Characteristics of the trauma recidivist: an exploratory descriptive study

Risk factors and predictors of violence: insights from the emergency department at a level 1 trauma center in the USA

BACKGROUND

This study aimed to assess the risk factors and predictors of violence among patients admitted to a Level 1 trauma center in a single institution.

METHODS

We conducted a retrospective analysis of patients who were admitted with a history of violence between 2012 and 2016.

RESULTS

A total of 9855 trauma patients were admitted, of whom 746 (7.6%) had a history of violence prior to the index admission. Patients who had history of violence were younger and more likely to be males, Black, Hispanic and covered by low-income primary payer in comparison to non-assault trauma patients (P < 0.001 for all). Multivariate logistic regression analysis showed that covariate-adjusted predictors of violence were being Black, male having low-income primary payer, Asian, drug user, alcohol intoxicated and smoker.

CONCLUSIONS

Violence is a major problem among young age subjects with certain demographic, social and ethnic characteristics. Trauma centers should establish violence injury prevention programs for youth and diverse communities.

Violence Prevention Programs Are Effective When Initiated During the Initial Workup of Patients in an Urban Level I Trauma Center

This study represents the first attempt at evaluating the ability of the CureViolence Hospital-Response Intervention Program (previously CeaseFire) to disrupt the pattern of violent reinjury. The clinical data points of 300 African American men who presented to our trauma center with a gunshot wound and received intervention at the bedside between 2005 and 2007 (with a 48-month follow-up) were collected. This cohort was matched with a post hoc historical control group using hospital records from 2003 to 2005. The mean age for both groups was 23.9 years. Odds ratios and 95% confidence intervals were obtained. Using a binary logistical regression model, we assessed the performance of three variables of interest: age at the time of the initial injury, treatment group, and initial disposition group to predict recidivism. We utilized the Nagelkerke R square method, which described the proportion of the variance of the reinjury rate and validated our findings using the Hosmer-Lemeshow test (for goodness-of-fit). Six percent (n = 18) of subjects in the treatment group and 11% (n = 33) in the control group returned with a new injury, yielding a total reinjury rate of 8.5%. Most patients returned only once with another violent injury. Individuals who did not receive CureViolence services were nearly twice as likely (odds ratio = 1.94; 95% confidence interval = 1.065, 3.522) to return with a violent reinjury. This finding suggests that Hospital-Response Intervention Programs (HRIP) have a protective effect in violently injured patients. We therefore conclude our HRIP positively affected at-risk patients and prevented violent reinjury.

Treating trauma more effectively: A review of psychosocial programming

IMPORTANCE

Traumatic events are the leading cause of life-altering disability in adults of working age. The management of patients with traumatic injury has substantially improved due to development of sophisticated trauma centers increasing survival after injury. Unlike the adoption of the trauma system framework, the same has not occurred with specialized trauma recovery services to include mental and social health needs. This literature review will discuss unique issues facing trauma survivors, some current recovery programs available, outcomes and benefits of these programs, and barriers that impair widespread incorporation.

OBSERVATIONS

Studies have shown that patients with traumatic injury experience reduction in quality of life and concurrent threats to mental health, including post-traumatic stress disorder (PTSD), alcohol use disorder, and recreational substance abuse. Patients with traumatic injury also have high recidivism rates, low pain management satisfaction, and poor engagement in care following injury. Screening efforts for PTSD, mental illness, and alcohol and substance abuse are more widely available interventions. Early coordinated efforts included dedicated multidisciplinary recovery teams. Recently, more methodical and organized programs, such as the Trauma Survivors Network, trauma collaborative care, Trauma Recovery Services, and Center of Trauma Survivorship, have been implemented.

CONCLUSIONS AND RELEVANCE

The enrollment of patients with traumatic injury in novel programs to enhance recovery has led to heightened self-efficacy, better coping mechanisms, and increased use of mental health services. Additionally, trauma recovery services have been shown to reduce recidivism and have generated cost savings for hospital systems. While positive outcomes have been demonstrated, they are not consistently predictable. Barriers for widespread implementation include limitations of time, funding, and institutional support. This article describes models of successful programs initiated within some trauma centers, which may be duplicated to serve future trauma survivors.

