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Richards JA, Kuo E, Stewart C, Shulman L, Parrish R, Whiteside U, Boggs JM, Simon GE, Rowhani-Rahbar A, Betz ME. Reducing Firearm Access for Suicide Prevention: Implementation Evaluation of the Web-Based "Lock to Live" Decision Aid in Routine Health Care Encounters. JMIR Med Inform 2024; 12:e48007. [PMID: 38647319 PMCID: PMC11063417 DOI: 10.2196/48007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/12/2023] [Accepted: 02/27/2024] [Indexed: 04/25/2024] Open
Abstract
Background "Lock to Live" (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians. Objective The goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters. Methods The L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)-a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model-Reach, Adoption, and Implementation-were selected to inform and evaluate the implementation of L2L at KPWA (January 1, 2020, to December 31, 2021). Electronic health record (EHR) data were used to purposefully recruit adult patients, including firearm owners and patients reporting suicidality, to participate in semistructured interviews. Interview themes were used to facilitate L2L implementation and inform subsequent semistructured interviews with clinicians responsible for suicide risk mitigation. Audio-recorded interviews were conducted via the web, transcribed, and coded, using a rapid qualitative inquiry approach. A descriptive analysis of EHR data was performed to summarize L2L reach and adoption among patients identified at high risk of suicide. Results The initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) "have an open conversation," (2) "validate their situation," (3) "share what to expect," (4) "make it accessible and memorable," and (5) "walk through the tool." Clinicians' interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from <1% to 48% among mental health clinicians. Conclusions Understanding the value of L2L from users' perspectives was essential for facilitating implementation and increasing patient reach and clinician adoption. Incorporating L2L into the existing system-level, EHR-based safety plan template reduced the effort to use L2L and was likely the most impactful implementation strategy. As rising suicide rates galvanize the urgency of prevention, the findings from this project, including L2L implementation tools and strategies, will support efforts to promote safety for suicide prevention in health care nationwide.
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Affiliation(s)
- Julie Angerhofer Richards
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States
| | - Elena Kuo
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Christine Stewart
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Lisa Shulman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Rebecca Parrish
- Department of Mental Health & Wellness, Kaiser Permanente Washington, Seattle, WA, United States
| | - Ursula Whiteside
- NowMattersNow.org, Seattle, WA, United States
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Jennifer M Boggs
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, United States
| | - Gregory E Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
- Department of Mental Health & Wellness, Kaiser Permanente Washington, Seattle, WA, United States
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Ali Rowhani-Rahbar
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, United States
- Firearm Injury and Policy Research Program, University of Washington, Seattle, WA, United States
| | - Marian E Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, United States
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Mueller KL, Blomkalns AL, Ranney ML. Taking Aim at the Injury Prevention Curriculum: Educating Residents on Talking to Patients About Firearm Injury. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:1433-1437. [PMID: 35442908 DOI: 10.1097/acm.0000000000004707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The medical community recognizes that firearm injury is a public health problem. Yet we lack both the tools for and the implementation of evidence-based firearm injury screening and counseling techniques. One reason for these deficits is the lack of clinical training related to engaging patients in firearm injury risk reduction. In this issue, Rickert et al describe a pre-post evaluation of a 2-part firearm injury prevention training curriculum for first-year medical residents at a single academic medical center. Their manuscript serves an important, but still preliminary, step forward for the field of postgraduate medical education on firearm injury and its prevention. Important elements of this project and paper consist of the inclusion of multiple medical disciplines and the use of standardized patients to evaluate participants' learning. This project also points to the need for further growth. We must commit to consistently and conscientiously framing injuries from guns not as "gun violence" but rather as "firearm injuries" to ensure that they are considered squarely in both the public health space and the clinical space. An ideal curriculum would also highlight the importance of trauma-informed care, cultural competency, and antiracist medical practice while countering implicit biases (e.g., toward gun owners, victims of firearm violence, perpetrators of violence). It should address barriers, as well as facilitators, to change. And most importantly, future educational work must evaluate the effect of these trainings on actual clinical practice-and, even better, the efficacy of education in changing behavior and patient-level outcomes.
