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Lois K. Lee, MD, MPH
Suk-fong S.Tang, PhD
William L. Cull, PhD
Eric Fleegler, MD, MPH
Lynn M. Olson, PhD

Injuries from firearms and motor vehicle crashes are the leading causes of death among U.S. children and youth 0-19 years old. Examining the intersections of age group, sex, race, and ethnicity is essential to focus prevention efforts. The objectives of this study were to examine firearm and motor vehicle crash fatality rates by population subgroups and analyze changes over time.

We conducted a cross-sectional study of firearm and motor vehicle crash deaths among US children and youth 0-19 years old using data from the Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System (WISQARS) database. We reported firearm and motor vehicle collision (MVC) fatality rates by year and over time. To examine changes over time we performed JoinPoint regression analyses reporting average percent change (APC) per year for fatality rates by age, sex, race, and ethnicity.

From 2011-2021 there were 35,684 firearm and 40,735 MVC fatalities among US youth 0-19 years old. For firearms there were 21,332 (59.8%) homicides, 12,113 (33.9%) suicides, and 1,359 (3.8%) unintentional shootings. For all firearm deaths, an overall increase occurred 2014-2021 (APC 8.7%). For firearm homicides no statistically significant increase occurred until 2018-2021 (APC 19.2%). In contrast, firearm suicide had an APC of 5.6% over the entire study period. When considering age group, sex, race and ethnicity, for firearm homicides among youth 15-19 years old the APCs were similar for non-Hispanic Black (21.8%) and Hispanic (22.2%) males from 2018-2021 though with different peak rates (104.22/100,000 and 17.80/100,000, respectively). Non-Hispanic Black females 15-19 years old demonstrated a dramatic APC increase of 40.7% from 2019-2021 (peak rate 14.07/100,000). For firearm suicide in youth 10-19 years old by sex, non-Hispanic Black females had the greatest APC increase of 22.0% from 2016-2021; however, the highest rate occurred among American Indian/Alaska Native males 15-19 years old (18.12/100,000). For MVCs overall no statistical changes occurred overtime. MVC fatalities increased at the highest rate for non-Hispanic Black males 15-19 years (APC 22.9% 2019-2021) with the highest rates in 2021 among non-Hispanic American Indian/Alaska Native males 15-19 years (38.16/100,000) and females (29.31/100,000).

US youth 0-19 years old experienced important disparities in firearm and MVC fatality rates and increases over time when considering the intersectionality by age group, sex, race, and ethnicity. A multi-pronged strategy focused on individual, community and policy level approaches for specific high risk groups for each injury mechanism are necessary to address these leading causes of death in US youth.

1. Compare trends in firearm and motor vehicle collision deaths over time.
2. Describe differences in fatality rates from firearms by intent when considering the intersections of age group, sex, race, and ethnicity.
3. Discuss changes in motor vehicle collision fatality rates by age group, sex, race, and ethnicity.

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Nina Agrawal, MD
Pallavi Arora, MPH, MA
Christopher Knoepke
Gale Burstein
Lucy Leid Simon
Alison Mitzner
Carine Hedari

Firearm-related harm towards self and others is a significant adolescent health problem. Extreme risk protection orders (ERPOs), also known as “Red Flag Laws”, offer an evidence-informed prevention approach. Through a non-criminalizing process, ERPOs remove legal access to firearms from individuals at risk of causing harm. Despite passage of ERPO laws in numerous states and expansion to authorize clinicians to independently file for such orders in some states, including New York, ERPOs remain underutilized. While federal funds are available to promote uptake, there has been a lack of attention to youth-serving clinicians. This study aimed to assess New York State (NYS) pediatricians’ familiarity with and willingness to use ERPOs, understand barriers and facilitators to ERPO use, and offer strategies to improve uptake in pediatric settings.

An anonymous online survey was distributed to New York State American Academy of Pediatrics members from October to December 2023. The survey included 24 items covering awareness, attitudes, and barriers/facilitators to utilizing ERPOs, as well as participant demographics. Responses were descriptively analyzed, with thematic analysis used to characterize open-response data.

Of the 180 participants included in the analysis, most were pediatricians (97%, n=175), were practicing primary care (69%, n=119) for >20 years (56%, n=100) in urban areas (60%, n=107). Slightly more reported encountering, a few times a year, patients “in contact” with a person at risk of harm (e.g. parents, 61%) compared to patients at risk of harming themselves or others (54%). Less than half (42%, n=77) were familiar with ERPOs; while 63% (n=113) reported being likely to file an ERPO, none had ever done so. Most common barriers were lack of knowledge about the ERPO filing process (82%, n=148) and filing criteria (68%, n=123), followed by conducting risk assessments (53%, n=95). Additional barriers described in open-response data included perceived inapplicability to their practice (e.g. neonatology), gun rights infringement, belief in centering mental health support, and retaliation risk from patients/families. Commonly identified facilitators were access to ERPO training (72%, n=130), legal consultation (67%, n=120), filing coordinators (64%, n=115), patient supports (52%, n=94), clinician anonymity (51%, n=103), and liability protections (50%, n=90).