Recidivism at the puerto rico trauma hospital

Purpose

Although trauma represents a leading cause of morbidity and mortality worldwide, there is limited and heterogeneous evidence regarding trauma recidivism and its outcomes. This analysis determined the rate and independent risk factors of trauma recidivism and compared the first and second injury episode among recidivists.

Methods

An IRB-approved retrospective cohort study was performed with data from the Puerto Rico Trauma Hospital Registry. Bivariate analyses were done using Pearson’s Chi squared, Wilcoxon rank-sum, McNemar, Stuart-Maxwell or Wilcoxon signed-rank tests, as appropriate. Independent predictors for recidivism were determined through a logistic regression model. Statistical significance was set at p < 0.05.

Results

24,650 patients were admitted to the hospital during 2000–2017. Recidivism rate was 14 per 1,000 patients discharged alive. Males and individuals aged 15–24 years old were 3.88 (95% CI: 2.21–6.80) and 3.80 (95% CI: 2.24–6.46) times more likely to be recidivists, respectively. Contrariwise, an ISS \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 25 [adjusted odds ratio (AOR) = 0.44; 95% CI: 0.28–0.68] and a GCS \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\le$$\end{document}≤ 8 (AOR = 0.56; 95% CI 0.34–0.92) were protective factors. Furthermore, recidivists exhibited less in-hospital mortality than their non-recidivist counterparts (7.2% vs. 10.7%; p = 0.045).

For recidivists, the median (interquartile range) time to reinjury was 42 (59) months; and the second injury episode was more severe than the first one, as the proportion of patients with ISS \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 25 increased (7.9% vs. 14.1%; p = 0.022).

Conclusion

The independent predictors of trauma recidivism and the median time to reinjury identified in this study provide valuable information to the development of prevention strategies aimed at reducing the burden of injury.

The Complexity of Adaptation to Childhood Polyvictimization in Youth and Young Adults: Recommendations for Multidisciplinary Responders

Exposure to violence is pervasive in our society. An abundance of research has demonstrated that individuals who experience polyvictimization (PV)-prolonged or multiple forms of traumatic victimizations-are at heightened risk for continuing to experience repeated victimizations throughout their lifetimes. The current article reviews several overlapping constructs of traumatic victimizations with the ultimate goal of providing a unifying framework for conceptualizing prolonged and multiple victimization (defined in this article as PV) as a precursor to complex post-traumatic biopsychosocial adaptations, revictimization, and in some instances reenactment as a perpetrator (defined as complex trauma [CT]). This model is then applied to three socially disadvantaged victim populations-lesbian, gay, bisexual, transgender, queer, or questioning; commercially sexually exploited individuals; and urban communities of color-who are at heightened risk for PV and for exhibiting complex clinical presentations to demonstrate how the PV-CT framework can destigmatize, reframe, and ultimately reduce health disparities experienced by these populations. Trauma-informed recommendations are provided to aid researchers and multidisciplinary providers working to reduce harm and improve the quality of life for polyvictims.

Association between the detection of alcohol, illicit drugs and/or psychotropic medications/opioids in patients admitted due to trauma and trauma recidivism: A cohort study

OBJECTIVE

To quantify the association between the presence and type of drug detected and trauma recidivism in a cohort of patients admitted due to trauma.

METHOD

A cohort study was conducted based on data from a project where the presence of alcohol and other drugs (cannabis, cocaine, amphetamines, methamphetamines, tricyclic antidepressants, barbiturates, opiates and benzodiazepines) was analysed in 1,187 patients aged 16 to 70 years admitted due to trauma. The patients were followed for a period of between 10 to 52 months until June 2016. For this study, the recurrence of injuries from a sample of 929 patients from this cohort was analysed according to their consumption profile. Survival curves were estimated and adjusted Hazard Rate Ratios (aHRR) and adjusted incidence rate ratios (aIRR) were calculated.

RESULTS

The incidence rate of TR was 10.94 cases per 100 patient-years in the group of patients negative for substances and 27.99 per 100 patient-years in positive patients. The survival curves show very significant differences in cumulative recurrence-free survival between the groups (Log Rank: p<0.001). Both the aHRR and the aIRR estimates show an increased risk of re-injury due to alcohol consumption (aIRR: 2.33 (1.72-3.15), p<0.001), cannabis use (aIRR: 1.87 (1.09-3.20), p = 0.022) and polydrug use (aIRR: 2.34 (1.80-3.04), p<0.001).