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Affiliation(s)
- Kristen L Mueller
- K.L. Mueller is assistant professor, Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri; ORCID: https://orcid.org/0000-0001-9799-0861
| | - Andra L Blomkalns
- A.L. Blomkalns is professor and chair, Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Megan L Ranney
- M.L. Ranney is professor, Department of Emergency Medicine, Warren Alpert Medical School, and academic dean, School of Public Health, Brown University, Providence, Rhode Island
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Hoops K, McCourt A, Crifasi CK. The 5 A's of firearm safety counseling: Validating a clinical counseling methodology for firearms in a simulation-based randomized controlled trial. Prev Med Rep 2022; 27:101811. [PMID: 35656203 PMCID: PMC9152792 DOI: 10.1016/j.pmedr.2022.101811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 04/27/2022] [Accepted: 04/30/2022] [Indexed: 11/30/2022] Open
Abstract
The 5 A's of Firearm Safety Counseling is a novel framework by which clinicians can approach firearm injury prevention counseling. To evaluate this methodology as a tool for clinicians, a single-center, simulation-based randomized controlled trial was performed with clinical trainees in psychiatry, medicine, and pediatrics in an urban quaternary care center. Participants received didactic education on firearm injury epidemiology and evidence-based policies and training on a specific counseling framework, the 5 A's of Firearm Safety Counseling which they then implemented in a simulation setting with standardized patients. Of the 29 participants who were randomized, 28 completed the trial. Most participants were psychiatry trainees (residents or subspecialty fellows). While over 60% of participants were uncomfortable or extremely uncomfortable counseling on firearm injury prior to the interventions, only 4% reported being uncomfortable after receiving education and participating in simulated encounters. There was no significant difference between the quality and content of the counseling provided before and after the didactic-only session. There was a significant difference between the quality and content of the counseling provided before and after the specific training on the 5 A's for Firearm Safety Counseling strategy. The 5 A's for Firearm Safety Counseling is a promising educational tool to improve quality, content, and comfort delivering patient-centered counseling on firearm injury prevention in a simulation-based setting. These findings suggest that further validation in a clinical setting is warranted given there is an urgent need for feasible and effective firearm injury prevention strategies among clinicians.
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Affiliation(s)
- Katherine Hoops
- Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine, United States
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Alexander McCourt
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Cassandra K. Crifasi
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
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Emergency Medicine Nurse Practitioner and Physician Assistant Burnout, Perceived Stress, and Utilization of Wellness Resources During 2020 in a Large Urban Medical Center. Adv Emerg Nurs J 2022; 44:63-73. [PMID: 35089284 DOI: 10.1097/tme.0000000000000392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objectives of this study were to measure perceived stress, burnout, and utilization and perceived benefit of wellness practices among emergency medicine (EM) nurse practitioners (NPs) and physician assistants (PAs). An additional aim was to evaluate attributions of stress to racism and the COVID-19 pandemic. A 28-item electronic survey of ED NPs/PAs at 3 hospitals was used to measure respondents' perceived stress (Perceived Stress Scale), stress attributed to COVID-19 and systemic racism, burnout (2-item measure), and utilization and helpfulness of wellness practices. The sample consisted of 53 ED NPs/PAs respondents (response rate 42.4%). More than one half (58.5%) reported burnout from their job, and a majority (58.5%) reported moderate to high stress. Burnout was reported by 70% of female respondents compared with 30.8% of male respondent (p = 0.002). A large majority (70%) of Black respondents reported concerns about experiencing racism at work, and 58.8% reported higher levels of stress attributed to racism. Respondents reported meals during shifts, community donated personal protective equipment, flexible work hours, and societal offerings of financial support (e.g., Internal Revenue Service stimulus check) as helpful. The COVID-19 pandemic and the impact of systemic racism are significant contributors to the stress and burnout of NPs/PAs. Female ED NPs/PAs disproportionally share the burden of burnout. Strategies to reduce burnout should be prioritized by institutional leadership. In addition, a majority of Black ED NPs/PAs are concerned about experiencing racism at work and report moderate to high stress associated with racism in general. There is an urgent need to address racism in the workplace with training on implicit bias, systemic racism, and allyship behavior.
