E. J. Kramer1,2, J. Dodington1, T. Henderson2, R. Dicker2, C. Juillard2 1Yale University School Of Medicine,New Haven, CT, USA 2University Of California San Francisco,Surgery,San Francisco, CA, USA
Introduction: Violent injury is the second most common cause of death among 15-24 year-olds in the US. Up to 45% of violently injured youth return to the emergency department with a second violent injury. Hospital-based violence intervention programs (HVIPs) have been shown to reduce injury recidivism through intensive case management to victims of violence at high risk for recidivism. To date, case manager gestalt has guided identification of victims at high risk for re-injury; no validated guidelines for risk-assessment strategies in the HVIP setting have been published. We aimed to use qualitative methods to investigate the key components of risk assessments employed by HVIP case managers in a mature HVIP with demonstrated effectiveness. We propose a risk assessment model based on this qualitative analysis, combined with literature review and review of current best practices of established HVIPs.
Methods: A qualitative approach was used due to the complexity and interconnectivity of inherently non-binary and socially-influenced risk factors. An established academic hospital-affiliated HVIP served as the nexus for this research. Thematic saturation was reached with 11 semi-structured interviews and 2 focus groups conducted with HVIP case managers and key informants identified through snowball-sampling. Interactions were audiotaped, transcribed, and analyzed by a four-member team using Nvivo and employing the constant comparison method. Risk factors identified were used to create a set of models presented in 2 follow-up HVIP case managers and leadership focus groups.
Results: Key themes emerged revolving around the imminent threat of violence, history of incarceration, dissociative behavior, weapons use, and pursuing “street”/gang lifestyle. In total, 141 potential risk factors for use in the risk assessment framework were identified. The most salient factors were incorporated into eight models that were presented to the HVIP case managers. A 29-item algorithmic structured professional judgment model was selected by focus group consensus. The model contains four categories of risk factors: high-risk (A), behavioral (B), severe conditional (C), and moderate conditional (D) factors. The presence of 1+ A factor indicates high-risk, while combinations of B/C/D factors can lead to an assessment of high-risk [Fig 1].
Conclusion: Qualitative methods identified four tiers of risk factors for violent re-injury that were incorporated into a proposed risk assessment instrument. Further research should assess the validity and generalizability of this instrument. A valid risk assessment instrument has the potential to identify high-risk individuals in diverse clinical settings, who may benefit from violence intervention strategies.