This study is the first to characterize pediatricians’ views regarding use of ERPOs for firearm-related harm prevention in pediatrics. Our findings highlight policy-practice gaps, including lack of knowledge about filing procedures and conducting risk assessments. Our study underscores the importance of allocation of ERPO resources for clinician and patient supports (e.g. education, filing coordinators, crisis response teams, legal protections), particularly within pediatric settings that demand greater sensitivity and caution.

1. Enhance awareness of ERPOs as a tool for firearm injury prevention by clinicians.
2. Understand barriers and facilitators to clinician initiated ERPOs and identify factors specific to pediatricians.
3. Bring attention to unique considerations for ERPO implementation in the pediatric population.

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Aashna Mehta, DO
Alexis Quinoy, PhD, ABPP
Andrew Jergel, MPH
Kiesha Fraser Doh, MD

Exposure to firearms has been shown to negatively impact youth’s mental and behavioral health. This study’s primary objective is to analyze the intersection of gun violence exposure (GVE) and school achievement (SA). The secondary objective is to investigate a difference in school achievement based on location of GVE in the community (at home, school, or both).

We utilized the Future of Families and Wellbeing Study (FFCWS), a longitudinal birth cohort study surveying urban youth and guardians specifically at age 15 utilizing surveys of parents and teens. SA was measured by 4 metrics: parent report of attending summer school and repeating a grade; and student report of honor roll and failing a grade. GVE data was obtained from the Gun Violence Archive (GVA), a national database that collects information on firearm injury and mortality data based on geographic locations. GVA data was cross referenced with survey data from FFCWS. GVE was categorized by presence of exposure within 1600 meters of home, school, or both. Two sample t-test and chi-squared tests adapted to complex survey samples were used for p-value calculations. P< 0.05 indicated statistical significance.

Our sample comprised of 2563 students. Students who attended summer school had more cumulative total GVE (5.72 vs. 3.66, p< 0.05) and school GVE (2.57 vs. 1.54, p< 0.05) than those who didn’t. Those who repeated a grade had twice as much GVE in both locations compared to those who did not repeat a grade (total 7.89 vs. 3.76, p< 0.05; home 4.09 vs. 2.18, p< 0.05; school 3.80 vs. 1.57, p< 0.05). Similarly, students who failed a class had more GVE in both locations compared to those who did not (total 4.99 vs. 3.45, p< 0.05; home 2.85 vs. 1.97, p< 0.05; school 2.13 vs. 1.48, p< 0.05). Those not on honor roll had more home GVE (2.77 vs. 1.87, p< 0.05) and total GVE (4.66 vs. 3.45, p< 0.05) than those on honor roll. Additionally, those on honor roll had a statistically significant higher proportion of no GVE (51% vs. 49%), less home (38% vs. 62%) and less combined home/school GVE (47% vs. 53%).

Our research reveals that an increase in cumulative exposure to gun violence is associated with attending summer school, repeating a grade, not achieving honor roll, or failing a class. This demonstrates that cumulative GVE can impact school achievement. The level of achievement in high school may carry significant ramifications that extend into one’s future career trajectory. Since academic accomplishments attained during this formative period could shape an individual's career opportunities in the years to come, further research is crucial to comprehend the full impact of GVE on youth wellbeing

1. Attendees will recognize the impact that gun violence exposure has on summer school attendance.
2. Understand that measures of school achievement such as honor roll or not failing a class are associated with lower rates of gun violence exposure.
3. Explain the impact of the number of gun violence exposure on honor roll achievement, repeating a grade, failing a class and attending summer school.

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Emma Cornell, MPH
Olivia Frank, MPH
Laura Harrison, MPH
Sandeep Kapoor, MD
Monica Shekher Kapoor, MD
Chethan Sathya, MD

As the leading cause of death for children and adolescents, firearm injury requires healthcare-led solutions to meaningfully address and reduce the epidemic of gun violence in the US. We implemented a universal Firearm Injury and Mortality Prevention (FIMP) screening program in three emergency departments (EDs) to identify and subsequently provide resources to patients who may be at risk for firearm injury based on violence risk or access to a firearm within or outside the home. Anecdotal reports from ED staff indicated high risk trauma patients including those with firearm-related injuries were not being screened in the ED. We retrospectively reviewed all pediatric patients with a trauma-related discharge diagnoses to determine the frequency of FIMP screening among this subpopulation.

