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Zoe Miller
Daphne Lew
Kateri Chapman-Kramer
Ben Cooper
Lindsay D. Clukies, MD, FAAP
Kristen L. Mueller

Firearm injury is the leading cause of death among youth in the United States. Individuals who experience one firearm injury are at an increased risk of subsequent injury by firearm. As many patients receive care from multiple hospitals and health systems in a geographic region, there is need to develop comprehensive liked data sets to assess constructs such as violence-related injury. The present study aims to identify demographic and clinical risk factors associated with repeat firearm injury within the pediatric population.

This study is a 10-year retrospective observational cohort analysis of all consecutive firearm injured children who presented to one of four St. Louis adult or pediatric level I traumas hospital for acute care. Data were collected on demographics from the St. Louis-Hospital Violence Intervention Program Data Repository (STL-HVIP-DR). This multi-hospital system repository contains encounter-level data on all patients who present for a violent injury (blunt assault, stabbing, firearm injury) from 2010 onward. A Kaplan-Meier survival analysis was performed to estimate the cumulative incidence of repeat firearm injury within the study population stratified by age group. A Cox proportional hazards regression model was performed to estimate the association between repeat firearm injury and demographic and clinical risk factors.

Of the 1,340 patients treated for an initial firearm injury, 160 (12%) of patients experienced a repeat firearm injury during the study period. Among reinjured patients, 78% were Black, non-Hispanic males between the ages of 15 and 17. Youth were significantly less likely to be reinjured if they were treated at a children’s hospital in both the 10-14, X2(1, N=263) = 13.89, (p < 0.05), and the 15-17 age groups, X2 (1, N=898) = 5.84, (p < 0.05). However, older Black adolescents were less likely to be treated at a children’s hospital than white youth, X2 (1, N=1,340) = 18.58, (p < 0.05).

Among the distressingly large cohort of firearm injured youth receiving care at a partner level I trauma hospital in the St. Louis region, there were substantial race, gender and age disparities. Of note, Black teens were significantly less likely to be treated at a children’s hospital, which may have implications for receipt of age appropriate trauma informed care during and after hospitalization. Additional study is needed to examine factors perpetuating this inequitable care.

Participants will learn the epidemiology of firearm injuries nationally and locally, within the St. Louis area region. They will also learn about the STL-HVIP-DR through our regional, multi-centered HVIP program. Lastly, they will identify key disparities in demographic and clinical risk factors associated with repeat firearm injury within the pediatric population.

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Benjamin Linden, BS
Megan Sinik, BS
Kristel Wetjen, RN, MSN
Pam Hoogerwerf, BA
Junlin Liao, PhD
Charles Jennissen, MD

Firearm-related unintentional and suicide death rates are greater in rural areas, and firearm access greatly increases the risk of suicide. A major factor in preventing these tragedies is safe firearm storage. Our study objective was to evaluate firearm exposure and storage practices in the homes of rural adolescents including those living on farms and ranches.

An anonymous survey was administered to a convenience sample of attendees at the 2021 National FFA (formerly Future Farmers of America) Convention & Expo at the University of Iowa Stead Family Children’s Hospital injury prevention booth. The data was entered into Qualtrics and then imported into Stata 15.1 (StataCorp, College Station, Texas) for descriptive (frequencies), bivariate (chi-square, Fisher’s exact test) and multivariable logistic regression analyses.

3,206 adolescents who were 13-18 years old participated; 45% lived on a farm, 34% lived in the country but not a farm and 21% lived in a town. In their homes, 87% of participants reported having rifles/shotguns, 71% had handguns and 69% had both rifles/shotguns and handguns. Those living on farms were 7.5x and 2x more likely to have rifles/shotguns and handguns, respectively, as compared to those from towns. Other U.S. Census Regions were at least 2.3x and 1.6x more likely to have rifles/shotguns and handguns, respectively, as compared to those from the Northeast. Rifles/shotguns and handguns were stored unlocked and/or loaded at least some of the time in 66% and 64% of homes, respectively. Those from farms were 1.5x and 1.7x more likely to have rifles/shotguns and handguns stored unlocked and loaded, respectively, as compared to those from town. The South, West and Midwest were 5.9x, 3.2x and 2.8x more likely to have rifles/shotguns and 8.1x, 5.2x and 4.3x more likely to have handguns stored loaded and unlocked, respectively, as compared to the Northeast. For homes with unlocked rifles/shotguns and unlocked handguns, 37% and 36% also stored ammunition unlocked, respectively.

Our study found that the vast majority of rural adolescents surveyed lived in homes with firearms, and a large proportion of those firearms were not stored safely. There were significant differences regarding the presence and storage of firearms by demographic factors, especially the region where youth lived and their home setting (i.e., farms and ranches). Unsafe storage practices are likely contributing to the higher unintentional and suicide death rates seen in rural areas. Widespread efforts are needed to educate rural families about the importance of proper firearm and ammunition storage.

1. To understand the degree of firearm/rifle and handgun presence in the homes of rural youth.
2. To be able to state the storage patterns of firearms/rifles and handguns in rural homes where youth live.
3. To be able to list at least two factors that are associated with an increase in the proportion of homes of rural youth with firearms/rifles and handguns being present, as well as improperly stored.