CONCLUSIONS

The presence of alcohol and/or illicit drugs in these patients doubles the risk of trauma recidivism.

Methodological Considerations for Research With Black Male Victims of Violent Injury in an Urban Trauma Unit

There is a body of research over the last three decades that has focused on the etiology of violence among victims of violent injury. This body of literature indicates that Black men are disproportionately represented among victims of violent injury seen in emergency departments and trauma centers across the country. Despite the disproportionate number of low-income young Black men treated for violent injury in urban trauma units and the growing body of literature accompanying it, little is known about the unique methodological challenges violent injury researchers face when conducting research on this vulnerable population in a clinical setting. This article describes the unique and often nuanced methodological difficulties a research team encountered while conducting a longitudinal qualitative study on risk factors for repeat violent injury among low-income young Black male victims of violent injury treated at a Level II trauma center in the Eastern United States. Four methodological challenges are identified: (a) the identification and screening of participants, (b) recruitment and interviewing, (c) understanding hospital culture, policies, and procedures, and (d) retention and attrition of sample. Recommendations to overcome these challenges are offered.

A systematic review of socioeconomic status measurement in 13 years of U.S. injury research

OBJECTIVE

The purpose of this review was to assess the impact of socioeconomic status (SES) on injury and to evaluate how U.S. injury researchers have measured SES over the past 13years in observational research studies.

DESIGN & METHODS

This systematic review included 119 US injury studies indexed in PubMed between January 1, 2002 and August 31, 2015 that used one or more individual and/or area-level measures of SES as independent variables. Study findings were compared to the results of a previous review published in 2002.

RESULTS

Findings indicate SES remains an important predictor of injury. SES was inversely related to injury in 78 (66%) of the studies; inverse relationships were more consistently found in studies of fatal injury (77.4%) than in studies of non-fatal injury (58%). Approximately two-thirds of the studies (n=73, 61%) measured SES along a gradient and 59% used more than one measure of SES (n=70). Studies that used a gradient measure of SES and/or more than one measure of SES identified significant relationships more often. These findings were essentially equivalent to those of a similar 2002 review (Cubbin & Smith, 2002).

CONCLUSIONS

There remains a need to improve measurement of SES in injury research. Public health training programs should include best practices for measurement of SES, which include: measuring SES along a gradient, selecting SES indicators based on the injury mechanism, using the smallest geographic region possible for area-level measures, using multiple indicators when possible, and using both individual and area-level measures as both contribute independently to injury risk. Area-level indicators of SES are not accurate estimates of individual-level SES.

PRACTICAL APPLICATIONS

Injury researchers should measure SES along a gradient and incorporate individual and area-level SES measures that are appropriate to the injury outcome under study.

Violent reinjury risk assessment instrument (VRRAI) for hospital-based violence intervention programs

BACKGROUND

Violent injury is the second most common cause of death among 15- to 24-year olds in the US. Up to 58% of violently injured youth return to the hospital with a second violent injury. Hospital-based violence intervention programs (HVIPs) have been shown to reduce injury recidivism through intensive case management. However, no validated guidelines for risk assessment strategies in the HVIP setting have been reported. We aimed to use qualitative methods to investigate the key components of risk assessments employed by HVIP case managers and to propose a risk assessment model based on this qualitative analysis.

MATERIALS AND METHODS

An established academic hospital-affiliated HVIP served as the nexus for this research. Thematic saturation was reached with 11 semi-structured interviews and two focus groups conducted with HVIP case managers and key informants identified through snowball sampling. Interactions were analyzed by a four-member team using Nvivo 10, employing the constant comparison method. Risk factors identified were used to create a set of models presented in two follow-up HVIP case managers and leadership focus groups.

RESULTS

Eighteen key themes within seven domains (environment, identity, mental health, behavior, conflict, indicators of lower risk, and case management) and 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 chosen.

CONCLUSIONS

We identified four tiers of risk factors for violent reinjury that were incorporated into a proposed risk assessment instrument, VRRAI.

Trauma recidivism at an emergency department of a Swedish medical center

Background

To inform targeted prevention, we studied patterns of trauma recidivism and whether a first injury predicts the risk for a recurrent injury.

Methods

In a population-based study of 98,502 adult injury events 1999–2012, at the emergency department of Umeå University Hospital, Sweden, we compared non-recidivists with recidivists in terms of patients’ sex, age, type of injury and severity of the injury.