Beginning in July 2021, universal screening for firearm injury risk for patients ?12 years was implemented across three health system hospitals including our pediatric level one trauma center. This screening includes a question about firearm access within or outside of the home, and the 4-question SaFETy score, a validated tool shown to predict future firearm violence risk. Data for all pediatric patients were extracted from the electronic medical record (EMR) and REDCap. Following data extraction, chief complaint and primary diagnosis were reviewed and coded as “trauma,” or “medical, according to ICD-10 CM diagnoses; patients coded as “trauma” were included. Standard descriptive statistical analyses were performed using SPSS (Statistical Package for Social Sciences).

From implementation in July 2021 through March 31, 2024, 42,492 patients ages 12-17 were seen in the pediatric ED, including 7,144 trauma patients (16.8% of total patients). Among trauma patients, 18.4% (n=1,311) received FIMP screening in the ED among which 4.3% (n=57) screened positive for either access to a firearm or risk for future firearm violence. Youth aged 15 and 14 accounted for the greatest percentage of trauma patients screened (20.7% and 17.5% respectively), and males accounted for 65.7% (n=861) of these patients. White and African American/Black children accounted for the largest percentage of trauma patients receiving the screening (30.6% and 27.6% respectively). There were 309 patients with a violent injury listed as their primary diagnosis following discharge (stab wound, gunshot wound, assault, child abuse, and self-injury), 30.1% of whom (n=93) received FIMP screening.

The majority of high-risk trauma patients including those with violent mechanisms of injury are not receiving FIMP screening while in the ED. Factors that may be associated with reduced screening include severity of injury and patient acuity for trauma patients, many of whom enter the ED as a trauma activation and may go directly to the OR from the trauma bay, thus preventing a comprehensive evaluation. Future steps should evaluate the feasibility of delivery of FIMP Screening and intervention in the inpatient setting for patients with severe traumatic injuries who require hospitalization and complex care.

1. Attendees will be able to describe trends observed in the implementation of firearm injury and mortality prevention screenings.
2. Attendees will be able to identify opportunities to integrate firearm injury and mortality prevention screening among trauma patients.
3. Attendees will be able to potential barriers and facilitators to firearm injury and mortality prevention screening among high risk populations.

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Jennifer E. McCain, MD
Michele Nichols, MD
Lisa Maloney, MSN, RN
Cursey Sitzler, MSN, CRNP
Jamie Smelcer, MSN, RN
Kathy Monroe, MD, MSQI

Firearm-related injuries have become the leading cause of death in children. Over the last five years at our children’s hospital, annual ED visits for children with firearm-related injuries increased by 141% (41 in 2018 to 99 in 2023). Recognizing this alarming trend, a firearm injury prevention team began meeting in August 2023 to find ways to address this multifaceted problem.

With support from hospital administration, a multidisciplinary team was developed by Emergency Department (ED) leaders with funding from the hospital foundation and corporate communications. Teams included representatives from the Emergency Department, Integrative Care, Government Relations, Communications, and Mental Health. Physicians were also present from Rehabilitation Medicine, ED, Hospital Medicine, and Critical Care. Many were already addressing firearm injury prevention individually.

The goal of the team, which meets bimonthly, is to slow the rising trend at our hospital of firearm-related injuries. The initial action was to improve awareness of hospital staff of the significant increase in firearm-related injuries. The next goal was to encourage community pediatricians to engage in discussions during patient encounters regarding securing all firearms. A needs assessment tool was administered to hospital-affiliated general pediatricians to gauge the culture of firearm discussions during visits, measure interest in further education, and provide firearm locks to patients.

Data demonstrating the rise of firearm injuries over the last 20 years was shared with hospital administration and campus leaders. Three podcasts offered multiple communications and discussions. A state House Representative met with the team to discuss upcoming legislation. Team members working with pediatric residents in Health Equity Scholars shared BeSMART educational materials and resources at community meetings. Team members participated in our local chapter’s National Injury Prevention Day along with other community events.

The team developed a pathway to screen all ED and surgical ward patients for the presence of unsecured firearms within the patient’s home. The care team provides cable gun lock(s) and educational materials to families with unsecured firearms. A hospital violence intervention program is being developed by the team which is also providing wraparound services for patients in anticipation of hospital discharge.

Of the 78 community physicians contacted for the needs assessment, 60 (78%) responded. Regarding whether firearms discussions occur, 33/51 (64.9%) reported they discussed firearms only with certain at risk populations or not at all. Most of the physicians (80%) were interested in further education about having these discussions. Based on this needs assessment, the team is partnering with four practices to offer guidance regarding secure firearm education and gun locks for their patients’ families.

The creation of a firearm injury prevention team allowed disparate groups to work together instead of in silos. Bringing stakeholders together was a logistic challenge. Once the team convened, though, efforts were coordinated and combined. We believe this team has made significant progress toward combatting this serious concern.

1. Firearm injuries are increasing significantly in the last 5 years.
2. Community pediatricians are interested in learning how to provide firearm injury prevention in their clinics.
3. Multidisciplinary teams can make much more progress than individuals working on their own to address injury prevention.

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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