. Presented as part of: Stolbach B, Watson A, Smith J, McCory J, Purtle J. We shall overcome: urban narratives of the struggle to heal from personal and structural violence. International Society for Traumatic Stress Studies Annual Meeting; 2013 Nov 7; Philadelphia. 41. James TL, Bibi S, Langlois BK, Dugan E, Mitchell PM. Boston Violence Intervention Advocacy Program: a qualitative study of client experiences and perceived effect. Acad Emerg Med 2014;21:742-51.
Public Health Reports / November–December 2015 / Volume 130
The Youth Nonfatal Violent Injury Review Panel: An Innovative Model to Inform Policy and Systems Change
Jonathan Purtle, DrPH, MSca Linda J. Rich, MAb John A. Rich, MD, MPHa Jazzmin Cooper, MPHb Erica J. Harris, MDb Theodore J. Corbin, MD, MPHc
ABSTRACT Among young people in the United States, nonfatal violent injuries outnumber fatal violent injuries by 171 to 1. The Child Fatality Review Team (CFRT) is a well-established model for informing injury prevention planning. The CFRT’s restricted focus on fatal injuries, however, limits its ability to identify opportunities to prevent violent reinjury and address issues unique to nonfatal violent injuries. We adapted the CFRT model to develop and implement a Youth Nonfatal Violent Injury Review Panel. We convened representatives from 23 agencies (e.g., police, housing, and education) quarterly to share administrative information and confidentially discuss cases of nonfatal violent injury. In this article, we describe the panel model and present preliminary data on participants’ perceptions of the process. Although outcomes research is needed to evaluate its impacts, the Youth Nonfatal Violent Injury Review Panel offers an innovative, promising, and replicable model for interagency collaboration to prevent youth violence and its effects.
Drexel University School of Public Health, Department of Health Management and Policy, Philadelphia, PA
a
Drexel University College of Medicine, Center for Nonviolence and Social Justice, Philadelphia, PA
b
Drexel University College of Medicine, Department of Emergency Medicine, Philadelphia, PA
c
Address correspondence to: Jonathan Purtle, DrPH, MSc, Drexel University School of Public Health, Department of Health Management and Policy, 3215 Market St., 3rd Fl., Philadelphia, PA 19102; tel. 267-359-6167; fax 267-359-6001; e-mail . 2015 Association of Schools and Programs of Public Health
610
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Nonfatal violent injury is a common, but often underrecognized, problem among young people in the United States. In 2011, among those aged 0–18 years, 354,218 incidents of nonfatal hospital-treated violent injury occurred compared with 2,076 incidents of fatal violent injury (defined as nonsexual, intentional injury inflicted by another person)—a 171:1 ratio.1,2 In addition to the physical consequences of nonfatal violent injury, young people are at risk for psychological aftereffects, such as posttraumatic stress and depression.3–9 Many violently injured young people are reinjured after they leave the hospital.10 The estimated one-year violent reinjury rate among U.S. high school students is 9%,11 and a study of violently injured young people (mean age: 14.5 years) participating in a hospital-based violence intervention program (HVIP) found that 23% had previously sustained a violent injury resulting in medical care.12 Among adults, the five-year violent reinjury rate is estimated to be as high as 45%.13–18 Despite the high incidence of nonfatal violent injury, its consequences, and recurrent nature, little information exists about the issues that young people encounter after they sustain nonfatal violent injuries. Furthermore, the public health and medical literature provides little guidance about how public policies and systems might most effectively prevent violent reinjury and improve the health and social trajectories of violently injured young people. The Child Fatality Review Team (CFRT) is an established model that can potentially be adapted to facilitate a coordinated, systemslevel response to the problem of nonfatal violent injury. A CFRT is a multidisciplinary group of representatives from different sectors, such as education, health care, child welfare, law enforcement, and public health, who regularly convene to systematically discuss cases of child death and, occasionally, serious injuries.19,20 CFRT participants share data from their agencies about child decedents and the circumstances surrounding their deaths with the aim of identifying prevention opportunities.21–25 First established in Los Angeles, California, in 1978,26 the CFRT model has been widely adopted. As of 2012, a CFRT existed in every state in the United States27 and in many other countries.28–31 PURPOSE We adapted the CFRT model to develop and implement a Youth Nonfatal Violent Injury Review Panel in Philadelphia, Pennsylvania. By using the CFRT model to examine cases of nonfatal violent injury, the panel aimed to (1) identify issues encountered by violently injured young people during their recoveries and (2) generate empirically grounded recommendations
