Firearm violence is a leading cause of morbidity and mortality among adolescents and young adults in the United States. Prior research has identified numerous predictors of non-fatal firearm injury; however, there is limited evidence on the longitudinal impacts of violence exposure during adolescence specifically on firearm violence victimization later in life. Using data from the first three waves (1994-2002) of the National Longitudinal Study of Adolescent to Adult Health (Add Health), we conducted a path analysis using survey-weighted generalized structural equation models to identify associations between exposures to violence and weapons during adolescence and firearm violence victimization during early adulthood. Analyses controlled for participant age, sex, race/ethnicity, and rurality of residence as reported in Wave 1. In fully adjusted and trimmed models, violence perpetration, violence exposure, and weapon carrying in adolescence were independently associated either directly or indirectly with participants' self-reports of being shot and with having a gun pulled on them in early adulthood. Firearm violence victimization in Wave 1 was associated with being shot in Wave 3. A notable path between violence exposure in Wave 1 and being shot in Wave 3 was via weapon carrying in Wave 2. Interventions aimed at reducing weapon carrying among adolescents who have been exposed to violence may represent a modifiable way in which firearm violence victimization in early adulthood can be reduced.

Emerging adults are disproportionately at risk for substance misuse and assault injury. Assault-injured emerging adults with substance misuse have increased risk of morbidity and mortality compared to those without and often receive care in the Emergency Department (ED). This manuscript describes the development of a protocol for a pilot randomized trial of an adapted brief behavioral intervention, the Brief Negotiation Interview (BNI), for use among assault-injured emerging adults with alcohol and/or cannabis misuse presenting to the ED. First, we will perform a mixed methods study of assault-injured emerging adults with alcohol and/or cannabis misuse to elicit the shared psychosocial risk factors that contribute to both alcohol and/or cannabis misuse in the context of assault injury. We will then use these data to adapt the BNI for use among assault-injured emerging adults with alcohol and/or cannabis misuse. We will evaluate the feasibility and acceptability of the adapted BNI in a randomized trial in the ED setting (N = 50). This pilot study is a critical initial step in developing an effective brief behavioral intervention for reducing alcohol and cannabis use among assault-injured emerging adults. Trial Registration Number NCT07070414.

OBJECTIVE:Unintentional ingestions in children are a common presenting chief complaint in the emergency department (ED). The decision to consult social work or report to Child Protective Services (CPS) relies on the provider's discretion. We sought to investigate the association between race or insurance status and providers' decisions. METHODS:A retrospective cross-sectional study of children younger than 6 years of age presenting to 1 of 6 hospitals within the Yale New Haven Health system in 2013 to 2021 with an ICD-9/10 code of poisoning or accidental ingestion. Multivariable logistic regression was used to assess factors associated with social work and CPS consults. RESULTS:Among 759 children with unintentional ingestions, there were 467 (48.4%) ingestions of over-the-counter substances, 359 (47.3%) ingestions of prescription medications and 24 (3.2%) ingestions of illicit substances. Medication error by caregiver accounted for 46 cases (6.1%). Social work was consulted in 23% of cases. Factors associated with social work consults were changes in baseline mental status and vital signs (adjusted odds ratio [aOR]=3.35 [95% CI: 1.62-6.92]), requiring inpatient care (aOR=14.3 [8.04-25.6]), PICU admission (aOR=24.5 [5.57-107.9]), and having toxicology tests ordered (aOR=3.2 [1.85-5.51]). Presentation to a general ED decreased the odds of a social work consult (aOR=0.14 [0.08-0.24]). CPS reports were filed in 6.7% of cases. Factors associated with CPS reports were ingestion type (prescription aOR=2.73 [95%CI 1.19-6.27]; substances illegal for a minor [eg, alcohol, nicotine, THC-containing products] aOR=21.8 [6.76-70.4]), change in mental status or vital signs from baseline (aOR=3.18 [1.39-7.26]), requiring inpatient care (aOR=4.17 [1.95-8.91]) PICU (aOR=6.23 [95%CI 1.67-23.3]) and having toxicology tests ordered (aOR=3.6 [1.71-7.57]). CONCLUSIONS:In children presenting after unintentional ingestion, involvement of social work or CPS was associated with clinical severity and substance type but not with race or insurance status.

IMPACT:Motor vehicle deaths have declined due to safety regulations and policies, but firearm deaths have not seen similar efforts or outcomes. No regulatory agencies focus on firearm safety and some laws prohibit liability for firearm manufacturers from firearm-related harm. Challenges to federal laws prohibiting sales of handguns to individuals under 21 years old may have important implications for suicides among 18-20 year-olds and for homicides in all ages. Secure firearm storage education and Community Violence Intervention programs are two strategies to reduce firearm-related injuries. Ongoing research and advocacy are essential to reduce pediatric firearm violence.

