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Narmeen Khan, MD
Michael Levas, MD, MS
Marlene Melzer-Lange, MD

Thousands of children are treated for firearm-related injuries in emergency departments (EDs) in the United States (US) annually, with mortality rates as high as 20%. Our children’s hospital resides in an urban county within the Midwest that has one of the highest rates of firearm injuries in the US. Our hospital-based violence intervention program (HVIP) is a collaborative support network that assists pediatric victims of violence and their families during and after hospitalization. The program provides resources including housing, mental health, job security, and legal support as these individuals attempt to recover from their trauma and navigate societal stressors. Our global aim is to increase HVIP services (through increasing referral and acceptance rates) at our pediatric ED. Our specific aim is to increase HVIP referral rates in our ED by 20% over a 12-month period. We highlight the needs assessment and quality improvement strategies utilized to reach our goals.

Inclusion criteria for our HVIP are children up to 18 years of age residing within our county who have faced interpersonal violence. Injuries include firearm injuries, stab wounds, and hit-and-runs. Exclusions include being under police and/or child protective services custodies, out-of-home placement, and sexual assaults. We looked at 974 ED encounters who presented to the ED from 2020 to 2023 and met the above inclusion criteria to perform a retrospective chart review. Thirty-two of these encounters were excluded as the patient was deceased or transferred to another facility. We created p-charts from the raw data and conducted focused interviews with and surveys to stakeholders, including nurses, providers, crime victim advocates (CVAs who discuss the HVIP to patients and families), and social workers. We retrospectively reviewed de-identified patient data including chief complaint and ED disposition to create the p-charts and review HVIP-eligible patients who were missed.

Six hundred and eighty-four out of the 942 HVIP-eligible encounters (73%) were not admitted to the hospital for their injuries, whereas 27% were. From the children who were discharged home (73%), 44% had HVIP consults placed, with 99% placed in the ED. Sixty-nine percent of patients who had a consult placed accepted enrollment into the program. From the children (27%) admitted to the hospital (including general floor, intensive care unit, or operating room), 75% had an HVIP consult placed, with only 43% placed in the ED. Seventy-six percent of these patients were ultimately enrolled in the HVIP.

From our needs assessment and chart reviews, we learned that we are missing large volumes of HVIP-eligible referrals. As next steps, we will be implementing plan-do-study-act cycles to test whether two of many possible interventions can help us achieve our specific aim. The two interventions will be to make modifications to our ED’s electronic medical record software as well as increase the visibility of and provide more resources to our HVIP’s CVAs.

1. Discuss the importance of hospital-based violence intervention programs (HVIPs), particularly in the pediatric emergency department setting.
2. Highlight a needs assessment to critically appraise an HVIP using a quality improvement approach.
3. Gather tools for next steps, including possible interventions, to improve the HVIP.

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Emma Cornell, MPH
Laura Harrison, MPH
Monica Shekher-Kapoor, MD
Sandeep Kapoor, MD, MS-HPPL
Chethan Sathya, MD, MSc, FRCSC, FACS

Firearms are the leading cause of death for US children and adolescents. Emergency departments (EDs) present unique opportunities to adopt Firearm Injury and Mortality Prevention (FIMP) strategies, serving as safety nets during times of crisis, providing care for those without primary healthcare sources, and treating patients with firearm-related injuries. Pediatric healthcare providers routinely screen for a variety of health concerns, providing anticipatory guidance and educational resources to patients and caregivers to promote health and safety. Thus, pediatric EDs provide optimal environments for implementation of FIMP strategies as part of usual care. We implemented a universal FIMP screening program to normalize conversations about firearm safety and violence risk for all patients, caregivers, and healthcare team members. This universal screening strategy was based on successful implementation of a “We Ask Everyone” approach using Screening, Brief Intervention, and Referral to Treatment (SBIRT) for substance use. We applied this SBIRT framework for substance use to FIMP, based on synergistic goals and harm reduction principles, to maximize reach to all patients and destigmatize firearm injury risk.

