Youth Violence and Injury Prevention

This paper describes an initiative launched by the Los Angeles County (LAC) Emergency Medical Services (EMS) Agency to bolster emergency power resilience for hospitals operating in LAC. The multiyear initiative, launched in 2019 and concluded in October 2023, culminated in the publication of the 'Healthcare Facility Emergency Power Resilience Playbook',1 a heralded resource that introduces innovative protocols to address significant vulnerabilities uncovered during the initiative. These vulnerabilities included seriously outdated generators, facilities with no redundant emergency power and facilities with limited onsite generator fuel storage capacity. New protocols developed to address these gaps include accelerated emergency power threat reporting by hospitals and a first-ever, confidential risk rating of hospital emergency power systems by a government agency. This move is intended to help the LAC EMS Agency maintain closer vigilance of higher-risk facilities during an outage. The new protocols far exceed the federal government's emergency power requirements for hospitals. This paper also outlines the additional steps jurisdictions could consider to build on the LAC EMS Agency's groundbreaking work to achieve even higher levels of emergency power resilience. This article is also included in The Business & Management Collection which can be accessed at https://hstalks.com/business/.

The effectiveness of out-of-hospital regionalization of ST-elevation myocardial infarction (STEMI) patients to hospitals providing primary percutaneous coronary intervention depends on the accuracy of the out-of-hospital 12-lead electrocardiogram (PHTL). Although estimates of sensitivity and specificity of PHTL for STEMI have been reported, the impact of out-of-hospital STEMI prevalence on positive predictive value (PPV) has not been evaluated. To describe the relationship between varying population STEMI prevalences and PHTL predictive values, using ranges of PHTL sensitivity and specificity. The authors performed a Bayesian analysis using PHTL, where values for sensitivities (60%-70%), specificities (98%), and two prevalence ranges (0.5%-5% and 5%-20%) were derived from a literature review. PPV prediction intervals were compared with three months of prospective data from the Los Angeles County Emergency Medical Services Agency STEMI regionalization program. When the estimated prevalence of STEMI in the out-of-hospital population is 5%-20%, the median PPV of the PHTL is 83% (95% credible interval [CrI] = 53% to 97%). However, if the population prevalence of STEMI is between 0.5% and 5%, the median PPV is 43% (95% CrI = 12% to 86%). When the PPV prediction intervals were incorporated with the Los Angeles County Emergency Medical Services Agency data, the PPV was 66%. Even when assuming high specificity for PHTL, the false-positive rate will be considerable if applied to a population at low risk for STEMI. Before broadening application of PHTL to low-risk patients, the implications of a high false-positive rate should be considered.

Objectives Extracorporeal cardiopulmonary resuscitation (ECPR) has seen increasing use globally as a life-saving intervention for patients with refractory cardiac arrest, including those suffering out-of-hospital cardiac arrests (OHCA) transported to the Emergency Department (ED). ECPR requires extensive resource commitment and outcome data for OHCA patients transported to ECPR capable EDs remain limited. The objective of this study was to evaluate the association of implementing an ED ECPR program on OHCA ambulance arrivals to an academic medical center ED. Methods We conducted a before-after study at an urban, academic, level 1 trauma, and STEMI-receiving center ED (annual census approximately 50,000). The regional county Emergency Medical Services (EMS) agency (population 3.1 million) initiated an ECPR pilot program to direct Advanced Life Support (ALS) 911 transports of refractory OHCA patients to a limited number of designated as ECPR receiving centers (i.e., ECPR-capable EDs). We analyzed ECPR, OHCA, and total ALS 911 EMS ED transports in the 6 months before (July–Oct 2024, pre-ECPR) and 6 months following (Dec 2024–May 2025, ECPR) county EMS agency designation as an ECPR receiving center. The implementation month, November, was excluded from all analyses. In addition, we compared these 6-month periods with the 6-month period 1 year prior to the implementation (July–Oct 2023, pre1y-ECPR). The number of OHCA per 1,000 ALS transports was compared for each of the three time periods using descriptive statistics and Fisher's exact testing as indicated, with a p < 0.05 considered statistically significant. Results After ECPR designation, there was an increase in OHCA transports compared with both the pre-ECPR and pre1y-ECPR periods (7.8 vs. 3.2 vs. 3.5 per 1,000 ALS transports, respectively, p < 0.05). Of note, only eight OHCA patients transported to the ED in the ECPR period met the County ECPR criteria, and only one was placed on veno-arterial extracorporeal membrane oxygenation. Conclusion Inclusion into a county wide ED ECPR program for refractory OHCA resulted in a significant increase in the number of OHCA and ALS transports to an academic medical center ED, even though many of these patients did not actually meet pre-determined criteria for ECPR activation from the field.

