Lethal means restriction for suicide prevention: beliefs and behaviors of emergency department providers

Emergency medical services (EMS) clinicians' views on EMS-delivered interventions to promote secure firearm storage practices

INTRODUCTION

Lethal means safety counseling (LMSC) to promote secure firearm storage may reduce the risk of firearm-involved deaths, including suicide. We examined if emergency medical services (EMS) clinicians, including emergency medical technicians and paramedics, may be suitable LMSC messengers.

METHOD

We conducted a web-based survey of 229 US EMS clinicians.

RESULTS

While few EMS clinicians supported EMS-delivered LMSC to all patients (17.0%), most supported EMS-delivered LMSC to patients in an acute suicidal crisis (64.2%) or with a known suicide attempt history (55.9%). Barriers to EMS-delivered LMSC included lack of training (73.4%), perceptions that LMSC is outside EMS clinicians' scope of practice (58.1%), and lack of standard operating procedures (56.3%). Most reported at least some interest in receiving training on EMS-delivered LMSC (67.7%). Participants holding more accurate beliefs about the link between firearm storage practices and suicide risk, as well as the efficacy of LMSC, were more likely to support EMS-delivered LMSC across patient scenarios (ORs = 2.18-5.21, ps <0.01) and express interest in receiving LMSC training (ORs = 3.78-5.43, ps <0.001).

CONCLUSION

Given that many EMS clinicians interface with patients at elevated suicide risk, targeted LMSC training may be strategic; however, research is needed to determine if and how EMS clinicians might be viable LMSC messengers.

Effect of an Emergency Department Process Improvement Package on Suicide Prevention: The ED-SAFE 2 Cluster Randomized Clinical Trial

Importance

Suicide is a leading cause of deaths in the US. Although the emergency department (ED) is an opportune setting, ED-initiated interventions remain underdeveloped and understudied.

Objective

To determine if an ED process improvement package, with a subfocus on improving the implementation of collaborative safety planning, reduces subsequent suicide-related behaviors.

Design, Setting, and Participants

The Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial, a stepped-wedge cluster randomized clinical trial conducted in 8 EDs across the US, used an interrupted time series design with three 12-month sequential phases: baseline, implementation, and maintenance. A random sample of 25 patients per month per site 18 years and older who screened positive on the Patient Safety Screener, a validated suicide risk screener, were included. The primary analyses focused on those who were discharged from the ED, while secondary analyses focused on all patients who screened positive, regardless of disposition. Data were collected on patients who presented for care from January 2014 to April 2018, and data were analyzed from April to December 2022.

Interventions

Each site received lean training and built a continuous quality improvement (CQI) team to evaluate the current suicide-related workflow in the ED, identify areas of improvement, and implement efforts to improve. Each site was expected to increase their universal suicide risk screening and implement collaborative safety planning for patients at risk of suicide who were discharged home from the ED. Site teams were centrally coached by engineers experienced in lean CQI and suicide prevention specialists.

Main Outcomes and Measures

The primary outcome was a composite comprising death by suicide or suicide-related acute health care visits, measured over a 6-month follow-up window.

Results

Across 3 phases, 2761 patient encounters were included in the analyses. Of these, 1391 (50.4%) were male, and the mean (SD) age was 37.4 (14.5) years. A total of 546 patients (19.8%) exhibited the suicide composite during the 6-month follow-up (9 [0.3%] died by suicide and 538 [19.5%] of a suicide-related acute health care visit). A significant difference was observed for the suicide composite outcome between the 3 phases (baseline, 216 of 1030 [21%]; implementation, 213 of 967 [22%]; maintenance, 117 of 764 [15.3%]; P = .001). The adjusted odds ratios of risk of the suicide composite during the maintenance phase was 0.57 (95% CI, 0.43-0.74) compared with baseline and 0.61 (0.46-0.79) compared with the implementation phase, which reflect a 43% and 39% reduction, respectively.

Conclusions and Relevance

In this multisite randomized clinical trial, using CQI methods to implement a department-wide change in suicide-related practices, including the implementation of a safety plan intervention, yielded a significant decrease in suicide behaviors in the maintenance period of the study.

Trial Registration

ClinicalTrials.gov Identifier: NCT02453243.

Perceptions of Firearm Accessibility and Suicide Among US Adults Living in Households With Firearms

This survey study of US adults living in households with firearms uses a counterfactual question to assess whether respondents believed restricting access to firearms might prevent death by suicide.

