Lethal Means Assessment and Counseling in the Emergency Department: Differences by Provider Type and Personal Home Firearms

Suicide Screening, Risk Assessment, and Lethal Means Counseling During Zero Suicide Implementation

OBJECTIVE

The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings.

METHODS

Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated.

RESULTS

In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care.

CONCLUSIONS

Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening.

Reducing firearm access for youth at risk for suicide in a pediatric emergency department

Background

Firearm-related suicide is the second leading cause of pediatric firearm death. Lethal means counseling (LMC) can improve firearm safe-storage practices for families with youth at risk of suicide.

Objectives

This study aims to evaluate the feasibility of pediatric emergency department (ED) behavioral mental health (BMH) specialists providing LMC to caregivers of youth presenting with BMH complaints and to test for changes in firearm safety practices, pre-post ED LMC intervention, as measures of preliminary efficacy.

Methods

Prospective pilot feasibility study of caregivers of youth presenting to a pediatric ED with BMH complaints. Caregivers completed an electronic survey regarding demographics and firearm safe-storage knowledge/practices followed by BMH specialist LMC. Firearm owners were offered a free lockbox and/or trigger lock. One-week follow-up surveys gathered self-reported data on firearm safety practices and intervention acceptability. One-month interviews with randomly sampled firearm owners collected additional firearm safety data. Primary outcomes were feasibility measures, including participant accrual/attrition and LMC intervention acceptability. Secondary outcomes included self-reported firearm safety practice changes. Feasibility benchmarks were manually tabulated, and Likert-scale acceptability responses were dichotomized to strongly agree/agree vs. neutral/disagree/strongly disagree. Descriptive statistics were used for univariate and paired data responses.

Results

In total, 81 caregivers were approached; of which, 50 (81%) caregivers enrolled. A total of 44% reported having a firearm at home, 80% completed follow-up at one week. More than 80% affirmed that ED firearm safety education was useful and that the ED is an appropriate place for firearm safety discussions. In total, 58% of participants reported not having prior firearm safety education/counseling. Among firearm owners (n = 22), 18% reported rarely/never previously using a safe-storage device, and 59% of firearm owners requested safe storage devices.At 1-week follow-up (n = 40), a greater proportion of caregivers self-reported asking about firearms before their child visited other homes (+28%). Among firearm owners that completed follow-up (n = 19), 100% reported storing all firearms locked at one week (+23% post-intervention). In total, 10 caregivers reported temporarily/permanently removing firearms from the home.

Conclusion

It is feasible to provide LMC in the pediatric ED via BMH specialists to families of high-risk youth. Caregivers were receptive to LMC and reported finding this intervention useful, acceptable, and appropriate. Additionally, LMC and device distribution led to reported changes in safe storage practices.

Improving Identification of Firearm Access in Children With Mental Health Complaints

OBJECTIVE

To determine if electronic medical record (EMR) changes and implementation of a study on firearm storage practices changed identification of firearm exposure in children presenting to a pediatric emergency department (PED) with mental health complaints. We also sought to determine the accuracy of information collected on firearm storage practices.

METHODS

Retrospective study of EMR documentation of firearm exposure in PED patients with mental health complaints from January 20, 2015 until November 20, 2017. EMR changes occurred on January 20, 2016 and the firearms study began on February 13, 2016. The primary outcome was documentation of firearm exposure. Secondary outcomes were documentation of unsafe firearm storage practices. We also examined differences between clinical and research documentation of unsafe firearm storage practices post-intervention. We compared groups using descriptive statistics and chi-squared tests. We used statistical process control to examine the relationship between interventions and changes in outcomes.

RESULTS

5582 encounters were examined. Identification of firearm exposure increased from 11 to 17% postintervention. Identification of unsafe storage practices increased from 1.9% to 4.4% across all encounters. Special cause variation in both metrics occurred concurrently with the interventions. Postintervention, unsafe firearms storage practices in firearm owning families were under-identified (39% identified as not triple-safe in clinical data vs 75% in research data).

CONCLUSIONS

EMR changes and implementation of a firearms study improved identification of firearm exposure and unsafe storage practices in families of PED patients being evaluated for mental health complaints. However, unsafe storage practices continued to be under-identified in firearm-owning families.