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Hoops K, Fahimi J, Khoeur L, Studenmund C, Barber C, Barnhorst A, Betz ME, Crifasi CK, Davis JA, Dewispelaere W, Fisher L, Howard PK, Ketterer A, Marcolini E, Nestadt PS, Rozel J, Simonetti JA, Spitzer S, Victoroff M, Williams BH, Howley L, Ranney ML. Consensus-Driven Priorities for Firearm Injury Education Among Medical Professionals. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:93-104. [PMID: 34232149 DOI: 10.1097/acm.0000000000004226] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
PURPOSE Firearm injury is a leading cause of morbidity and mortality in the United States. However, many medical professionals currently receive minimal or no education on firearm injury or its prevention. The authors sought to convene a diverse group of national experts in firearm injury epidemiology, injury prevention, and medical education to develop consensus on priorities to inform the creation of learning objectives and curricula for firearm injury education for medical professionals. METHOD In 2019, the authors convened an advisory group that was geographically, demographically, and professionally diverse, composed of 33 clinicians, researchers, and educators from across the United States. They used the nominal group technique to achieve consensus on priorities for health professions education on firearm injury. The process involved an initial idea-generating phase, followed by a round-robin sharing of ideas and further idea generation, facilitated discussion and clarification, and the ranking of ideas to generate a prioritized list. RESULTS This report provides the first national consensus guidelines on firearm injury education for medical professionals. These priorities include a set of crosscutting, basic, and advanced learning objectives applicable to all contexts of firearm injury and all medical disciplines, specialties, and levels of training. They focus on 7 contextual categories that had previously been identified in the literature: 1 category of general priorities applicable to all contexts and 6 categories of specific contexts, including intimate partner violence, mass violence, officer-involved shootings, peer (nonpartner) violence, suicide, and unintentional injury. CONCLUSIONS Robust, data- and consensus-driven priorities for health professions education on firearm injury create a pathway to clinician competence and self-efficacy. With an improved foundation for curriculum development and educational program-building, clinicians will be better informed to engage in a host of firearm injury prevention initiatives both at the bedside and in their communities.
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Affiliation(s)
- Katherine Hoops
- K. Hoops is assistant professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jahan Fahimi
- J. Fahimi is associate professor, Department of Emergency Medicine, University of California, San Francisco School of Medicine and Institute for Health Policy Studies, San Francisco, California
| | - Lina Khoeur
- L. Khoeur is a third-year medical student, University of California, San Francisco School of Medicine, San Francisco, California
| | - Christine Studenmund
- C. Studenmund is a third-year medical student, University of California, San Francisco School of Medicine, San Francisco, California
| | - Catherine Barber
- C. Barber is senior researcher, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Amy Barnhorst
- A. Barnhorst is associate professor, Department of Psychiatry and Behavioral Sciences and Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, California
| | - Marian E Betz
- M.E. Betz is associate professor, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Cassandra K Crifasi
- C.K. Crifasi is assistant professor, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - John A Davis
- J.A. Davis is professor and associate dean for curriculum, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - William Dewispelaere
- W. Dewispelaere is a resident, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Lynn Fisher
- L. Fisher is assistant professor, Department of Family and Community Medicine, University of Kansas School of Medicine, Wichita, Kansas
| | - Patricia K Howard
- P.K. Howard is adjunct assistant professor, University of Kentucky, Lexington, Kentucky
| | - Andrew Ketterer
- A. Ketterer is clinical instructor, Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Evie Marcolini
- E. Marcolini is assistant professor, Department of Emergency Medicine and Department of Neurology, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Paul S Nestadt
- P.S. Nestadt is assistant professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, and Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - John Rozel
- J. Rozel is associate professor, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joseph A Simonetti
- J.A. Simonetti is assistant professor, Department of Medicine, University of Colorado School of Medicine, and Veterans Health Administration, Aurora, Colorado
| | - Sarabeth Spitzer
- S. Spitzer is a resident, Department of Surgery, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Victoroff
- M. Victoroff is clinical professor, Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Brian H Williams