Lethal Means Assessment in Psychiatric Emergency Services: Frequency and Characteristics of Assessment

OBJECTIVE

Lethal means safety is an effective suicide prevention strategy with demonstrated results at the population level, yet individual-level uptake is less well understood.

METHODS

Using automated data extraction methods, we conducted an investigation of electronic health records from psychiatric emergency service (PES) patients from January 1, 2012 to December 31, 2017 at a busy urban medical center in the Pacific Northwest. At each PES mental health evaluation, every patient received a Suicide Risk Assessment during which providers used an electronic template with standardized fields to record lethal means access and other suicide risk factors.

RESULTS

We assessed 32,658 records belonging to 15,652 patients. Among all visits, 69.9% (n = 22,824) had some documentation of lethal means assessment. However, 54.1% (n = 17,674) of all visits lacked some or all potential documentation detail. Additionally, among 59.6% of visits in which a patient had documented access to lethal means, the specific means available were not indicated. Across the twenty risk and demographic factors we assessed, the prevalence of documentation did not vary by any given risk factor and only varied minimally by age and race. For example, when comparing visits which indicated family history of suicide to those which indicated no family history of suicide, the prevalence ratio was 0.99 (95% CI: 0.95, 1.03).

CONCLUSION

Despite the high-risk patient population, mental health focus of the facility, and the presence of a standardized tool, lethal means documentation was suboptimal. In alignment with recent recommendations, our findings indicate that additional focus on implementation is needed to improve documentation of lethal means assessment.HighlightsFifteen times larger than prior comparable studiesFindings demonstrate persistent under-documentation patterns in new setting and regionStandardized methods likely needed to improve documentation detail and frequency.

A high-need, high-impact educational session on firearms and death by suicide

BACKGROUND

The suicide rate among Veterans is 1.5 times greater than that for civilians, partly a result of the high use of firearms as the means for suicide. One effective strategy to reduce Veteran suicide by firearms is to provide counseling on firearm safety as a method of means reduction. However, many clinicians do not discuss firearm safety with Veterans.

AIMS

This study evaluates a one-hour educational seminar for clinicians on lethal means safety.

MATERIALS AND METHODS

One hundred and ninety clinicians from the Veterans Health Administration, including social workers, psychologists, psychiatrists, and nurses, participated in the training. The seminar was streamed during the South Central Mental Health Illness Research, Education and Clinical Center's Community-Based Outpatient Clinic Mental Health Grand Rounds, for which participants were eligible for continuing education units. Data were collected immediately after the training and four months later.

RESULTS

After completing the training, participants believed that it was important to speak with Veterans about firearm safety and felt knowledgeable and empowered to do so. Four months after the seminar, participants had counseled, on average, over half of Veterans treated about lethal means safety.

DISCUSSION

Participants reported the value of normalizing discussions about firearm safety with their Veterans and focusing on the safety aspect while discussing firearms.

CONCLUSIONS

This webinar was effective in providing clinicians the skills to talk with Veterans about firearm safety and continued to impact their practice four months after training. The training is available for free on our website at https://www.mirecc.va.gov/visn16/public-health-approach-to-firearms-and-death-by-suicide.asp.

The practice of lethal means restriction counseling in US emergency departments to reduce suicide risk: a systematic review of the literature

BACKGROUND

Suicide is a leading cause of death in the US. Lethal means restriction (LMR), which encourages limiting access and reducing the lethality of particular methods of suicide, has been identified as a viable prevention strategy. For this approach to be successful, adequate education about risks and means must be communicated to families and individuals at risk for suicide. This systematic review aims to identify LMR methods most commonly communicated by healthcare providers in the emergency department, and barriers to the delivery of such counseling.

METHODS

The protocol for this systematic review is registered with PROSPERO (CRD42018076734). Included studies were identified through searching four databases (PubMed, Scopus, PsycInfo, and EBSCO). Studies were selected and coded independently by two researchers using the PICOS framework. Included studies examined LMR counseling delivered in the ED regardless of patient age, sex or race/ethnicity.

RESULTS

A total of 1282 studies were screened; 9 met the inclusion criteria. Included studies were published from 1998 to 2020. Study participants were majority female, and safe firearm storage was the most common form of LMR counseling provided. Eight studies included counseling on multiple forms of lethal means, [e.g., alcohol, medication, and firearm storage] and one study focused solely on safe firearm storage. Two studies reported barriers limiting healthcare providers' delivery of LMR counseling, including lack of specialized skills and skepticism regarding the effectiveness of LMR counseling.