Determining who healthcare providers screen for firearm access in the United States

Healthcare providers are well positioned to screen for firearm access to reduce risk of suicides, yet there is a limited understanding of how often and for whom firearm access screening occurs. The present study examined the extent to which providers screen for firearm access and sought to identify who has been screened in the past. The representative sample included 3510 residents from five US states who reported whether they have been asked about their access to firearms by a healthcare provider. The findings demonstrate that most participants have never been asked by a provider about firearm access. People who have been asked were more likely to be White, male, and firearm owners. Those with children under 17 years old in the home, that have been in mental health treatment, and report a history of suicidal ideation were more likely to be screened for firearm access. Although there are interventions for mitigating firearm related risks in healthcare settings, many providers may be missing the opportunity to implement these because they do not ask about firearm access.

Emergency Departments Treating Veterans for Suicide: Ensuring Quality Care for Veterans Outside of Department of Veterans Affairs Health Care Facilities

INTRODUCTION

Veterans die by suicide at higher rates than nonveterans. Given that the emergency department is often the first point of entry to healthcare following a suicide attempt, it would be beneficial for community providers to have knowledge of the characteristics, medical issues, and effective treatments most often associated with those having served in the military to ensure guideline concordant and quality suicide care. This study aimed to identify assessment and referral practices of emergency departments at rural community hospitals related to care for suicidal veterans and explore the feasibility and acceptability of identifying veterans in need of postdischarge aftercare.

METHODS

This qualitative exploratory study involved content analysis of semistructured interviews. Ten emergency clinicians from 5 rural Arkansas counties with high suicide rates were interviewed about their experiences working with suicidal patients within the emergency department and perceptions of assessment, management, and referral practices.

RESULTS

Although most of the emergency departments had a process for assessing for suicide risk, emergency clinicians did not always feel confident in their knowledge of assessing and caring for suicidal patients. Military history was not included in assessment, treatment, or aftercare planning, nor were brief interventions such as safety planning or lethal means safety education provided.

DISCUSSION

Best practices for suicide assessment and management of veterans exist; however, challenges specific to the emergency department regarding staff training and engaging the community to effectively link at-risk veterans to needed care hinder implementation. Veteran-inclusive assessment and intervention practices could enhance the quality of care provided in community emergency departments.

Firearm-Related Injuries and Deaths in Children and Youth

Firearms are the leading cause of death in children and youth 0 to 24 years of age in the United States. In 2020, firearms resulted in 10,197 deaths (fatality rate 9.91/100,000 youth 0-24 years old). Firearms are the leading mechanism of death in pediatric suicides and homicides. Increased access to firearms is associated with increased rates of firearm deaths. Substantial disparities in firearm injuries and deaths exist by age, gender, race, ethnicity, and sexual orientation and gender identity and for deaths related to legal intervention. Barriers to firearm access can decrease the risk to youth for firearm suicide, homicide, or unintentional shooting injury and death. Given the high lethality of firearms and the impulsivity associated with suicidal ideation, removing firearms from the home or securely storing them-referred to as lethal means restriction of firearms-is critical, especially for youth at risk for suicide. Primary care-, emergency department-, mental health-, hospital-, and community-based intervention programs can effectively screen and intervene for individuals at risk for harming themselves or others. The delivery of anticipatory guidance coupled with safety equipment provision improves firearm safer storage. Strong state-level firearm legislation is associated with decreased rates of firearm injuries and death. This includes legislation focused on comprehensive firearm licensing strategies and extreme risk protection order laws. A firm commitment to confront this public health crisis with a multipronged approach engaging all stakeholders, including individuals, families, clinicians, health systems, communities, public health advocates, firearm owners and nonowners, and policy makers, is essential to address the worsening firearm crisis facing US youth today.

Taking Aim at the Injury Prevention Curriculum: Educating Residents on Talking to Patients About Firearm Injury

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.

“Lock to Live” for firearm and medication safety: Feasibility and acceptability of a suicide prevention tool in a learning healthcare system

Objective

Few patients with suicide risk are counseled on lethal means safety by health providers. This study tested the feasibility of different delivery methods for Lock to Live (L2L), a web-based decision aid of safe storage options for firearms and medications.

