By Sharlene George
Pediatric emergency department physicians work at a fast pace to problem solve and provide the right treatment at the right time. Embracing this sense of urgency, physician-researchers with Children’s Hospital of Philadelphia’s Violence Prevention Initiative (VPI) are studying if the ED could be an ideal atmosphere for clinicians to educate patients and families about the risk of firearms, both for unintentional injury and for suicide.
Guns are the second leading cause of injury-related deaths for children ages 1 to 17 in the U.S. Suicide is the second leading cause of adolescent death, and most cases involve a family member’s unlocked gun. Parents often are unware of their adolescents’ suicidal thoughts, according to a recent study.
Looking for a way to stop these trends from spiraling, the VPI team is exploring the feasibility of launching a pilot program to empower families to keep their children safe. The firearm safety promotion would be universal in nature, involving clinicians who would initiate nonjudgmental conversations with families in the ED about firearm ownership, gun storage practices, and safety tips, and then send them home with free or low-cost firearm lock devices and educational materials.
“We’re essentially providing the reasoning for why it’s important to use gun lock devices — a rationale and method to protect children, from toddlers to teenagers, who may unintentionally or intentionally find a firearm that the caregivers have no intention of them using,” said Sofia Chaudhary, MD, a CHOP Emergency Medicine Fellow, who has seen firsthand the devastating impact on youth who have been victims of firearm injuries. “If there is anything I can do to help educate the community on the risks of having firearms in their homes and ways to mitigate those risks, I’m motivated to do that.”
Community needs assessments conducted by VPI investigators have shown people living in the neighborhoods served by Children’s Hospital of Philadelphia are deeply concerned about gun safety and want to know how to protect their children. In order to understand the best approach to initiating that dialogue in the ED, the VPI study team conducted a small subset of interviews to get all the opinions of those who would be affected by implementing an evidence-based approach to firearm safety promotion, including parents of youth, ED clinicians, and division leaders.
The VPI researchers shaped the framework for the qualitative study based in part on a JAMA Network Open article that described important factors to consider in implementing a similar prevention strategy during pediatric primary care office wellness visits. Co-author Joel Fein, MD, MPH, who is an ED physician at CHOP, co-director of VPI, and a professor of Pediatrics and Emergency Medicine at the Perelman School of Medicine at the University of Pennsylvania, said he gained insights into the facilitators and barriers they could anticipate when piloting the same type of intervention in a busy ED setting. The article’s first author Courtney Benjamin Wolk, PhD, and senior author Rinad Beidas, PhD, are his colleagues who conduct research in the Department of Psychiatry at Penn.
Time was the most frequently noted barrier to implementation, and the primary care physicians suggested that face-to-face counseling around safe firearm storage be brief and bundled with other safety questions. They also noted that administrative support from their healthcare systems, such as training procedures and integrating the intervention into the electronic health record, would likely ease implementation.
“Overall, the paper was enlightening and reassuring because it showed us the approach that families would be receptive to,” Dr. Chaudhary said. “Some MDs felt like they didn’t have adequate training or were not comfortable speaking about the topic, although they seemed to be in the minority. Those are very valuable issues that we would expect to have in the ED as well.”
While the results of the VPI team’s qualitative study are under consideration for publication, they plan to use what they learned so far to identify strategies to get buy-in from staff and administration, develop staff education on how to deliver the intervention, and create a comfortable environment where families feel they can be forthright about firearm ownership.
Applying such a rigorous approach to fully understand how to effectively influence social determinants of health is a mainstay of VPI’s research. VPI’s team relied on qualitative research methods to institute an evidence-based practice for a computerized behavioral health screening for adolescents who visit the ED. Similarly, they introduced a novel method for screening for intimate partner violence that allows clinicians to silently screen a parent while the child is in the room and make a referral as needed to a community partner electronically.
“I believe we’re doing very innovative things in the CHOP Emergency Department already around social determinants of health and safety that make our culture a little bit different,” Dr. Fein said. “Our providers are used to addressing issues that may not have been classically taught in medical school as their purview, yet they recognize them as important. We take their opinions into consideration, and we recognize the time and effort it takes for implementation of these projects.”
Prior research suggests that providing not only education and safety information about firearms but also handing somebody a firearm lock increases the chances of gun safety practices in the home. If the VPI pilot program in the ED, which is expected to launch this year, is successful, Drs. Chaudhary and Fein hope to see the same type of results. Once they can demonstrate the long-term benefit, the project could potentially provide a platform for other institutions to consider replicating in more pediatric EDs to provide firearm safety resources and tools to families across the country.