CONCLUSION

There is limited published evidence that identifies the most effective methods and target populations for LMR counseling. Given the growing literature that provides evidence of gender differences in suicide modality (e.g., guns, medications, suffocation), LMR counseling should be multifaceted, to address common means of suicide in both men and women. Despite evidence that the majority of suicide attempts and half of completed suicides do not involve firearms, results showed that LMR counseling is frequently focused on promoting the safe storage of firearms. This highlights the need to include counseling focused on a variety of lethal means to reduce risk of suicide completion. Prospective studies should also aim to identify the most efficacious methods of delivering LMR counseling in the clinical settings.

Patient Characteristics and Perspectives of Firearm Safety Discussions in the Emergency Department

Introduction

Firearm injury prevention discussions with emergency department (ED) patients provide a unique opportunity to prevent death and injury in high-risk patient groups. Building mutual understanding of safe firearm practices between patients and providers will aid the development of effective interventions. Examining ED patient baseline characteristics, perspectives on healthcare-based safety discussions, and experience with and access to firearms, will allow practitioners to craft more effective messaging and interventions.

Methods

Using an institutional review board-approved cross-sectional survey modified from a validated national instrument, we recruited 625 patients from three large, urban, academically affiliated EDs in the South to assess patient baseline characteristics, perspectives regarding firearms and firearm safety discussions, and prior violence history, as well as firearm access and safety habits. We compared the degree to which patients were open to discussions regarding firearms across a variety of provider types and clinical scenarios between those with and without gun access.

Results

Of the 625 patients consented and eligible for the study, 306 had access to firearms. The patients with firearm access were predominantly male, were more likely to have military experience, live in an urban or suburban region, and have experienced prior violence when compared to those without firearm access. Patients with and without gun access view firearm safety discussions with their healthcare provider as acceptable and analogous to other behavioral health interventions (i.e., helmet/seat belt use, alcohol/cigarette use). Patients were also accepting of these firearm safety discussions in many clinical contexts and led by multiple provider types. Of the patients with gun access, storage of each type of firearm was reviewed and the primary reason for ownership was for personal protection across all firearm types.

Conclusion

Patients in the ED indicate openness to firearm safety discussions delivered by a variety of providers and in diverse clinical scenarios. Healthcare providers engaging firearm owners in appropriate risk-benefit discussions using a trauma-informed approach is a critical next step in research and intervention.

Documentation of Screening for Firearm Access by Healthcare Providers in the Veterans Healthcare System: A Retrospective Study

INTRODUCTION

Presence of a firearm is associated with increased risk of violence and suicide. United States military veterans are at disproportionate risk of suicide. Routine healthcare provider screening of firearm access may prompt counseling on safe storage and handling of firearms. The objective of this study was to determine the frequency with which Veterans Health Administration (VHA) healthcare providers document firearm access in electronic health record (EHR) clinical notes, and whether this varied by patient characteristics.

METHODS

The study sample is a post-9-11 cohort of veterans in their first year of VHA care, with at least one outpatient care visit between 2012-2017 (N = 762,953). Demographic data, veteran military service characteristics, and clinical comorbidities were obtained from VHA EHR. We extracted clinical notes for outpatient visits to primary, urgent, or emergency clinics (total 105,316,004). Natural language processing and machine learning (ML) approaches were used to identify documentation of firearm access. A taxonomy of firearm terms was identified and manually annotated with text anchored by these terms, and then trained the ML algorithm. The random-forest algorithm achieved 81.9% accuracy in identifying documentation of firearm access.

RESULTS

The proportion of patients with EHR-documented access to one or more firearms during their first year of care in the VHA was relatively low and varied by patient characteristics. Men had significantly higher documentation of firearms than women (9.8% vs 7.1%; P < .001) and veterans >50 years old had the lowest (6.5%). Among veterans with any firearm term present, only 24.4% were classified as positive for access to a firearm (24.7% of men and 20.9% of women).

CONCLUSION

Natural language processing can identify documentation of access to firearms in clinical notes with acceptable accuracy, but there is a need for investigation into facilitators and barriers for providers and veterans to improve a systemwide process of firearm access screening. Screening, regardless of race/ethnicity, gender, and age, provides additional opportunities to protect veterans from self-harm and violence.