Injury is the leading cause of death and a frequent cause of disability in children and negatively affects physical health, mental health, and quality of life in both the short- and long-term. The goal of a pediatric trauma system is to optimize the care for children within a state or region encompassing the entire continuum of care regardless of where children live or where traumatic events occur. This continuum includes injury prevention, prehospital care, emergency department care, interfacility transport, acute and critical inpatient care, inpatient and outpatient rehabilitation, and reintegration into the community and primary care medical home. A systems-based approach requires distinct elements of structure and function to perform together in an interrelated and cohesive manner to improve care quality. In this case, it represents a sequential practice of evidence-based evaluation and management along the continuum of care. To improve outcomes after injury, a cohesive system must effectively provide optimal care for the “right child, at the right place, at the right time” across this continuum.

Injury is the leading cause of death and a cause of disability in children and negatively affects physical health, mental health, and quality of life in both the short- and long-term. The goal of a pediatric trauma system is to optimize the care for children within a state, regional, or national trauma system across the entire continuum of care regardless of where they live or where the traumatic event occurs. This continuum includes injury prevention, prehospital care, interfacility transport between hospitals providing different levels of care, acute and critical inpatient care, inpatient and outpatient rehabilitation, and reintegration into the community and primary care medical home. A systems-based approach, one that requires distinct elements of structure and function to perform together in an interrelated and cohesive manner to improve care quality, is essential. To improve outcomes after injury, a cohesive system must effectively provide optimal care for the “right child, at the right place, at the right time” across this continuum.

OBJECTIVE:To determine if the utilization of an Electronic Health Record-integrated clinical pathway increased the provision of recommended medical and forensic care to adult sexual assault survivors in the ED. METHODS:This was a retrospective chart review of 552 adult survivors of sexual assault who received care at a health care system in the Northeast between January 1, 2020, and December 31, 2022. Our six outcomes were the proportion of patients who were offered a consultation with a sexual assault advocate, the proportion of patients who had the sexual assault forensic evidence kit collected, pregnancy test ordered, emergency contraception ordered, HIV post-exposure prophylaxis ordered, and sexually transmitted infection prophylaxis ordered. Primary analysis compared the impact of the pathway on outcomes before and after the implementation. Secondary analysis included the impact on outcomes of pathway use compared to non-pathway use after implementation. RESULTS:The pathway was used in 128 (51%) patient encounters after it was implemented. Offering consultation with a sexual assault advocate and ordering HIV post-exposure prophylaxis improved post-implementation compared to pre-implementation. In the post-implementation period, there was an improvement in recommended medical and forensic care across all outcomes, including offering an advocate, collecting forensic evidence, ordering STI prophylaxis, HIV PEP, pregnancy tests, and emergency contraception. Patients were less likely to have a SAFE kit collected if the pathway was not used compared to pre-implementation. CONCLUSIONS:Pathway usage led to improved medical and forensic care of sexual assault survivors. Implementation of Electronic Health Record-integrated clinical pathways requires active use of the pathway rather than indirect learning from the presence of the pathway.

To gain insight into how youth who live amid community violence define resilience, identify supportive social connections, and describe their needs when coping with traumatic experiences in an effort to inform public health approaches to Community Violence Intervention. This qualitative study represents a community-based participatory research project. Twenty-two youths aged 14 to 25 engaged in semi-structured interviews. Thematic analysis was completed and then triangulated with community members. Demographic data were characterized by frequency statistics. A youth-driven resilience framework was derived with three components: acceptance of adversity, perseverance, and self-reliance. Participants described coping mechanisms, expectations of adult support members, and a predilection for a small social support system. Findings build on previous work and underscore the importance of independence, perseverance, acceptance, and family for youth experiencing community violence. Youth may have an interest in interventions that foster safe, supportive, nurturing relationships with parents. Youth perspective can inform community violence prevention efforts and lead to more effective community intervention strategies.