Methods

Patients reporting suicide ideation on the PHQ9 depression screener during outpatient health visits were included. Invitation messages to visit L2L were sent via combinations of email, text, Electronic Health Record (EHR) message, mailed letter, or provider referral, followed by a survey about storage behavior and acceptability. Provider interviews evaluated logistical considerations and acceptability.

Results

The population-based method reached 2,729 patients and the best method (EHR message plus 2 email reminders) had 11% uptake (L2L visitation rate). Provider referral had small reach (14 patients) and 100% uptake (all visited). Provider interviews identified several strategies to promote uptake including: EHR reminders, provider training, quality metrics with accountability, a clearly communicated lethal means screening/counseling policy, and strong organizational leadership support.

Conclusion

Despite the low uptake for population-based (11%), far more patients with suicide risk were engaged in the L2L tool through population-based outreach than provider-referral over the same time frame.

Examining Recovery Status and Supports before and after Substance Abuse Disorder Treatment Among Clients Who Experienced Lifetime and Recent Firearm-Related Threats

Firearm-related risks have often been overlooked in the sequela of substance use and substance use disorders. This study compares adult substance abuse disorder treatment (SADT) clients who experienced recent ( n = 274) and lifetime ( n = 889) firearm threats to adults who were not threatened with a firearm ( n = 2029) before and 12 months after program entry. More men experienced firearm threats (38.8%) than women (34.2%). However, among those with any firearm threats, more women (27.2%) experienced firearm threats in the year before program entry than men (20.2%). Being threatened with a firearm was associated with increased economic vulnerability, criminal justice system involvement, mental health problems, and victimization both before and after SADT program entry. A higher number of adverse childhood experiences were associated with firearm threats and particularly recent firearm threats. Results of this study underscore the importance of screening for firearm-related risks in substance abuse disorder treatment programs.

Lethal Means Counseling for Suicidal Adults in the Emergency Department: A Qualitative Study

Introduction

Lethal means counseling (to reduce access to firearms or other suicide methods) is a recommended critical yet challenging component of care of suicidal patients. Questions remain about communication strategies for those in acute crisis.

Methods

This qualitative study was an analysis of semi-structured interviews with English-speaking, community-dwelling adults with a history of lived-experience of suicidal ideation or attempts in themselves or a family member. We used a mixed inductive and deductive approach to identify descriptive themes related to communication and decision-making.

Results

Among 27 participants, 14 (52%) had personal and 23 (85%) had family experience with suicide ideation or attempts. Emergent themes fell into two domains: (1) communication in a state of high emotionality; and (2) specific challenges in communication: initiating, maintaining engagement, considering context.

Conclusion

Engaging suicidal individuals in lethal means counseling may be more effective when messaging and approaches consider their emotional state and communication challenges.

Lethal means counseling for suicide prevention: Views of emergency department clinicians

OBJECTIVE

Lethal means safety - counseling and guidance about reducing access to home firearms and medications - is recommended for emergency department patients at risk of suicide. Decision aids are tools that can facilitate potentially difficult decisions by incorporating personal preferences and values. The present study evaluates clinician perceptions about the implementation and utility of "Lock to Live," a lethal means safety decision aid.

METHOD

One-on-one qualitative interviews were conducted with clinicians (n = 15) at three large emergency departments. Interviewees were asked to evaluate the "Lock to Live" decision tool and its potential implementation and utilization in the emergency department. Interviews were recorded and transcribed. Data were coded via thematic analysis; two coders developed a shared codebook iteratively with high interrater reliability.

RESULTS

Perspectives on the tool fell into three domains: (1) patients (use with patients and families), (2) clinicians, and (3) emergency department system. Interviewees noted that the tool had numerous potential benefits but that its uptake and effectiveness would depend on clinicians' perceptions on its utility, time constraints, and integration into workflow. Addressable concerns related to relationship to other resources, fit within emergency department workflow, and clarification about which emergency department clinician types should use the tool.

CONCLUSIONS

"Lock to Live" represents a promising new tool for use in suicide prevention as an aid to lethal means counseling. This qualitative study provides insights into the importance of considering the clinical environment when designing and implementing interventions.