Exploring nurse suicide by firearms: A mixed-method longitudinal (2003-2017) analysis of death investigations

BACKGROUND

Previously it was noted that firearm use by nurses in suicide was changing. The Center for Disease Control and Prevention suicide dataset contains investigation narratives that no researcher has analyzed and may provide context to inform suicide prevention.

OBJECTIVE

Explore firearm deaths in nurse suicide. Second, test topic modeling techniques to analyze investigation narratives.

METHODS/STATISTICAL ANALYSIS

Mixed-method retrospective analysis of 739 nurse versus 94,838 nonnurse suicides. Odds ratios (OR) were calculated to determine relative incidence. After tokenization and stop word removal, Latent Dirichlet Analysis and Latent Semantic Indexing topic modeling techniques were applied. Topics were evaluated for clinical significance and content analysis performed.

RESULTS

Aim 1: Female nurses used firearms significantly less often than other females between 2003 and 2013 (OR: 0.71; p < .001; 95% confidence interval [CI]: 4.23%-9.83%). A rise in nurse firearm use occurred between 2014 and 2017; with rates now similar to nonnurse females (OR: 0.98; p = .7574; 95% CI: -2.68 to 3.49). Clinically relevant topics identified by topic modeling: preventable deaths, chronic pain, and job loss before suicide.

CONCLUSIONS

From this research we know that work-related issues in nurse suicides by firearms center around chronic pain, substance use, and job loss. The codes tied to suicidal ideation, previous attempt and/or depression, represented preventable deaths because it is known that if a weapon is removed from the home in these situations a suicide can be aborted. The change in firearm use warrants nurse education regarding firearm safety and suicide prevention. Topic modeling holds promise in focusing analyses of suicide investigations.

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

OBJECTIVE

This study examined emergency department (ED) and behavioral health (BH) provider attitudes and behaviors related to lethal means screening and counseling of patients with suicide risk, specifically examining differences by provider type and whether providers had firearms in their own home.

METHODS

Emergency department providers (physicians and mid-level practitioners) and behavioral health (BH) providers at four Colorado EDs completed an anonymous, web-based survey.

RESULTS

Fewer ED providers (35%) than BH providers (81%) felt confident in their ability to counsel patients about lethal means (p < .001). In multivariable analysis, the only clinical or provider factor associated with often or almost always asking patients about firearm access was provider type, with BH providers more likely than ED providers to ask in all scenarios (OR: 5.58, 95% CI 1.68-18.6). Behaviors and attitudes about lethal means counseling did not vary by whether the provider had firearms at home. Almost all providers said that additional training and protocols about how to help patients make firearm storage decisions would be helpful.

CONCLUSIONS

Gaps in ED-delivered lethal means counseling persist, highlighting directions for future provider education and protocol development.

Counseling on Access to Lethal Means in the Emergency Department: A Script for Improved Comfort

Individuals with suicidal ideation (SI) frequently present to the emergency department (ED). We hypothesized that CALM: Counseling on Access to Lethal Means training improves non-physician provider comfort with delivering an ED-based counseling intervention on lethal means restriction. Ten non-physician intervention counselors who currently provide CALM to ED patients presenting with SI were surveyed for demographics, prior experience caring for patients with SI, prior CALM experience, comfort providing CALM, and which method of training most improved comfort with CALM. Survey response rate was 100%. Following CALM training, 80% of respondents expressed confidence in their ability to counsel patients on safe storage of lethal means, although 50% felt that a script most improved comfort. Most survey respondents reported feeling comfortable counseling suicidal patients on safe storage of lethal means, but that the addition of a script for the counseling session improved comfort more than the online CALM training.

Counseling on Access to Lethal Means-Emergency Department (CALM-ED): A Quality Improvement Program for Firearm Injury Prevention

INTRODUCTION

Suicide is the 10^th leading cause of death in the United States, with firearms reported as the cause of death in up to 50% of these cases. Our goal was to evaluate the feasibility of the Counseling on Access to Lethal Means intervention in the Emergency Department (CALM-ED) by non-physician personnel.

METHODS

We conducted this single-center, prospective, quality improvement study (QI) in an urban, academic ED with over 90,000 annual patient visits. The study looked at adult patients who were discharged after presenting to the ED with suicidal crisis. Assessment of access to lethal means was conducted at the bedside, followed by a counseling session regarding safe storage of lethal means and follow-up via telephone call 48-72 hours after ED discharge. We collected data on patient's sociodemographics, psychiatric history, access to lethal means, lethal means storage methods, the patient's specific plans for lethal means storage after discharge, and post-discharge follow-up care.