STUDY OBJECTIVE:We evaluate the impact of the COVID-19 pandemic on care for survivors of sexual assault in three urban Emergency Departments (ED) in the United States. METHODS:A retrospective chart review was conducted on patients who presented after sexual assault to three EDs during 6-month intervals before and during the COVID-19 pandemic. We excluded individuals <18 years old. We performed a structured chart review to ascertain demographics, ED treatments, and adherence to guidelines for care of sexual assault survivors. RESULTS:Of 105 patients who received care after a sexual assault, 57 presented during the COVID-19 pandemic. The majority were female, White/Caucasian, and presented within 120 h of sexual assault. There was an increase in ED presentations for sexual assault during the pandemic. While there was no difference in medical care, there were fewer sexual assault advocates called during the pandemic. In addition, there was an increase in non-White survivors in the first 3 months of the pandemic that did not remain at 6 months. CONCLUSION:The care of survivors in the ED was disrupted by the COVID-19 pandemic. While medical care remained similar, fewer calls to sexual assault advocates, a key component of ED and long-term care of survivors, demonstrate a disruption in their care.

Injuries and deaths due to firearms in children and young adults is a public health crisis in the United States. Pediatric clinicians are powerful advocates to reduce harm due to firearms. By forming coalitions with legislators on a bipartisan basis, working with government relations teams in the hospitals, and partnering with community allies and stakeholders, pediatric clinicians can work to enact legislation and influence policies at the individual, state, and national levels. This can include advocacy for strengthening Child Access Prevention Laws and firearm safer storage campaigns.

Background Injuries, the leading cause of death in children 1–17 years old, are often preventable. Injury patterns are impacted by changes in the child’s environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic. Methods This multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00–T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020. Results The study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% ( p < 0.001) and deaths increased 0.03% ( p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (− 4.9%) and overexertion (− 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019. Conclusions The proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

Injuries and deaths due to firearms in children and young adults is a public health crisis in the United States. Pediatric clinicians are powerful advocates to reduce harm due to firearms. By forming coalitions with legislators on a bipartisan basis, working with government relations teams in the hospitals, and partnering with community allies and stakeholders, pediatric clinicians can work to enact legislation and influence policies at the individual, state, and national levels. This can include advocacy for strengthening Child Access Prevention Laws and firearm safer storage campaigns.

Background Individuals who experience assaultive firearm injury are at elevated risk for violent reinjury and multiple negative physical and psychological health outcomes. Hospital-based violence intervention programs (HVIPs) may improve patient outcomes through intensive, community-based case management.Methods We conducted a multimethod evaluation of an emerging HVIP at a large trauma center using the RE-AIM framework. We assessed recruitment, violent reinjury outcomes, and service provision from 2020 to 2022. Semistructured, qualitative interviews were performed with HVIP participants and program administrators to elicit experiences with HVIP services. Directed content analysis was used to generate and organize codes from the data. We also conducted clinician surveys to assess awareness and referral patterns.Results Of the 319 HVIP-eligible individuals who presented with non-fatal assaultive firearm injury, 39 individuals (12%) were enrolled in the HVIP. Inpatient admission was independently associated with HVIP enrollment (OR 2.6, 95% CI 1.3 to 5.2; p=0.01). Facilitators of Reach included engaging with credible messengers, personal relationships with HVIP program administrators, and encouragement from family to enroll. Fear of disclosure to police was cited as a key barrier to enrollment. For the Effectiveness domain, enrollment was not associated with reinjury (OR 0.70, 95% CI 0.16 to 3.1). Participants identified key areas of focus where needs were not met including housing and mental health. Limited awareness of HVIP services was a barrier to Adoption. Participants described strengths of Implementation, highlighting the deep relationships built between clients and administrators. For the long-term Maintenance of the program, both clinicians and HVIP clients reported that there is a need for HVIP services for individuals who experience violent injury.Conclusions Credible messengers facilitate engagement with potential participants, whereas concerns around police involvement is an important barrier. Inpatient admission provides an opportunity to engage patients and may facilitate recruitment. HVIPs may benefit from increased program intensity.Level of evidence IV.

Firearm injury is the leading cause of death in children and adolescents in the US, surpassing motor vehicle crashes. There is a need for greater legislative advocacy around firearm injury prevention, specifically around safer storage of firearms. A national medical trainee-based program convened in 2021 with the goal of increasing advocacy efforts around common causes of pediatric injury. A focus was to create a set of advocacy training tools that could be utilized by a wide variety of stakeholders. The subgroup sought to design policy-based training tools; one focused on general firearm injury prevention principles and another specifically focused on Child Access Prevention (CAP) laws. We explicate the utility of these documents and the need for greater advocacy around pediatric firearm injuries

Community violence happens between unrelated individuals, who may or may not know each other, generally outside the home, and often results in assaultive injuries. Community violence interventions can prevent assaultive injuries and assist victims of community violence. Trauma-informed care is foundational to the success of community violence intervention. Place-based environmental interventions can decrease community violence on the population level, and further research and developments are needed in this area. Substance use is a significant barrier to intervention program involvement and greater research and program development is needed to support substance use treatment of those impacted by community violence.

