PC1008: Improving Documentation of Firearm Access Among Emergency Department Patients with Suicidal Ideation

Purpose/Objectives: About half of youth suicides involve firearms, and safe firearm storage in the home reduces suicide risk among adolescents. For children who present to the emergency department (ED) with suicidal ideation, lethal means restriction counseling with documentation of its provision is considered best practice. We aimed to increase the documentation of firearm access among children presenting to the ED with suicidal ideation to 80% within 12 months. Secondarily, among children endorsing firearm access, we aimed to increase documentation of firearm storage practices to 80%. Among children indicating firearm access, we offered cable gun locks to decrease access to lethal means.

Design/Methods: We convened an interdisciplinary quality improvement team and used the Institute for Healthcare Improvement’s Model for Improvement to generate a key driver diagram (Figure 1). We conducted a retrospective review of firearm documentation among ED visits by children 0-18 years old with a diagnosis code indicating suicide or self-injury from 2/01/2020 through 3/31/2022. We reviewed full note texts and iteratively identified keywords related to firearm access using six months of baseline data. Once we identified reliable keywords, we determined the presence of firearm documentation through manual review of keyword snippets abstracted from the electronic health record. We defined documentation of firearm access as any ED note indicating the presence/absence of a firearm around the child's home. We defined documentation of firearm storage as any ED note indicating how a firearm was stored and assessed complete documentation as incorporating all safe firearm storage elements (i.e. whether firearm was locked, unloaded and separate from ammunition). On 10/18/21, we implemented an intervention consisting of a templated phrase (i.e., “Access to guns: yes/no”) in the ED psychiatric social worker consult note. Concurrently, we made free cable gun locks available to children who endorsed firearm access. Statistical process control charts were generated monthly to monitor progress towards achieving goals.

Results: We identified 1769 encounters for suicide or self-injury. Documentation of firearm access increased from a mean of 12.7% (151/1187) during the baseline period to 77.2% (449/582) in the post-intervention period, resulting in a centerline shift (Figure 2). Among those with firearm access, documentation of firearm storage increased from 56.3% to 82.4%, but this documentation was always incomplete. Seven cable gun locks were provided over six months during the post-intervention period.

Conclusion/Discussion: Adding a standardized question to the ED psychiatric social worker consult note template facilitated a substantial increase in documentation of firearm access for ED patients with suicidal ideation. This approach may be considered by other EDs seeking to improve screening for safe firearm storage practices. A future intervention will include modification of the note template to incorporate all safe firearm storage elements (i.e., locked, unloaded, separate from ammunition).