about how public policies and systems can more effectively meet the needs of violently injured young people and prevent violent reinjury. Furthermore, because the people meeting the case definition are still alive, we intended for the panel to produce tangible benefits for the violently injured young people who served as case subjects for panel discussions. The panel was funded as a practice-based, pilot initiative to promote interagency collaboration and systems solutions to address youth violence. We did not implement the panel as a research project, and the panel did not review a sufficient number of cases to attribute any outcomes (e.g., policy changes) to itself. As a result, we do not present evidence of effectiveness, but, rather, describe a novel and replicable model from the field and offer it as a blueprint for establishing Youth Nonfatal Violent Injury Review Panels—and a template for other interagency collaboration to address youth violence—in cities across the United States. METHODS Panel engagement and composition The staff of our organization—an academic center operating an HVIP that provides case management, behavioral health, and psychoeducational services to violently injured young people—designed and convened the panel. Informed by our knowledge of the CFRT model and local public systems and services, we developed a list of agencies to serve on the panel. We invited prospective panel participants via an e-mail that described the aims of the panel and included details about what participation would entail. We sent these e-mails to 44 agency leaders (e.g., commissioners and deputy directors), and all of the invited agency leaders agreed to participate. Although we did not explicitly limit the number of representatives who could attend from each agency, we requested at least one highlevel employee with policy-making authority and one employee who provides direct services (e.g., a dyad of a deputy police commissioner and patrol officer). The panel convened four times during the course of one year, and 44 individuals from 23 different agencies attended (Table 1). Case subject identification and interagency information sharing Violently injured young people participating in our HVIP served as case subjects for the panel discussions. The study subjects, aged 15–24 years, had received hospital care for nonfatal violent injuries resulting from blunt, knife, and firearm assaults. HVIP social workers identified these young people through daily reviews of
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Table 1. Organizations participating in a Youth Nonfatal Violent Injury Review Panel, Philadelphia, Pennsylvania, 2013–2014 Sector
Organization
Public
Department of Public Health Court System Department of Behavioral Health Department of Child Welfare Division of Juvenile Justice Office of Supportive Housing District Attorney’s Office Police Department Probation/Parole Department State Safe Schools Advocacy Office U.S. Congressperson’s Office U.S. Attorney’s Office
Community-based organizations
Violence Prevention Program Crime Prevention Program Grief Counseling Program Youth Enrichment Program
Health care
Family Medicine Psychology/Psychiatry Internal Medicine Emergency Medicine
Academia
College of Medicine School of Public Health
Other
Youth-Focused Philanthropy Public Defender’s Association
hospital electronic health record systems and recruited them to participate in the program after they had been medically cleared. A total of 66 violently injured young people completed intake and were fully enrolled in our program during the one-year panel period. To ensure that panel participants from different sectors were engaged in the meetings, we deliberately selected HVIP clients who were interacting with multiple public systems to serve as potential case subjects. After identifying these case subjects, we described to them (and their primary caregiver, if the young person was a minor) the purpose of the panel and what serving as a case subject would entail. We emphasized that agreeing to serve as a case subject was not required for continued HVIP services and that their real names would not be disclosed at the panel meetings. If interested in serving as a case subject, the young person or his/her primary caregiver signed a consent form granting our center permission to request information about the person from the participating panel agencies. Of the 66 violently injured young people who were fully enrolled in the HVIP during the panel period, six were invited to serve as case subjects. All six consented.