RESULTS

Of 215 eligible patients, 166 voluntarily agreed to participate in CALM-ED, of whom 84 (51%) reported access to lethal means. Following the intervention, 75% of patients described a specific storage plan for their lethal means. Patients with and without access to firearms were equally likely to participate in the follow-up telephone call.

CONCLUSION

An ED-based CALM QI intervention is feasible for implementation by non-physician personnel and is well received by patients and families. This intervention has the potential to help saves lives at times of suicide crisis.

Usual Care for Emergency Department Patients Who Present with Suicide Risk: A Survey of Hospital Procedures in Washington State

Hospital emergency departments (EDs) are important settings for the implementation of effective suicide-specific care. Usual care for suicidal patients who present to EDs remains understudied. This study surveyed EDs in Washington State to assess the adoption of written procedures for recommended standards of care for treating suicidality. Most (N = 79, 84.9%) of the 93 EDs in Washington State participated. Most (n = 58, 73.4%) hospitals had a written protocol for suicide risk assessment, but half (n = 42, 53.2%) did not include documentation of access to lethal means. There was evidence of an association between patient volume and the adoption of suicide-specific protocols and procedures. Our findings suggest the need to enhance the adoption and implementation of recommended standard care in this setting.

A Quasi-Experimental Analysis of Lethal Means Assessment and Risk for Subsequent Suicide Attempts and Deaths

BACKGROUND

Counseling on access to lethal means is highly recommended for patients with suicide risk, but there are no formal evaluations of its impact in real-world settings.

OBJECTIVE

Evaluate whether lethal means assessment reduces the likelihood of suicide attempt and death outcomes.

DESIGN

Quasi-experimental design using an instrumental variable to overcome confounding due to unmeasured patient characteristics that could influence provider decisions to deliver lethal means assessment.

SETTING

Kaiser Permanente Colorado, an integrated health system serving over 600,000 members, with comprehensive capture of all electronic health records, medical claims, and death information.

PARTICIPANTS

Adult patients who endorsed suicide ideation on the Patient Health Questionnaire-9 (PHQ-9) depression screener administered in behavioral health and primary care settings from 2010 to 2016.

INTERVENTIONS

Provider documentation of lethal means assessment in the text of clinical notes, collected using a validated Natural Language Processing program.

MEASUREMENTS

Main outcome was ICD-9 or ICD-10 codes for self-inflicted injury or suicide death within 180 days of index PHQ-9 event.

RESULTS

We found 33% of patients with suicide ideation reported on the PHQ-9 received lethal means assessment in the 30 days following identification. Lethal means assessment reduced the risk of a suicide attempt or death within 180 days from 3.3 to 0.83% (p = .034, 95% CI = .069-.9).

LIMITATIONS

Unmeasured suicide prevention practices that co-occur with lethal means assessment may contribute to the effects observed.

CONCLUSIONS

Clinicians should expand the use of counseling on access to lethal means, along with co-occurring suicide prevention practices, to all patients who report suicide ideation.

Access to Firearms Among People Assessed by Psychiatric Services in the Emergency Department

OBJECTIVE

In Canada, 80% of firearm-related deaths are suicides. Access to firearms is associated with increased suicide rates. This study examines the frequency and factors that influence assessment of firearm access in an emergency setting.

METHODS

A total of 15,847 consecutive adults seen for psychiatric consultation in two tertiary emergency departments (EDs) in Winnipeg, Manitoba were interviewed. Data captured whether access to firearms was assessed, and whether respondents endorsed access or not. Comparisons were done to determine group differences among those with and without and with known and unknown firearm access.

RESULTS

Access to firearms was unknown in 47% (n = 7,363) of psychiatric ED consultations, including 43% (n = 998) of individuals who presented with a suicide attempt. Female sex was associated with decreased odds of firearm access (odds ratio [OR] 0.28; 95% CI, 0.22 to 0.35). Being single was associated with lower odds of known firearm access (OR 0.83; 95% CI, 0.77 to 0.89) yet higher likelihood of firearm access (OR 1.36; 95% CI, 1.11 to 1.68). Presenting with a suicide attempt (OR 2.45; 95% CI, 1.80 to 3.34), preparatory acts (OR 6.40; 95% CI, 4.38 to 9.36) and suicidal ideation (OR 2.45; 95% CI, 1.87 to 3.21) were associated with increased odds of reporting access. When clinicians felt there was a high likelihood of future suicide, firearm access remained unknown in half of cases.

