“I was tired of seeing kids die on my shifts.”
That’s what Katie Donnelly, MD, MPH, emergency medicine physician and medical director of the Youth Violence Intervention Program at Children’s National Hospital, said after treating yet another young victim of gun violence.
A 6-year-old was rushed to the emergency department after being hit by a stray bullet.
Five years later, the same child was seen for post-concussive symptoms after being assaulted at school.
And at 16, they were shot in the chest, and the outcome looked grim.
"This chronic disease of community violence is incredibly common for kids across the country," Donnelly said.
Children’s hospitals know how to care for physical wounds, but how can they address the underlying issues?
Across the country, pediatric hospitals have developed or are in the process of developing hospital-based violence intervention programs (HVIP). HVIPs are comprehensive, multidisciplinary initiatives using a public health and trauma-informed approach to survivors of violent crimes and their families, with the goal of breaking the cycle of violence.
Research shows patients are more receptive to interventions after a violent injury. HVIPs have been effective in decreasing rates of reinjury and retaliation and increasing mental well-being.
HVIP partners often include adult hospitals, academic medical centers, law enforcement agencies, community-based organizations, and local governments. Many are developed in partnership with The Health Alliance for Violence Intervention (HAVI), which provides national expertise and advocacy for HVIPs and has a pediatric-focused subgroup.
The programs provide case management and wraparound support for victims of violence, connecting them with mental health services, providing mentors, teaching coping mechanisms, offering school support, and addressing other social drivers of health.
At Children’s National, Donnelly had seen kids with bullet wounds rushed in for treatment over and over again. She says they created an HVIP to try to prevent the next child from being shot.
Donnelly offers five tips any children’s hospital can use in developing their violence intervention program:
1. Get stakeholder buy-in from the start.
Violence intervention specialists involved in HVIPs are critical to ensure trust is built, messages are heard, and interventions are effective. These team members are focused on healing the psychological wounds caused by gun violence and engaging participants in ways traditional medical staff cannot.
Donnelly says HVIP staff should be representatives of the communities they serve. These individuals may be survivors of gun violence or formerly incarcerated and can share personal experiences that make them relatable communicators and mentors to participants.
But Donnelly says they may not be easy hires.
“Requiring a college degree is not always a realistic ask for the individuals who are going to be the most effective at this job,” Donnelly said. “You’ll have to make the argument with human resources that their life experiences make them a far more valuable employee to your program.”
At Children’s National, violence interventionists dress in bright orange fleece vests that look professional, but not too formal. Wearing street clothes makes these workers more approachable for participants, but they also need something consistent for staff to recognize their role.
2. Find the right partners.
No HVIP can offer all the services kids need, and that’s why partnerships are important in this work.
Internally, Donnelly partners with social workers, ED providers, and intensive care unit staff to make sure teams know about the program and send referrals.
Outside of Children's National’s walls, hospitals in the Washington, D.C., area with HVIPs gather monthly to talk about violence prevention efforts within the city. Intervention teams also tap into different government agencies and organizations dedicated to the work.
When Donnelly was looking to hire a violence intervention specialist at the hospital, she reached out to Jawanna Hardy, founder of Guns Down Friday, a nonprofit organization meant to reduce violence in the community Hardy grew up in.
“I might say something to a kid, and it just doesn’t resonate,” Donnelly said. “But when Miss Hardy says something, it does, and she works in a way that I’m not capable of.”
Violence interventionists are trained in conflict resolution, interpersonal relationships, and documentation. They also learn how to practice self-care and about units and treatments they will see throughout the hospital, like what the ICU is or what an intubation looks like.
3. Choose your focus population.
To have an effective HVIP, organizations should determine the primary population and needs to be addressed.
During this process, leaders should study patient populations and review injury types and demographics including age, location, gender, and ethnicity.
At Children’s National, Donnelly discovered most patients with recurring injuries from violence were under 14 years old, so she was going to need a specific pediatric approach. She also learned most violence happened within a chronically underserved area of the community. This allowed the team to tailor the program for the children who need it most.
4. Define your goals.
Once the population is defined, leaders should establish participant and program goals.
Common participant goals may be to prevent reinjury, reengage in school, obtain employment, obtain safe and stable housing, and manage anger.
Program goals may aim to develop educational materials, establish work protocols, connect with community partners, and train new skills. For example, an objective could be to have a 20% reduction in reinjuries from assault in one year.
5. Utilize data.
This growing public health problem continues to place a significant burden on children’s hospitals that can be demonstrated through data.
Donnelly used data to present the burden of violence among the hospital’s ED adolescent population and show the impact of firearm and assault injuries, return visits, and the need for ongoing care and support for survivors of violence.
Data was also used to determine when ED staff were most likely to connect with victims of violence. She looked at the time of day victims were coming into the hospital, if they were admitted, and the lengths of stay.
Gathering accurate process data is also essential for evaluating program effectiveness and making informed improvements. Staff maintain detailed logs on how often they approach patients about the program, the number of referrals made, follow-up efforts, and the frequency of patients who agree to participate.
Breaking the cycle
Gun violence affects more than just the children injured; it ripples through families, schools, and communities. Engaging patients in the hospital and during recovery is an essential opportunity to improve lives and reduce retaliation and recidivism.
And whether it’s at other children’s hospitals or at Children’s National, HVIPs across the nation can prevent and disrupt the cycles of violence.
“A journey of a thousand miles begins with a single step, so take that first step with me for the better in your communities, and because a better world is possible,” Donnelly said.
This article is based on a presentation from the Children’s Hospital Association’s Keeping Kids Safe webinar series.
