Wounds, Gunshot Clinical Trial
Official title:
Helping Individuals With Firearm Injuries: A Cluster Randomized Trial
The investigators will conduct a cluster randomized trial of an intervention program that
combines a hospital-based intervention, structured outreach program, and multi-agency
attention. The goal of the study is to test the effect of this multi-component intervention
on criminal activity, injury, substance abuse, mental health, quality of life, violent
behavior, and death.
Investigators aim to enroll a total of 300 patients admitted to the Harborview Medical Center
(HMC) for firearm-related injuries. Patients will be randomized to receive a multi-component
intervention or treatment as usual. All participants will complete surveys at the time of
study consent (baseline) and then at designated time points for 12 months post-consent. Study
staff will routinely collect participant records from Washington State Patrol records, HMC
medical records, Washington State trauma registry, Washington State Emergency Department
Information Exchange, Administrative Office of the Courts, and vital records. The
investigators will test the impact of the intervention against standard care. The hypothesis
is that participants in the intervention group will see greater improvements in
aforementioned outcomes than those in the control group.
About 250 individuals present to an emergency department in King County, primarily Harborview
Medical Center (HMC), for firearm-related injuries each year. Almost two-third of these
patients require admission for their injuries. While the number of patients with firearm
injuries who present to HMC is relatively small, these individuals are at substantially
increased risk of subsequent re-hospitalization for another firearm or assault-related
injury, arrest for firearm-related or violent crime, non-firearm-related nonviolent crime or
firearm-related death in the five years after discharge from the hospital. Thus,
interventions among this high risk population have the potential to reduce recidivism,
morbidity, and mortality as well as decrease firearm violence and its consequences in the
community.
Patients with gunshot wounds (GSWs) seen at HMC receive many services; however, currently
there is no standardized intervention offered to GSW patients. A number of hospitals across
the country have created violence prevention and intervention programs to help patients who
sustain violent injuries. These programs engage patients in the hospital during their
recovery period, which is seen as an opportunity ("teachable moment") to change their life
and reduce retaliation and recidivism. As a result of the growing number of violence
prevention and intervention program, the National Network of Hospital-based Violence
Intervention Programs, has been established. Through working groups, meetings, e-newsletter,
and conferences, Network members collaborate in research and evaluation, explore
opportunities for funding sustainability, develop and share best practices, and identify ways
to collectively have an impact on policy. While the creation of this infrastructure is a step
in the right direction, researchers have not rigorously tested the effectiveness of these
intervention programs. Specifically, no trials have evaluated the effectiveness of
hospital-based violence intervention programs offered to GSW victims.
The investigators aim to conduct a cluster randomized trial of an violence intervention
program that combines a brief, hospital-based intervention, a structured outreach program,
and multi-agency attention. Study staff will provide a brief intervention derived from
motivational interviewing (MI). MI is is a patient-centered behavioral technique based on the
stages of change model and attempts to engage patients in order to find reason to change
behavior. By empathetically exploring ambivalent feelings about health-related behavior, MI
encourages reduction in risky behavior. Research has demonstrated the effectiveness of
providing MI-based brief interventions in the Emergency Department (ED) or inpatient wards,
primarily for alcohol use disorders but also for violent behaviors. Specifically, brief, MI
interventions have been successful at reducing youth violence in large urban populations,
with effects sustained through one year. Additionally, a behavioral-based intervention
including MI targeting adolescents admitted to HMC with trauma showed a reduction in weapon
carriage during the year post-hospitalization.
A longitudinal outreach intervention program provides the added benefit of continued
engagement. GSW patients must transition back to the community after their hospitalization,
and the transitional period, when patients must navigate a complex and fragmented system of
care, is especially challenging. Providing GSW patients with outreach and follow-up after the
healthcare encounter holds promise for reducing their future violence and criminal activity.
The Critical Time Intervention (CTI) approach may provide a strong framework for providing
these patients with appropriate outreach and follow-up. Strong evidence supports CTI's
effectiveness. The CTI model meets the Coalition for Evidence-based Policy's rigorous "Top
Tier" standard for interventions: well-designed and implemented randomized controlled trials,
preferably conducted in typical community settings, [that] produced sizable, sustained
benefits to participants and/or society. CTI is a time-limited, evidence-based case
management model that mobilizes support for society's most vulnerable individuals during
periods of transition such as discharge from inpatient services to the community. It
facilitates community integration and continuity of care by ensuring that a person has
enduring ties to their community and support systems during these critical periods. CTI has
been used worldwide among veterans, people with mental illness, homeless or incarcerated
individuals, and many other groups. From the beginning, CTI was thought of as an intervention
that could be applied in myriad contexts. This approach has the potential to provide an
intervention framework for a second tier outreach to GSW victims in King and neighboring
counties.
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