CONCLUSION

Firearm ownership and access is an essential component of a suicide risk assessment and remains unknown in half of individuals seen by psychiatry in this tertiary care ED sample. People presenting with suicidal ideation and attempts were more likely to report access to firearms.

Physician Documentation of Access to Firearms in Suicidal Patients in the Emergency Department

Introduction

Suicide is the 10th leading cause of death in the United States. An estimated 50% of these deaths are due to firearms. Suicidal ideation (SI) is a common complaint presenting to the emergency department (ED). Despite these facts, provider documentation on access to lethal means is lacking. Our primary aim was to quantify documentation of access to firearms in patients presenting to the ED with a chief complaint of SI.

Methods

This was a cross-sectional study of consecutive patients, nearly all of whom presented to an academic, urban ED with SI during July 2014. We collected data from all provider documentation in the electronic health record. Primary outcome assessed was whether the emergency physician (EP) team documented access to firearms. Secondary outcomes included demographic information, preexisting psychiatric diagnoses, and disposition.

Results

We reviewed 100 patient charts. The median age of patients was 38 years. The majority of patients had a psychiatric condition. EPs documented access to firearms in only 3% of patient charts.

Conclusion

EPs do not adequately document access to firearms in patients with SI. There is a clear need for educational initiatives regarding risk-factor assessment and counseling against lethal means in this patient cohort.

Applying Computer Adaptive Testing Methods to Suicide Risk Screening in the Emergency Department

OBJECTIVE

Combine test theory with technology to develop brief, reliable suicide risk measures in the emergency department.

METHODS

A computer adaptive test for suicide risk was built using the Beck Scale for Suicide Ideation and tested among the emergency department population. Data were analyzed from a sample of 1,350 patients in several Massachusetts emergency departments. The test was built as outlined by the National Institutes of Health Patient-Reported Outcomes Measurement Information System.

RESULTS

Of 1,350 patients, 74 (5%) scored above the cutoff of BSS > 2. Item 2, "Wish to die", was the most informative item. When using only Item 2, 20% (n = 15/74) of at-risk patients and 3% (n = 40/1,276) of not-at-risk patients were misclassified. Patients were classified after four items with computer adaptive testing trait estimates highly comparable to those of the full scale. The precision rule model did not reduce the scale.

CONCLUSIONS

This study models the creation of a computer adaptive test for suicide ideation and marks the start of the development of computer adaptive tests as a novel suicide risk screening tool in the emergency department. Computer adaptive tests hold promise for revolutionizing behavioral health screening by addressing barriers including time and knowledge deficits.

An educational intervention for medical students to improve self-efficacy in firearm injury prevention counseling

Background

Most physicians support counseling patients about firearm injury prevention (FIP), but infrequently do so due to lack of training and low confidence. Interventions to increase counseling frequency should focus on improving physician self-efficacy. Firearm injuries affect many clinical specialties; therefore, trainees would benefit from early FIP education. This study aims to determine if a 20-min educational intervention improves self-efficacy in FIP counseling in third-year medical students. Knowledge and beliefs were also assessed as secondary indicators of self-efficacy.

Methods

This was a prospective study performed at a medical school associated with a tertiary care children’s hospital during the 2016–17 academic year. Groups of 12–15 different third-year medical students were selected to receive either a 20-min intervention or control lecture during their monthly pediatric lectures. The intervention consisted of two clinical vignettes, a brief discussion about the importance of FIP, and suggestions for clinical integration. The control session was a case-based lecture about pediatric emergencies. Participants completed baseline electronic assessments. Intervention students also completed post-intervention assessments immediately following each session. All participants completed final assessments at 6 months. Data were analyzed using Wilcoxon signed-rank tests and Wilcoxon rank-sum.

Results

We surveyed a total of 130 students. Sixty-five students completed the entire series of assessments – 22 from the control and 43 from the intervention group. There were no significant differences between the control and intervention groups at baseline. Immediately after, intervention, participants reported feeling more self-efficacious, had improved knowledge of FIP risk factors, and had beliefs more consistent with providing FIP anticipatory guidance (p <  0.001 for all three measures). After 6 months, participants sustained improvement in one of two self-efficacy questions (“I feel ready to counsel patients about firearm injury prevention”) and retained knowledge of risk factors (p <  0.05 for both). However, their beliefs did not significantly favor FIP counseling, and they were not more likely to engage in a conversation about firearm safety.