BackgroundThe Health Behaviour in School-aged Children Survey is one of very few cross-national health surveys that includes information on injury occurrence and prevention within adolescent populations. A collaboration to develop a Canadian youth injury report using these data resulted in, Injury among Young Canadians: A national study of contextual determinants. The objective of this study was to develop specific evidence-based, policy-oriented recommendations arising from the national report, using a modified-Delphi process with a panel of expert stakeholders.MethodEight injury prevention experts and a 3-person youth advisory team associated with a Canadian injury prevention organization (Parachute Canada) reviewed, edited and commented on report recommendations through a three-stage iterative modified-Delphi process.ResultsFrom an initial list of 27 draft recommendations, the modified-Delphi process resulted in a final list of 19 specific recommendations, worded to resonate with the group(s) responsible to lead or take the recommended action. Two recommendations were rated as “extremely important” or “very important” by 100 % of the expert panel, two were deleted, a further two recommendations were deleted but the content included as text in the report, and four were merged with other existing recommendations.ConclusionsThe modified-Delphi process was an appropriate method to achieve agreement on 19 specific evidence-based, policy-oriented recommendations to complement the national youth injury report. In providing their input, it is noted that the injury stakeholders each acted as individual experts, unattached to any organizational position or policy. These recommendations will require multidisciplinary collaborations in order to support the proposed policy development, additional research, programming and clear decision-making for youth injury prevention.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-2600-x) contains supplementary material, which is available to authorized users.

Background and Purpose- We quantified population access to endovascular-capable centers, timing, and rates of thrombectomy in Los Angeles County before and after implementing 2-tiered routing in a regional stroke system of care. Methods- In 2018, the Los Angeles County Emergency Medical Services Agency implemented transport of patients with suspected large vessel occlusions identified by Los Angeles Motor Scale ≥4 directly to designated endovascular-capable centers. We calculated population access to a designated endovascular-capable center within 30 minutes comparing 2016, before 2-tiered system planning began, to 2018 after implementation. We analyzed data from stroke centers in the region from 1 year before and after implementation to delineate changes in rates and speed of administration of tPA (tissue-type plasminogen activator) and thrombectomy and frequency of interfacility transfer. Results- With implementation of the 2-tier system, certified endovascular-capable hospitals increased from 4 to 19 centers, and within 30-minute access to endovascular care for the public in Los Angeles County, from 40% in 2016 to 93% in 2018. Comparing Emergency Medical Services-transported stroke patients in the first post-implementation year (N=3303) with those transported in the last pre-implementation year (N=3008), age, sex, and presenting deficit severity were similar. The frequency of thrombolytic therapy increased from 23.8% to 26.9% (odds ratio, 1.2 [95% CI, 1.05-1.3]; P=0.006), and median first medical contact by paramedic-to-needle time decreased by 3 minutes ([95% CI, 0-5] P=0.03). The frequency of thrombectomy increased from 6.8% to 15.1% (odds ratio, 2.4 [95% CI, 2.0-2.9]; P<0.0001), although first medical contact-to-puncture time did not change significantly, median decrease of 8 minutes ([95% CI, -4 to 20] P=0.2). The frequency of interfacility transfers declined from 3.2% to 1.0% (odds ratio, 0.3 [95% CI, 0.2-0.5]; P<0.0001). Conclusions- After implementation of 2-tiered stroke routing in the most populous US county, thrombectomy access increased to 93% of the population, and the frequency of thrombectomy more than doubled, whereas interfacility transfers declined.

Do-not-resuscitate (DNR) orders are written by physicians so that cardiopulmonary resuscitation (CPR) is not administered to patients who do not want to be resuscitated should they have a cardiac or pulmonary arrest. DNR orders are appropriate, effective, and common in hospitals: it is difficult to understand why they have largely been excluded from pre-hospital settings (1)(2)(3)(4). It is also surprising how little effort has been expended to make DNR orders portable between settings and durable in time. We will discuss the development of a pre-hospital DNR program in Orange County, California, with primary emphasis on the supportive role played by the Orange County Bioethics Network (OCBEN). Emergency room physicians and nurses as well as emergency medical technicians and paramedics have long been concerned about the occasional resuscitated patient for whom resuscitation seemed inappropriate, most particularly when the patient's surrogate, or the patient him/herself subsequently said that he/she would not have wanted resuscitation. These are the exceptions that prove the rule that under emergency circumstances the presumption should be in favor of life-sustaining or life-restoring treatment. To address some of these exceptions, emergency room personnel, the Program Director of the Orange County Emergency Medical Services Agency (OC-EMSA), and