Universal screening for firearm access and violence risk for patients > 12 years was implemented in three New York hospitals, including one pediatric ED beginning in July 2021. For adolescent patients ages 12-17, screening consists of a question about firearm access within or outside the household, and the 4-question SaFETy score, a validated tool to predict future firearm violence risk. Screening tools and reports were programmed into the electronic health record (EHR). Prior to implementation, asynchronous online education for healthcare team members was disseminated exploring FIMP as a public health issue, reviewing the screening tool, workflow, documentation, and available resources. Additional synchronous education was provided to team members providing support to patients who screened positive.

Since implementation through April 2023, 4,649 pediatric patients ages 12-17 across the three EDs were screened for firearm injury and violence risk. Among patients at our pediatric ED, 16.13% of all patients (4,503 total) were screened. 79 (1.75%) screened positive for firearm access, and 134 (2.98%) screened positive for violence risk, with 217 (4.67%) positive screens overall. Among pediatric patients with a positive screen, 77 (19.35%) were approached for a full screen, brief intervention (using motivational interviewing and the brief negotiated interview) and resources.

Pediatric ED FIMP screening is a promising tool to identify, and subsequently provide patients and families with resources and support to increase safety and reduce risk associated with firearm access and violence risk. Factors associated with increased FIMP utilization include robust championship by ED leadership and ongoing, health system-wide prioritization of firearm injuries as a public health concern. Disruptions to clinical workflows including COVID-19 and subsequent RSV and influenza surges temporarily reduced pediatric FIMP screens, which improved over time. Future steps include expansion of FIMP screening to additional pediatric service lines system-wide.

1. Attendees will be able to describe the utility of universal screening for firearm injury risk in the pediatric emergency department setting
2. Attendees will be able to identify opportunities to integrate conversations around firearm safety and violence prevention within standard clinical interactions
3. Attendees will be able to determine barriers and facilitators to ED adoption of firearm injury prevention strategies

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Jamie (Miller) Koopman, MD
Benjamin Linden, BS
Megan Sinik, BS
Kristel Wetjen, RN, MSN
Pam Hoogerwerf, BA
Junlin Liao, PhD
Charles Jennissen, MD

Data regarding rural youth’s experience with firearms is limited despite their frequent presence in homes. Firearm training is considered an important aspect of safety and preventing unintentional firearm injuries and deaths. Our objective was to investigate rural adolescents' use of firearms and whether they had received formal firearm training.

A convenience sample of 2021 National FFA (formerly Future Farmers of America) Convention & Expo attendees were given an anonymous survey at the University of Iowa Stead Family Children’s Hospital injury prevention booth. The survey explored their use of rifles/shotguns and handguns, when they first fired them, and whether they had completed a firearm training certification course. Data was compiled in Qualtrics and exported to Stata 15.1 (StataCorp, College Station, Texas). Descriptive (frequencies), bivariate (chi-square, Fisher’s exact test) and multivariable logistic regression analyses were performed.

3,206 adolescents of ages 13-18 years participated with 45% reporting they lived on a farm or ranch, 34% lived in the country but not on a farm and 21% lived in town. The vast majority of participants (85%) had fired a rifle/shotgun; 43% reported firing them >100 times. Of those that had fired rifles/shotguns, 41% had done so before 9 years old and 71% before 12 years. Most had also fired a handgun (69%), with 23% having fired handguns >100 times. Of those that had fired handguns, 44% had done so before 11 years of age and 77% before 14 years. Average age for first firing rifles/shotguns was 9.5 (SD 3.1) years, and 11.1 (SD 3.0) years for handguns. Males, non-Hispanic Whites, and those living on farms or in the country had significantly greater percentages that had fired a rifle/shotgun or a handgun. Significant differences were also seen by U.S. Census Region. Over half (64%) reported they had gone hunting with 32% first hunting before 9 years old and 55% before 11 years. Of those that had used a firearm, 67% had completed a firearm safety training course. Overall, 23% were/had been members of a school or club shooting team and of these, 87% had taken a safety course.