Results

Thirty-six percent of all patients suffered recurrent injuries, which were associated with a higher proportion of inpatient care and more hospital days. Young men and elderly women were at the highest risk for trauma recidivism. At 20 to 24 years, men had a 2.4 (CI 95 % 2.3–2.5) higher risk than women, a 90 years old woman had almost a 10-fold higher risk for another moderate/severe injury than a 20 years old one. A fracture were associated with a hazard ratio of 1.28 (CI 95 % 1.15–1.42) among men younger than 65 years and 1.31 (CI 95 % 1.12–1.54) for men older than 65 years for a subsequent moderate/severe injury. For women younger than 65 years a fracture was associated with a hazard ratio of 1.44 (CI 95 % 1.28–1.62) for a subsequent moderate/severe injury. A sprain carries a higher risk for a new moderate/severe injury for both men and women and in both age groups; the hazard ratio was 1.13 (CI 95 % 1.00–1.26) for men younger than 65 years, 1.42 (CI 95 % 1.01–1.99) for men older than 65 years, 1.19 (CI 95 % 1.05–1.35) for women younger than 65 years and 1.26 (CI 95 % 1.02–1.56) for women older than 65 years. A higher degree of injury severity was associated with a higher risk for a new moderate/severe injury.

Conclusion

Trauma recidivism is common and represents a large proportion of all injured. Age and sex are associated with the risk for new injury. Injury types and severity, also have implications for future injury.

Risk factors for recurrent violent injury among black men

BACKGROUND

Black men are disproportionately overrepresented among victims of repeat violent injury. However, little is known about the risk factors that influence violent trauma recidivism among black men. We hypothesize that the following risk factors would be significant among black male victims of repeat violent injury: disrespect; being under the influence; being in a fight and using a weapon in the past year; and previous incarceration when comparing trauma recidivists versus nonrecidivists.

METHODS

Using secondary data analysis, we identified a sample of 191 (n = 191) urban low-income black men treated by a level I trauma unit in Baltimore for violent injury (e.g., gunshot wound, stabbing, or assault) who participated in a hospital-based violence intervention program from 1998 to 2011. Participants in the program completed a risk factor for violent injury questionnaire to assess: exposure to chronic violence, criminal justice involvement, substance abuse, and disrespect (code of the street).

RESULTS

We found that 58% of the sample is characterized as trauma recidivists (defined as hospitalization two or more times for violent injury). Black male patients of violent injury who engage in the following: substance abuse; had previously been in a fight or used a weapon in the past year; perceived disrespect as a precursor to violence; and experienced a previous incarceration were more likely to have multiple hospitalizations for violent injury.

CONCLUSIONS

Trauma recidivism among urban black male victims of violent injury is a major public health issue. Hospital-based violence intervention programs should be engaged in reducing trauma recidivism among this population.

Who Shot Ya? How Emergency Departments Can Collect Reliable Police Shooting Data

This paper examines an alternative solution for collecting reliable police shooting data. One alternative is the collection of police shooting data from hospital trauma units, specifically hospital-based violence intervention programs. These programs are situated in Level I trauma units in many major cities in USA. While the intent of these programs is to reduce the risk factors associated with trauma recidivism among victims of violent injury, they also collect reliable data on the number of individuals treated for gunshot wounds. While most trauma units do a great job collecting data on mode of injury, many do not collect data on the circumstances surrounding the injury, particularly police-involved shootings. Research protocol on firearm-related injury conducted in emergency departments typically does not allow researchers to interview victims of violent injury who are under arrest. Most victims of nonfatal police-involved shootings are under arrest at the time they are treated by the ED for their injury. Research protocol on victims of violent injury often excludes individuals under arrest; they fall under the exclusion criteria when recruiting potential participants for research on violence. Researchers working in hospital emergency departments are prohibited from recruited individuals under arrests. The trauma staff, particularly ED physicians and nurses, are in a strategic position to collect this kind of data. Thus, this paper examines how trauma units can serve as an alternative in the reliable collection of police shooting data.