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Ashley Blanchard, MD, MS
Joandalys Tejada, MPH
Emma Cornell, MPH
Joan Asarnow, PhD
Randy P. Auerbach, PhD
Peter Dayan, MD, MSc

Emergency department (ED) visits for adolescent suicidal ideation or attempts have doubled in recent decades. Providing lethal means counseling to guardians in EDs is a promising method to prevent suicide attempts and death in adolescents. Our multi-disciplinary clinical and investigative team has systematically developed Lock and Protect, a novel lethal means restriction decision aid for guardians presenting to EDs with their adolescent child. Lock and Protect is a web-based, decision aid, that uses a non-judgmental, self-directed approach to offer a range of options to reduce access to lethal means. We aimed to determine the acceptability and feasibility of implementing the Lock and Protect decision aid and the feasibility of conducting a future trial in the ED among parents whose adolescents are at risk of suicide.

We conducted a prospective cohort study of caregivers and adolescents. Caregivers received the Lock and Protect intervention during evaluation of their child in the ED. We included caregivers of adolescents ages 13-17 years-old presenting to the ED for suicidal ideation, suicide attempt, or non-suicidal self-injury. Though our study is not powered to determine effectiveness, our primary outcome assessed change in home access of medications and/or firearms at 2-weeks and 4-weeks after ED visit. Secondary outcomes included measures of decision quality, acceptability and behavioral intent. Decision quality is a fundamental element of the Ottawa Decision Support Framework, as a precursor to behavior change. We used standard descriptive statistics with appropriate distribution measures to summarize feasibility, acceptability, and behavior change.

Of 40 enrolled, caregivers were 52.5% Latine, 42.5% White, and 30% Black. Among caregivers, Lock and Protect was found to be respectful of their family values about medications (100%) and firearms (97.5%), with 92.5% of caregivers reporting that the length and amount of information in Lock and Protect was “just right.” All caregivers would recommend the tool to a friend or family member in a similar situation, and 93.3% found that the options presented were realistic. 97.5% of guardians found Lock and Protect to be useful for changing home access to lethal means. Caregivers used the tool for an average of 9.5 minutes and 100% of caregivers completed the tool. Follow up procedures were completed for 71% of caregivers and adolescents and 70.9% of caregivers increased safe storage of firearms or medications in their home.

Lock and Protect, a web-based lethal means counseling decision aid, is feasible to implement in the ED and acceptable to guardians of adolescents presenting to a single, urban ED for suicidal thoughts and behaviors.

1. Understand the acceptability and feasibility of a novel, web-based ED-based lethal-means counseling decision aid
2. Understand how a novel, web-based lethal means counseling decision aid might be integrated into ED-care of adolescents at increased risk for suicide.

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Sofia Chaudhary, MD
Caroline Chivily, MPH
Emily Morris, MD
Scott Gillespie, MS, MSPH
Donnetta Shanté Washington, DSW, LCSW, LICSW, CCTP
Kiesha Fraser, MD
Sarah Lazarus, DO
Angela Costa, DO
Nathan Call, PhD
Jonathan Rupp, PhD
Harold Simon, MD, MBA

Firearm-related suicide is the second leading cause of pediatric firearm death. Lethal means counseling (LMC) can improve firearm safe-storage practices and be a critical intervention for families with youth at-risk of suicide. Our study objectives were to evaluate feasibility and acceptability of pediatric emergency department (ED) behavioral health (BH) specialists providing LMC to caregivers of youth presenting with BH complaints and to investigate practice changes pre- to post-intervention.

Prospective feasibility study of caregivers of youth presenting to pediatric ED with BH complaints. Caregivers completed a self-administered electronic survey regarding self-reported demographics and firearm safe-storage knowledge/practices. All participants received LMC from BH specialist after primary BH concerns were addressed. Gun-owners were offered a free lockbox and/or trigger lock. 1-week follow-up electronic surveys gathered self-reported data on firearm-safety practices and intervention acceptability. Primary outcomes include proportion of gun-owning participants, follow-up survey response, and acceptability of LMC. Secondary outcomes include reported change in firearm-safety practices. Descriptive statistics were used for univariate and paired data responses. Likert-scale acceptability responses were dichotomized to strongly agree/agree (affirmative) vs. neutral/disagree/strongly disagree.

81 subjects were approached with 50 (62%) enrolling (96% female, 47% Black, mean age 40 years (SD± 8.3)). 60% had no prior gun-safety counseling/education; 44% had at least one gun at home. Among gun-owners (n=22), 81% had handguns and 45% had shotguns. 63% always used safe-storage device. 45% used gun-safe, 27% used lock box, and 23% used trigger lock. 59% of gun-owners requested safe-storage devices.

78% (n=39/50) of enrolled participants completed follow-up, where 69% of participants asked about household guns prior to child visiting other homes compared to 46% pre-intervention (+23%). More than 80% affirmed at intake and follow-up that ED gun-safety education was useful and 85% affirmed at intake and follow-up that ED is appropriate place for gun safety discussions. Among gun-owners that completed follow-up (n=19), 100% stored all guns locked at 1-week compared to 74% pre-intervention (+26%). Ten families removed guns temporarily or permanently after the ED intervention.

Pilot results show that it is feasible to provide LMC in the ED via BH specialists to families of high-risk youth. Caregivers report finding this intervention useful, acceptable, and appropriate. Additionally, LMC and device distribution led to reported changes in safe-storage practices.

1. Attendees will learn that lethal means counseling (LMC) is a critical intervention for caregivers of youth presenting with behavioral health complaints to a pediatric emergency department (ED).
2. Attendees will learn that pediatric caregivers find ED-based LMC acceptable.
3. Attendees will learn that pediatric caregiver gun owners demonstrate changes in self-reported secure storage practices after LMC intervention.