- B.H. Williams is associate professor, Department of Surgery, University of Chicago Pritzker School of Medicine and Biological Sciences, Chicago, Illinois
| | - Lisa Howley
- L. Howley is senior director of strategic initiatives and partnerships, Association of American Medical Colleges, Washington, DC
| | - Megan L Ranney
- M.L. Ranney is associate professor, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Ketterer AR, Lewis JJ, Ellis JC, Hall MM, Abuhasira R, Ullman EA, Dubosh NM. A Simulation-Based Prospective Cohort Study on Teaching Best Practices in Firearms Safety. Simul Healthc 2021; 16:e116-e122. [PMID: 32701864 DOI: 10.1097/sih.0000000000000490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gun violence in the United States is a significant public health concern. The high rate of weapons carriage by Americans places medical providers at risk for exposure to firearms in the workplace and provides an opportunity for patient safety counseling. Few curricular interventions have been published on teaching firearms safety principles to medical providers. Given the risk of encountering firearms in the workplace and the opportunity to engage patients in firearms safety counseling, providers may benefit from dedicated training on safely handling firearms. METHODS This was a prospective cohort pilot study of a simulation-based educational intervention for third- and fourth-year medical students enrolled in an emergency medicine subinternship and emergency medicine bootcamp elective. Before undergoing the educational intervention, students completed a preintervention simulation case during which they discovered a model firearm in the patient's belongings and were asked to remove it. Students then received the intervention that included a discussion and demonstration on how to safely remove a firearm in the clinical setting. Two weeks later, the students were presented with a model firearm in a different simulation case, which they needed to remove. During the preintervention and postintervention simulations, students were evaluated on their performance of the critical actions in firearm removal using an 8-item checklist. Students' scores on this checklist were compared. RESULTS Fifty-three students participated in the study, 25 of whom completed the postintervention assessment. The median number of correctly performed critical actions preintervention was 5 (interquartile range = 4-6) and postintervention was 7 (interquartile range = 6-8, P < 0.001). Students showed particular improvement in 4 steps: holding the firearm by the grip only, pointing the firearm in a safe direction at all times, removing the firearm from the immediate patient care area and placing it in a safe area, and ensuring that the firearm is monitored and untouched until police or security personnel arrive to secure it. CONCLUSIONS This educational intervention is the first to formally teach students about the safe handling of firearms found in the clinical care space. This low-cost pilot project is easily transferrable to other training centers for teaching principles of safe firearms handling.
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Affiliation(s)
- Andrew R Ketterer
- From the Department of Emergency Medicine (A.R.K., J.J.L., J.C.E., M.M.H., E.A.U., N.M.D.), Beth Israel Deaconess Medical Center, Boston, MA, and Clinical Research Center (R.A.), Soroka University Medical Center, Ben-Gurion University of the Negev, Beersheba, Israel
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Farcy DA, Doria N, Moreno-Walton L, Gordon H, Sánchez J, Cubeddu LX, Ranney ML. Emergency Physician Survey on Firearm Injury Prevention: Where Can We Improve? West J Emerg Med 2021; 22:257-265. [PMID: 33856309 PMCID: PMC7972360 DOI: 10.5811/westjem.2020.11.49283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/16/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Firearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention. The aim of this study was to describe EPs' beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED). METHODS We conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons' Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate. RESULTS A total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home. CONCLUSIONS Among respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed.
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Affiliation(s)
- David A Farcy
- Mount Sinai Medical Center, Department of Emergency Medicine, Miami Beach, Florida.,Florida International University Herbert Wertheim College of Medicine, Department of Emergency Medicine & Critical Care, Miami Florida
| | - Nicole Doria
- Dalhousie University, School of Health and Human Performance, Halifax, Canada
| | - Lisa Moreno-Walton
- Louisiana State University Health Sciences Center, Department of Emergency Medicine, New Orleans, Louisiana
| | - Hannah Gordon
- Mount Sinai Medical Center, Department of Emergency Medicine, Miami Beach, Florida
| | - Jesus Sánchez
- NOVA Southeastern University, Department of Socio Behavioral Sciences, COP, Davie, Florida
| | - Luigi X Cubeddu
- NOVA Southeastern University, Department of Pharmaceutical Sciences, COP, Davie, Florida
| | - Megan L Ranney
- Brown University, Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
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