Conclusions

A 20-min educational intervention acutely improved self-efficacy in FIP counseling in third-year medical students, but improvements weakened after six months. Without further training, the beneficial effects of a one-time intervention will likely wane with time.

"Hey, let me hold your guns for a while": A qualitative study of messaging for firearm suicide prevention

A recommended component of suicide prevention is encouraging at-risk individuals to voluntarily and temporarily reduce access to firearms and other lethal methods. Yet delivering counseling on the topic can be difficult, given the political sensitivity of firearm discussions. To support such counseling, we sought to identify recommended framing and content of messages about reducing firearm access for suicide prevention. Through qualitative interviews with firearm owners and enthusiasts, we identified key points for use in framing (identity as a gun owner, trust, voluntary and temporary storage, and context and motivation) and specific content (preference for "firearm" over "gun," and legal issues such as background checks for transfers). These findings build on prior work and should enhance efforts to develop and deliver effective, acceptable counseling and-ultimately-prevent firearm suicide.

Counseling Suicidal Patients About Access to Lethal Means: Attitudes of Emergency Nurse Leaders

INTRODUCTION

For ED patients at risk of suicide, counseling to reduce access to lethal means (including firearms) is recommended yet not routine. To enhance practice uptake, we sought to examine the attitudes and beliefs of emergency nurse leaders concerning the acceptability and effectiveness of lethal-means counseling.

METHODS

We invited a nurse leader (ED nurse manager or Chief Nursing Officer [CNO]) at each hospital-based emergency department in the 8-state Mountain West region of the United States to complete a closed-ended telephone survey. Questions assessed current practices and leaders' views on suicide prevention and lethal-means counseling. Reponses were weighted to all eligible hospitals to adjust for nonresponse.

RESULTS

From 363 eligible hospitals, 190 emergency nurse leaders responded (overall response rate: 52%). Emergency nurse leaders thought providers at their emergency departments did an excellent job of safety counseling (74%) for suicidal patients. Most respondents believed that talking about firearms with suicidal patients is acceptable to patients (77%), supported by hospital administration (64%), effective in preventing suicide (69%), and something that providers should do (91%). However, the majority also had doubts about whether suicide is preventable (60%).

DISCUSSION

Despite expressing high levels of support for the acceptability and effectiveness of lethal-means counseling, high proportions of emergency nurse leaders expressed skepticism regarding the preventability of suicide, a finding consistent with previous work. Our results support the need to address and modify misperceptions about prevention of suicide in any efforts for widespread implementation and dissemination of lethal-means counseling.

Steps to Achieve Universal Suicide Screening in Emergency Departments: A Call to Action

American individuals attempt suicide at alarmingly high rates of approximately 1.1 million times per year. Yet the United States has failed to adopt a systematic approach to suicide prevention, particularly via universal screening. Given the increasing number of individuals with suicidal ideation presenting to emergency departments (EDs), all patients who present to the ED for treatment should be screened, as opposed to only individuals with mental health complaints. In the current article, barriers to suicide screening in the ED are discussed, as well as strategies to move ED providers toward the goal of universal screening. The current article entreats nurses to be leaders in achieving universal screening and provides practical actions to begin the process. Specific recommendations for action include improving training, increasing lethal means assessment, and achieving compliance with The Joint Commission suicide screening guidelines. [Journal of Psychosocial Nursing and Mental Health Services, 56(10), 21-26.].

Counseling on Access to Lethal Means (CALM): An Evaluation of a Suicide Prevention Means Restriction Training Program for Mental Health Providers

This paper evaluates the effectiveness of the Counseling on Access to Lethal Means (CALM) suicide prevention program. CALM trains mental health providers how to counsel suicidal individuals and those who support them on mean restriction during times of crisis. Pre/post/3-month follow-up assessments measured knowledge of lethal means, confidence and comfort in discussing means restriction (self-efficacy), and future intentions to counsel clients on means restriction. Change in the number of clients receiving lethal means counseling was also assessed. All constructs increased significantly at posttest. Confidence and counseling intentions were sustained at follow-up and significantly more clients received means counseling in the 3 months following the CALM training. Knowledge and comfort levels decreased at follow-up but not to pre-training levels. CALM is effective at increasing mental health professionals' comfort, knowledge, and frequency of talking about means restriction with clients. an effective means restriction training program. A template to assess clients for suicidality and lethal means access and booster sessions are recommended to further sustain effects.