Most FFA member participants had fired both rifles/shotguns and handguns, many at very young ages. Significant differences in firearm use were noted by demographic factors including the youth’s home setting (i.e., farms and ranches) and their U.S. Census Region. Substantial numbers of adolescents that had used a firearm had not received formal training. Families should be advised when it is developmentally appropriate to introduce youth to firearms, and all should take firearm safety training before using them.

1. To understand at what ages rural youth are starting to shoot rifles/shotguns and handguns, and the frequency of their use.
2. To be able to list two factors that are associated with an increased proportion of rural youth having fired a rifle/shotgun or a handgun.
3. To be able to state the proportion of rural youth that have obtained firearm safety training and describe two factors associated with adolescent firearm users having received training or not.

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Bijan W. Ketabchi, MD, MPH
Michael A. Gittelman, MD
Yin Zhang, MS
Wendy J. Pomerantz, MD, MS

Suicide-related presentations to pediatric emergency departments (PED) have increased drastically in recent years. PED providers have the opportunity to reduce suicide risk by counseling caregivers on restricting access to lethal means, such as medications and firearms. Supplementing lethal means counseling (LMC) with safety device distribution is effective in improving home safety practices; however, data on efficacy in high-risk patient populations is limited. The objective of this study was to determine if receiving cable-style gun locks in addition to LMC, compared to LMC alone, improved securement of all household firearms, among caregivers of children presenting to a pediatric emergency department (PED) for mental health (MH) evaluation.

In this randomized controlled trial, caregivers of patients presenting for MH evaluation completed a survey on current safety practices surrounding firearms and medication in the home. Participants were randomized to receive either LMC (control) or LMC plus 2 cable-style gun locks (intervention). Follow-up survey reassessing safety practices was distributed 1 month after initial encounter. Primary outcome was proportion of households, at follow-up, reporting all firearms secured with a locking device. Secondary outcomes included: removal of firearms and/or medication from the home, purchase of additional safety devices, change from baseline securement practices, and acceptability of PED-based counseling. Additionally, those in the intervention arm were asked about use of PED-provided locks.

Two hundred participants were enrolled and randomized. Comparable portions of each study group completed follow-up surveys. The control and intervention arms had similar proportions of households reporting all firearms secured at baseline (89.9% vs 82.2%, p = 0.209) and follow-up (97.1% vs 98.5%, p = 0.96), respectively. Other safety behaviors such as removal of medication (19.1% vs 13.2%, p = 0.361), removal of firearms (17.6% vs 11.8%, p = 0.732), and purchase of additional safety devices (66.2% vs 61.8%, p = 0.721) were also alike between the two groups. There were increased odds of medication securement in both control (OR 8.8, 95% CI 3.1—20.9) and intervention arms (OR 8.2, 95% CI 3.8—19.4), compared to their respective baselines. Only the intervention arm had higher odds of firearm securement at follow-up (OR 14.5, 95% CI: 2.9—264), while the control arm did not (OR 3.7, 95% CI: 0.9—24.6). Greater than 92% of caregivers in both groups held favorable views of PED-based counseling. Within the intervention group, 70% reported utilization of PED-provided locks. Preference for different style of gun lock (e.g., lockbox) was the most cited reason among those not using PED-provided cable locks.

ED-based LMC is a favorably-viewed, effective tool for helping families of high-risk children decrease access to lethal means in the home. Providing cable-style gun locks did not produce higher rates of firearm securement than LMC alone—likely due to high baseline rates of firearm securement and preference for different style of lock among non-utilizers. Future studies should assess the efficacy of other devices on different aspects of home safety practices.

1. Understand opportunities and barriers to implementing effective ED-based lethal means counseling
2. Understand that ED-based lethal means counseling is a valuable tool for improving multiple home safety behaviors, among families of patients at high risk of suicide or unintentional injury
3. Understand that caregivers are open to discussion of firearm safety and the vast majority viewed ED-based counseling favorably