After the HVIP participants consented to serve as case subjects, we sent their names and other personal identifiers to a designated employee at each panel agency. We requested that this employee search agency records for information about the case subjects and their interactions with the agency before and after the nonfatal violent injury that was the focus of the case presentation. The employee sent this information to the center via secure e-mail. Panel agencies provided information, such as histories of involvement with child protective services, school records, and police reports. We typically received this information in a timely manner, but there were instances when the information provided was incomplete, an issue attributed to the transition from paper to electronic records within the agency. We used pseudonyms for all case subjects in the presentations. The designated employee who searched agency records for information about a case subject was not the same agency representative who attended the panel meetings. Thus, the agency representatives who attended the panel meetings were blind to the true identity of the case subjects, despite the fact that their agency provided information about the case subjects to the center. Case presentation format Each panel meeting lasted two hours and began with a 20-minute presentation about traumatic stress. Center staff provided these presentations, which covered topics about the epidemiology of traumatic stress; its physiological, social, emotional, and cognitive effects; and principles of trauma-informed care.32 We chose to integrate these presentations into panel meetings because all case subjects experienced violent injury trauma, and most had experienced multiple traumas in their lifetime. Following a 10-minute discussion about the content of the trauma presentation, HVIP social workers who were providing direct services to the case subjects presented cases. Using information obtained from panel agencies and collected through HVIP assessments (e.g., Survey of Children’s Exposure to Community Violence33 and Child Trauma Screening Questionnaire34), social workers presented subjects’ life histories using a series of slides. They placed emphasis on pre-injury circumstances and events related to violent injury risk (e.g., school and family environment, arrest history, and behavioral health issues),35–37 systems and services with which the case subject was currently involved, and specific challenges that the case subject was encountering post-injury. Social workers presented one or two cases at each panel meeting and each presentation lasted
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approximately 30 minutes. We did not invite the case subjects to attend panel meetings because we were concerned that the experience could be emotionally distressing for them. Discussion format After case presentation, center staff joined the HVIP social worker and co-facilitated a discussion about the case. Two center staff members captured panel discussions by writing notes on large notepads while a third staff member typed detailed notes. A list of questions that were informed by the Milwaukee Homicide Review Commission process,38 literature on interagency collaboration,39 and research about the experiences of HVIP participants40,41 helped structure the discussion. These questions included: • In what ways were agencies effective in responding to this injury? • How could your agency have more effectively served the case subject? • What strengths/assets does the case subject possess? • What systems/services currently exist to address the needs of the case subjects and prevent reinjury/other adverse outcomes? • Based on this case, what policy and systems-level change might need to be made? OUTCOMES: PERSPECTIVES OF PANEL PARTICIPANTS Two center staff members conducted semi-structured interviews with 13 panel participants in three weeks following the panel meeting. The interviews were conducted with a mix of high-level employees and direct service providers and explored their perceptions of the panel process. The aim of these interviews was not to evaluate the panel’s impact but to obtain preliminary feedback, identify opportunities to improve the panel process, and collect information to inform the selection of variables in a future outcome evaluation. Two center staff conducted the interviews in the three weeks following the final panel meeting. Interviews were audio recorded, transcribed, and analyzed using thematic content analysis. The interviews highlighted panel strengths, weaknesses, and areas for improvement (Table 2). Many participants emphasized the value of case subjects being living people—not deceased individuals as per the typical CFRT model—and expressed appreciation for the opportunity to hear different agencies’ perspectives on issues related to youth violence. The panel thought
the trauma presentations were beneficial, as they conveyed complex information in an accessible format and created a framework in which to guide productive interagency discussions. The interviews also identified panel weaknesses, and feedback offered suggestions for improvement. Interview respondents expressed a desire to ensure that panel recommendations translated into actual policy change and offered suggestions to improve the logistics of the panel, such as holding meetings more frequently and discussing a greater number of cases. Based on the interview findings, we identified interagency collaboration and knowledge about the recovery needs of violently injured young people as candidates for proximal outcome measures. LESSONS LEARNED We learned that it is possible to adapt the CFRT model for the purpose of reviewing cases of nonfatal violent injury in a confidential manner. We believe that using living individuals rather than decedents as case subjects can potentially illuminate challenges unique to the needs of young people who sustain nonfatal injuries and identify priorities for policy and systems-level change. We also propose that it is possible for this process to generate real-time suggestions and actions to address the immediate needs of violently injured young people. Although outcomes research is needed to test the empirical validity of these assumptions, the Youth Nonfatal Violent Injury Review Panel might offer an innovative, promising, and replicable model for interagency collaboration to prevent youth violence and its effects. All panel participants signed a confidentiality agreement when they entered the panel meetings. The Drexel University Institutional Review Board approved all aspects of the panel process.