This book is the work of the National Center for Injury Prevention and Control, part of the Centers for Disease Control and Prevention in Atlanta, United States of America (USA). It brings together 74 authors writing on the widest range of injury prevention topics. The book is in five parts. Part I includes a chapter on the subject of epidemiology and the cost of injury and violence as well as an overview of interventions. Part II is about effective and promising interventions, with five chapters on unintentional injury – falls in adults, motor vehicle injury, drowning, residential fire injury, and sports and recreation injury – and six chapters on violence prevention – child maltreatment, youth violence, suicide, intimate partner violence, sexual violence and maltreatment of elderly people. The chapters have a common broad structure including epidemiology from the USA, the history of prevention, an outline of interventions including commentary on the strength of evidence, some discussion, an outline of research gaps and a conclusion. For example, the chapter on drowning has six detailed pages on interventions divided under subheadings of: products, environment, individual/social behaviour, legislation and multi-level drowning prevention campaigns. The analysis of research gaps follows this same grouping. Part III covers cross-cutting issues, with chapters on changing the built environment to prevent injury, changing the social environment, prevention of alcohol-related injury, reducing misuse of firearms, parenting and the prevention of childhood injury, building resilience to mass trauma events, and trends and challenges in intervention research methods. Part IV is about interventions in the field and covers knowing when an intervention will work in your community, behavioural interventions, developing interventions when there is little science, developing and implementing communication messages, cultural appropriateness, evaluating effectiveness and involving the community. Part V concerns dissemination and adoption of effective interventions and policies, and it has a chapter on dissemination, implementation and the wider use of interventions and encouraging adoption of science-based interventions. There are four appendices on resources, evaluation, data and web material, and a detailed 30-page index. The intention of the publication is to follow its title and to be a handbook, bringing together a wide range of issue-specific and action-oriented analyses to facilitate both understanding and action in injury and violence prevention. The book is clearly directed at those trying to understand or intervene in the USA – the authors are predominantly American; the epidemiology, history, information in the appendices and the references cited have a strong American focus – but it will also have wider currency. While it is not directed at an international audience, the breadth of coverage, the degree of detail and the quality of the scholarship make it useful in understanding specific injury and violence issues and in crafting and implementing interventions. For those with a long memory, this publication is similar in scope and detail to the 1989 supplement to the American Journal of Preventive Medicine,1 reflecting the two decades of research and experience that have occurred since then and, as such, is a very welcome addition to the literature. ■

BackgroundInjury prevention has featured as a relatively low priority on Government health agendas in Europe and elsewhere, the result of which has been a lack of national policy development. Successful...

Success of youth violence intervention and prevention effects, particularly for gun violence, will be enhanced when efforts are appropriately informed by the antecedents and context of violence. Youth violence is guided by social and cultural norms that are shifting with the rise of technology. Bullying, gang violence, and self-directed violence is increasingly found to occur in the online space influencing peer groups across contexts. Through focus groups with youth at risk for violence and victimization, this study finds three themes emerge as common precursors to violence: defense of self or others, disrespect of self or family occurring in traditional community-based interactions, and threats or disrespect occurring through social media platforms. Youth violence prevention programs should consider how using social cognitive intervention framework could build knowledge, attitudes, and skills needed for violence intervention and prevention informed by precursors to violence found in this analysis.

Although seminal reviews have been published on acculturation and mental health in adults and adolescents, far less is known about how acculturation influences adolescent interpersonal and self-directed violence. This article aims to fill this gap by providing a comprehensive review of research linking acculturation and violence behavior for adolescents of three minority populations: Latino, Asian/Pacific Islander (A/PI), and American Indian/Alaskan Native (AI/AN). The preponderance of evidence from studies on Latino and A/PI youth indicate that higher levels of adolescent assimilation (i.e., measured by time in the United States, English language use, U.S. cultural involvement, or individualism scales) were a risk factor for youth violence. Ethnic group identity or culture-of-origin involvement appear to be cultural assets against youth violence with supporting evidence from studies on A/PI youth; however, more studies are needed on Latino and AI/AN youth. Although some evidence shows low acculturation or cultural marginality to be a risk factor for higher levels of fear, victimization, and being bullied, low acculturation also serves as a protective factor against dating violence victimization for Latino youth. An important emerging trend in both the Latino and, to a lesser extent, A/PI youth literature shows that the impact of acculturation processes on youth aggression and violence can be mediated by family dynamics. The literature on acculturation and self-directed violence is extremely limited and has conflicting results across the examined groups, with high acculturation being a risk factor for Latinos, low acculturation being a risk factor of A/PI youth, and acculturation-related variables being unrelated to suicidal behavior among AI/AN youth. Bicultural skills training as a youth violence and suicide prevention practice is discussed.