BACKGROUND Survivors of gun violence have significant sequelae including reinjury with a firearm and mental health disorders that often go undiagnosed and untreated. The Screening and Tool for Awareness and Relief of Trauma (START) is a targeted behavioral mental health intervention developed for patients who come from communities of color with sustained and persistent trauma. METHODS In this pilot study, we evaluate the feasibility of completing a randomized controlled trial to test the START intervention. Using a mixed methods study design, we used both quantitative and qualitative data collection to assess the START intervention and the feasibility of completing a randomized controlled trial. The purpose of this study was to estimate important study parameters that would enable a future randomized controlled trial. RESULTS We were able to make conclusions about several crucial domains of a behavioral intervention trial: (1) recruitment and retention—we had a high follow-up rate, but our recruitment was low (34% of eligible participants); (2) acceptability of the intervention—the addition of audiovisual resources would make the tools more accessible; (3) feasibility of the control—more appropriate for a stepped wedge cluster randomized controlled trial design; (4) intervention fidelity—there was an 81% concordance rate between the fidelity survey results and the audio recordings; (5) approximate effect size—there was a 0.4-point decrease in the PTSD Checklist—Civilian Version in the control compared with a 10.7-point decrease in the treatment group for the first month. CONCLUSION While it was feasible to conduct a randomized controlled trial, our findings suggest that a stepped wedge cluster randomized controlled trial design may be the most successful trial design for the START intervention. In addition, the inclusion of a “credible messenger” to recruit participants into the study and the development of audiovisual resources for START would improve recruitment and effectiveness. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.

Background: Homicide is a major cause of death and contributes to health disparities in the United States. This burden overwhelmingly affects people from racial and ethnic minority populations as homicide occurs more often in neighborhoods with high proportions of racial and ethnic minority residents. Research has identified that environmental factors contribute to variation in homicide rates between neighborhoods; however, it is not clear why some neighborhoods with high concentrations of racial and ethnic minority residents have high homicide rates while neighborhoods with similar demographic compositions do not. The aim of this study was to assess whether relative socioeconomic disadvantage, (i.e., income inequality), or absolute socioeconomic disadvantage (i.e., income) measured at the ZIP code- and state-levels, is associated with high homicide rates in US ZIP codes, independent of racial and ethnic composition. Methods: This ecological case-control study compared median household income and income inequality in 250 ZIP codes with the highest homicide rate in our sample in 2017 (cases) to 250 ZIP codes that did not experience any homicide deaths in 2017 (controls). Cases were matched to controls 1:1 based on demographic composition. Variables were measured at both the ZIP code- and state-levels. Results: Lower median household income at the ZIP code-level contributed most substantially to the homicide rate. Income inequality at the state-level, however, was additionally significant when controlling for both ZIP code- and state-level factors. Conclusions: Area-based interventions that improve absolute measures of ZIP code socioeconomic disadvantage may reduce gaps in homicide rates.

Introduction: The clinical model of screening, providing a brief psychosocial and/or pharmacological intervention, and directly referring patients to treatment (SBIRT) is a compelling model to address drug use among assault-injured individuals in the busy emergency department (ED) setting. Our objective in this study was to examine the current literature and determine ED-based strategies that have been reported that screen, directly refer to drug mis-use/addiction specialized treatment services, or initiate addiction treatment among individuals injured by non-partner assault in the United States. Methods: We conducted a systematic review of ED-based studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol. OVID, MEDLINE, OVID Embase, OVID AMED, Web of Science-Core Collection, Cochrane CENTRAL, and CINAHL were systematically searched using keywords and Medical Subject Heading terms. Studies were excluded if they only involved intimate partner assault-injury, tobacco, or alcohol use. We categorized ED-based strategies as screening, direct referral, or treatment initiation. Results: Of the 2,076 non-duplicated studies identified, we included 26 full-text articles in the final analysis. Fourteen studies were cross-sectional, 11 were cohort, and one was case-control in design. The most common drug use screening instrument used was the National Institute on Drug Abuse Quick Screen Question. Cannabis was the most common drug detected upon screening. Conclusion: Drug use, while highly prevalent, is a modifiable risk factor for non-partner assault-injury. The paucity of scientific studies is evidence for the need to intentionally address this area that remains a major challenge for the public’s health. Future research is needed to evaluate ED-based interventions for drug use in this population.