REFERENCES 1. Centers for Disease Control and Prevention (US). Injury prevention and control: data and statistics (WISQARS™). Nonfatal injury data [cited 2015 Feb 6]. Available from: URL: http://www.cdc.gov /injury/wisqars/nonfatal.html 2. Centers for Disease Control and Prevention (US). Injury prevention and control: data and statistics (WISQARS™). Fatal injury data [cited 2015 Feb 6]. Available from: URL: http://www.cdc .gov/injury/wisqars/fatal_injury_reports.html 3. Kassam-Adams N, Marsac ML, Hildenbrand A, Winston F. Posttraumatic stress following pediatric injury: update on diagnosis, risk factors, and intervention. JAMA Pediatr 2013;167:1158-65. 4. Langeland W, Olff M. Psychobiology of posttraumatic stress disorder in pediatric injury patients: a review of the literature. Neurosci Biobehav Rev 2008;32:161-74. 5. Fein JA, Kassam-Adams N, Vu T, Datner EM. Emergency department evaluation of acute stress disorder symptoms in violently injured youths. Ann Emerg Med 2001;38:391-6. 6. Fein JA, Kassam-Adams N, Gavin M, Huang R, Blanchard D, Datner EM. Persistence of posttraumatic stress in violently injured youth
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Table 2. Participants’ perceptions of the Youth Nonfatal Violent Injury Review Panel process, Philadelphia, Pennsylvania, 2013–2014 Domain Strengths of the panel
Theme
Illustrative quotes
Having living people “I had to keep reminding myself—because I’ve sat through enough fatality serve as case subjects for reviews—that we were thinking about and talking about an active, living, thriving panel discussions person, and that there was an opportunity to intervene and change the course of his life.” “We’re at least working with living individuals . . . we can still make a difference in their lives. That’s really powerful to me, the fact that we’re reviewing it in real time and talking together about what our respective systems can do to support that young person . . . with the injury review panel, it’s real time.” Hearing multidisciplinary perspectives about youth violence
“I’m so glad that finally something like this has come together . . . everyone in the same room [having] some thoughtful discussion about the subject of traumainformed care and how each various entity is actually dealing with the same child and how they can work better to really help a child and their family.” “Hearing from people who [speak] a different language than what I’m used to and thinking about these problems from other perspectives has been really useful. It helps us come back to our work and think about things a little more broadly.”
Perspectives on trauma Providing a framework to presentations discuss cases of nonfatal violent injury in trauma presentations Shedding new light on post-injury trajectories in trauma presentations
“I think [the trauma presentations] really laid the foundation and really helped people appreciate why it was that we were coming together.” “[The trauma presentations] brought everyone back to the same central idea that this is how we think about things and this is sort of our mission . . . and gets everyone back to the idea that they’re speaking the same language.” “[The trauma presentations] simplified [trauma] so that everybody could appreciate what it is, what the effects are, [and] what it really means, and you can look at anyone in the community and look through a different lens and [say] ‘Oh, that’s what it was, that maladaptive personality or that maladaptive behavior . . .’” “[Trauma-informed practice] is like trigonometry. You know, to this day, I don’t know what to do with a cosine because I learned it in a vacuum. But here we are, sitting with the trauma before us, learning about it, and it made it more powerful.”
Weaknesses and recommendations to improve the panel
Ensuring that panel discussions move from the case subject level to the systems level
“We haven’t gotten yet to the point where people are talking really openly about ‘What are we going do to change our systems?’ There’s conversation about ‘What could we do for this particular kid? Where could you send him?’ but that’s kind of the frustration that I have so often, that you can help one kid at a time and that’s really important, but we haven’t gotten to conversations about system change . . .” “I don’t know that we’re as deliberate as we could be . . . [we need to] come together and really start to talk about which policies we need to look at.”
Requiring each agency to “I think it would be better to compel people to contribute rather than to leave it to comment on every case their own volition.” Establishing small working groups within the panel
“Have small working groups—people who do speak the same language—to say, ‘What part of this can we take?’ Where is it that we’re seeing a pattern of failure to serve kids? What can we do to address this pattern?’”
Convening the panel more frequently
“I think you lose something in keeping [the frequency of the panel meetings] spaced so far apart [the panel met every three months]. I think probably having them more frequently would be useful.”
Limiting panel “Some of the people at the table are the right people, but some aren’t . . . you participation to agency need to identify the decision makers.” representatives with decision-making authority
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