Improving Awareness and Utilization of Safety Net Resources After Extremity Firearm Injury

Colleen M. Moreland, DO
Caleb W. Grote, MD, PhD
Richard M. Schwend, MD
Julia G. Harris, MD

Firearm-related injuries have surpassed motor vehicle collisions as the leading cause of death among children and adolescents. Children who survive firearm injuries are at increased risk of developing post-traumatic stress disorder, substance abuse, incarceration, and subsequent violent injuries. While there is no universally-accepted standard of aftercare for treating firearm injuries, best practices in caring for pediatric trauma victims involve multidisciplinary care coordination during and after initial hospital care. The orthopaedic surgery department sought to improve access to follow-on services by creating a defined list of and initiating referral to safety net resources at the time of initial orthopaedic consultation. As there was no prior utilization of a standard set of safety net resource referrals, the baseline was 0%. We set our target for standardized resource initiation to improve to 50% by June 2024.

The orthopaedic fellow queried other level 1 pediatric trauma centers to determine how similar institutions address post-violence aftercare for firearm-injured patients. After identifying best practices put in place by two sister institutions, the orthopaedic fellow collaborated with stakeholders in several departments including: the trauma committee, the department of pediatrics, the center for childhood safety and injury prevention, social work, the council on violence prevention, hospital security and local leaders of anti-violence initiatives. We then collated a list of safety net resources presently available at our institution and within the greater metropolitan area. Utilizing quality improvement methodology, a fishbone diagram was created to determine root causes and potential roadblocks to implementing actionable items intended to guide clinicians in addressing post-violence care needs. The fellow then developed and implemented countermeasures utilizing a driver diagram to define actionable interventions. The checklist interventions included consideration for baseline blood lead level, social work consultation, free physical gun lock, and a handout on gun safety, among others.

The checklist initiative was officially implemented February 2024. PDSA cycles and monthly run charts were processed to demonstrate resource initiation. In February the department was consulted on 7 patients with isolated extremity firearm injury, on 1 patient in March, and on 4 patients in April. The patients ranged in age from 31 months to 17 years, and 75% were male. Since undertaking this QI endeavor, 100% of the 12 firearm-injured patients have received at least 1 referral for follow-on care services, including 100% receiving social work consultation and consideration for baseline blood lead level screening. Interestingly, this initiative identified 2 patients with high baseline lead levels, 1 patient who survived a second firearm-related injury, and 3 patients who sustained an extremity firearm injury while handling a firearm under direct adult supervision.

Streamlining orders and consultation requests has the potential to minimize variability in healthcare delivery and improve access to safety net resources by ensuring all orthopaedic-related firearm victims have the same workup and consultation requests beginning at initial presentation. This initiative may mitigate post-trauma sequelae for pediatric victims of firearm violence.

1. Long-term sequelae of pediatric firearm injury
2. How to leverage existing resources within an institution
3. Elevated baseline lead level in trauma victims may be a proxy for social determinants of health