The prevalence of alcohol-related trauma recidivism: A systematic review

OBJECTIVE

Recurrent admission to a hospital or trauma centre for separate incidents of traumatic injury is known as trauma recidivism. Although use of alcohol is a known risk factor for injury and associated with trauma recidivism, the scale of alcohol-related trauma recidivism has not been well described. The purpose of this review was to search the published literature for studies that evaluated the prevalence of alcohol use among trauma recidivists. Our primary objective was to determine the proportion of trauma recidivism related to alcohol use. The association between alcohol and trauma recidivism was evaluated as a secondary objective.

METHODS

Four electronic databases (MEDLINE, Embase, CINAHL, Web of Science) were searched from inception until December 2015 for all articles that might provide evidence on the proportion of trauma recidivism related to use of alcohol. After removal of duplicates, the search strategy yielded 2470 records for screening. Only primary studies that reported on repeated admissions to a hospital or trauma centre for traumatic injuries specifically related to alcohol use were included. Descriptive statistics were used to assess study characteristics and the prevalence of trauma recidivism related to alcohol use. An aggregate weighted estimate of alcohol-related trauma recidivism was calculated.

RESULTS

A total of 12 studies met all inclusion criteria. Studies were published between 1989 and 2014. Overall, there were 3386 trauma recidivists among included studies. The proportion of trauma recidivists with evidence of alcohol use on admission ranged from 26.7% to 76.9% (median 46.4%). The aggregated sample produced a weighted estimate of 41.0% (1388/3386) for alcohol-related trauma recidivism. In four studies, the association between alcohol and trauma recidivism was examined; all four found a positive association between alcohol use and repeated admission for traumatic injury. Studies varied considerably in design, trauma populations, periods for evaluating recidivism, definitions for positive alcohol on admission, and methods used to determine alcohol use.

CONCLUSION

Evidence from current literature suggests that 41.0% of trauma recidivism is related to use of alcohol. Due to methodological limitations among the studies included for review, this may underestimate the actual prevalence of alcohol-related trauma recidivism.

The patient-body relationship and the "lived experience" of a facial burn injury: a phenomenological inquiry of early psychosocial adjustment

Background

Throughout development and into adulthood, a person’s face is the central focus for interpersonal communication, providing an important insight into one’s identity, age, sociocultural background, and emotional state. The face facilitates important social, including nonverbal, communication. Therefore, sustaining a severe burn, and in particular a facial burn, is a devastating and traumatizing injury. Burn survivors may encounter unique psychosocial problems and experience higher rates of psychosocial maladjustment, although there may be a number of potentially mediating factors.

Objectives

The purpose of this phenomenological study was to examine the early recovery experience of patients with a facial burn. In particular, this study focused on how the injury impacted on the participants’ relationship with their own body and the challenges of early psychosocial adjustment within the first 4 months of sustaining the injury.

Methods

In 2011, six adult participants encompassing two females and four males ranging from 29 to 55 years of age with superficial to deep dermal facial burns (with background burns of 0.8%–55% total body surface area) were recruited from a severe burn injury unit in Australia for participation in a Burns Modified Adult Attachment Interview. Narrative data were analyzed thematically and informed by Colaizzi’s method of data analysis.

Results

Three overarching themes emerged: relationship to self/other, coping, and meaning-making. Themes identified related to how the experience affected the participants’ sense of relationship with their own bodies and with others, as well as other challenges of early psychosocial adjustment. All participants indicated that they had experienced some early changes in their relationship with their body following their burn injury.

Conclusion

These findings highlight the struggle burn survivors experienced with postburn adjustment, but expressed altruism and optimism around their recovery. Past trauma was observed to be a significant finding in this sample. Understanding the “lived experience” supports the way clinical and family systems can foster positive adjustment and coping. Consequently, multidisciplinary burn teams and health care professionals need to understand the principles of trauma-informed care and translate these into practice in the treatment of this group of patients.

Pathways to early violent death: the voices of serious violent youth offenders

Quantitative studies have uncovered factors associated with early violent death among youth offenders detained in the juvenile justice system, but little is known about the contextual factors associated with pathways to early violent death among youths detained in adult jails. We interviewed young Black male serious violent youth offenders detained in an adult jail to understand their experience of violence. Their narratives reveal how the code of the street, informal rules that govern interpersonal violence among poor inner-city Black male youths, increases the likelihood of violent victimization. Youth offenders detained in adult jails have the lowest rate of service provision among all jail populations. We have addressed how services for youth offenders can be improved to reduce the pathways to early violent death.