Violence is a leading cause of death and disability for U.S. youth. The U.S. Centers for Disease Control and Prevention (CDC)'s Division of Violence Prevention (DVP) is committed to developing communities' capacity to engage in evidence-based youth violence (YV) prevention. We discuss the characteristics of communities that exert influence on the development and epidemiology of YV, and discuss opportunities for how community-research partnerships can enhance efforts to prevent violence in communities. The needs for YV prevention are unique; the nature and phenomenology of violence are community specific. Communities also vary widely in infrastructure and systems to support coordinated, evidence-based YV prevention strategies. These conditions highlight the need for community-research partnerships to enhance community capacity, employ local resources, and engage community members in the research process. DVP is committed to working towards creating communities in which youth are safe from violence. Approaches to YV prevention that emphasize community-research partnerships to build capacity and implement evidence-based prevention strategies can provide a supportive context for achieving that goal.

Incorporating the Experiences of Youth with Traumatic Injury into the Training of Health Professionals

Community members' and community partners' perspectives on community readiness to address youth violence prevention in a low-income urban community.

Introduction:Youth seen in the emergency department (ED) with injuries from youth violence (YV) have increased risk for future violent injury and death. Pediatric emergency medicine (PEM) physicians rarely receive training in, or perform, YV screening and intervention. Our objective was to examine effects of a web-based educational module on PEM physicians' knowledge, attitudes, and behaviors regarding YV screening and interventions in the ED.Methods:We invited all PEM fellows and attendings at an urban Level I pediatric trauma center to complete an interactive web-based education module (and 1-month booster) with information on YV's public health impact and how to screen, counsel and refer YV-involved patients. Consenting subjects completed electronic assessments of YV prevention knowledge and attitudes (using validated measures when possible) before and after the initial module and after the booster. To measure behavior change, chart review identified use of YV-specific discharge instructions in visits by YV-injured PEM patients (age 12–17; identified by E codes) 6 months before and after the intervention. We analyzed survey data were analyzed with Fisher's exact for binary outcomes and Kruskal-Wallis for Likert responses. Proportion of patients given YV discharge instructions before and after the intervention was compared using chi-square.Results:Eighteen (67%) of 27 PEM physicians participated; 1 was lost at post-module assessment and 5 at 1 month. Module completion time ranged from 15–30 minutes. At baseline, 50% of subjects could identify victims' re-injury rate; 28% were aware of ED YV discharge instructions. After the initial module and at 1 month, there were significant increases in knowledge (p<0.001) and level of confidence speaking with patients about avoiding YV (p=0.01, df=2). Almost all (94%) said the module would change future management. In pre-intervention visits, 1.6% of patients with YV injuries were discharged with YV instructions, versus 15.7% in the post-intervention period (p=0.006, 95%CI for difference 3.6%-24.5%).Conclusion:A brief web-based module influenced PEM physicians' knowledge and attitudes about YV prevention and may have affected behavior changes related to caring for YV victims in the ED. Further research should investigate web-based educational strategies to improve care of YV victims in a larger population of PEM physicians.

Youth violence is a major problem in the United States. It remains the third leading cause of death among youth between the ages of 10 and 24 years and the leading cause of death in Blacks between 10 and 24 years of age. In its effort to prevent youth violence, the Center for Disease Control and Prevention funds six Youth Violence Prevention Centers (YVPCs) to design, implement and evaluate community-based youth violence prevention programs. These Centers rely on surveillance data to monitor youth violence and evaluate the impact of their interventions. In public health, surveillance entails a systematic collection and analysis of data, typically within defined populations. In the case of youth violence, surveillance data may include archival records from medical examiners, death certificates, hospital discharges, emergency room visits, ambulance pickups, juvenile justice system intakes, police incident reports, and school disciplinary incidents and actions. This article illustrates the process the YVPCs used for collecting and utilizing youth violence surveillance data. Specifically, we will describe available surveillance data sources, describe community-level outcomes, illustrate effective utilization of the data, and discuss the benefits and limitations of each data source. Public health professionals should utilize local surveillance data to monitor and describe youth violence in the community. Further, the data can be used to evaluate the impact of interventions in improving community-level outcomes.