Hospital Emergency Department Lethal Means Counseling for Suicidal Patients

INTRODUCTION

Lethal means counseling of suicidal individuals in emergency departments has the potential to reduce suicide. This study examines the provision of lethal means counseling and the presence of written protocols in a region with high rates of both firearm ownership and suicide.

METHODS

In 2015-2016, emergency department nurse managers in hospital-based emergency departments throughout eight states were surveyed using an 80-item survey developed through qualitative interviews and pilot testing. Questions focused on discharge counseling with suicidal patients and the presence of written protocols. Using survey weights to adjust for nonresponse, relationships of protocols with counseling practices were examined.

RESULTS

Data were obtained from 52.3% of all 363 eligible hospital emergency departments in the region. Among facilities that discharge suicidal patients, 79.7% (95% CI=75.0%, 84.4%) reported asking about access to firearms and 68.9% (95% CI=62.9%, 74.8%) counsel about safe storage when patients reported access. Forty-four percent of emergency departments reported having written protocols for lethal means counseling. Presence of written protocols was associated with a higher rate of counseling for all suicidal patients even if they were not planning to use a gun (45.0% [95% CI=33.4%, 56.7%] in hospitals with protocols vs 21.5% [95% CI=14.9%, 29.0%] in facilities without protocols).

CONCLUSIONS

There are significant gaps in attention to lethal means counseling in emergency departments. This signals an opportunity to increase consistency and thoroughness of care for suicidal patients in the emergency department and for leadership from key professional organizations to advocate for protocols.

Frequency of lethal means assessment among emergency department patients with a positive suicide risk screen

Prior work from surveys and limited populations suggests many emergency department (ED) patients with suicide risk do not have documented lethal means assessments (e.g., being asked about home firearms). The specific objectives of this study were to, in an ED with universal screening for suicide risk: (1) estimate how often ED providers documented lethal means assessment for suicidal patients, and (2) compare patients with and without documented lethal means assessments. We reviewed 800 total charts from a random sample of adults in three a priori age groups (18-34 years; 35-59 years; ≥ 60 years) with a positive suicide risk screen from 8/2014 to 12/2015. Only 18% (n = 145) had documentation by ≥ 1 provider of assessment of lethal means access. Among these 145, only 8% (n = 11) had documentation that someone discussed an action plan to reduce access (most commonly changing home storage or moving objects out of the home). Among 545 suicidal patients discharged home from the ED, 85% had no documentation that any provider assessed access to lethal means. Our findings highlight an important area for improving care: routine, documented lethal means assessment and counseling for patients with suicide risk. There is an urgent need for further exploration of barriers and facilitators.

Discussing Firearm Ownership and Access as Part of Suicide Risk Assessment and Prevention: "Means Safety" versus "Means Restriction"

The goal of this study was to describe the relative utility of the terms "means safety" versus "means restriction" in counseling individuals to limit their access to firearms in the context of a mock suicide risk assessment. Overall, 370 participants were randomized to read a vignette depicting a clinical scenario in which managing firearm ownership and access was discussed either using the term "means safety" or "means restriction." Participants rated the term "means safety" as significantly more acceptable and preferable than "means restriction." Participants randomized to the "means safety" condition reported greater intentions to adhere to clinicians' recommendations to limit access to a firearm for safety purposes (F[1,367] = 7.393, p = .007, [Formula: see text]). The term "means safety" may be more advantageous than "means restriction" when discussing firearm ownership and access in clinical settings and public health-oriented suicide prevention efforts.

A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research

STUDY OBJECTIVE

To identify critical emergency medicine-focused firearm injury research questions and develop an evidence-based research agenda.

METHODS

National content experts were recruited to a technical advisory group for the American College of Emergency Physicians Research Committee. Nominal group technique was used to identify research questions by consensus. The technical advisory group decided to focus on 5 widely accepted categorizations of firearm injury. Subgroups conducted literature reviews on each topic and developed preliminary lists of emergency medicine-relevant research questions. In-person meetings and conference calls were held to iteratively refine the extensive list of research questions, following nominal group technique guidelines. Feedback from external stakeholders was reviewed and integrated.

RESULTS

Fifty-nine final emergency medicine-relevant research questions were identified, including questions that cut across all firearm injury topics and questions specific to self-directed violence (suicide and attempted suicide), intimate partner violence, peer (nonpartner) violence, mass violence, and unintentional ("accidental") injury. Some questions could be addressed through research conducted in emergency departments; others would require work in other settings.

CONCLUSION

The technical advisory group identified key emergency medicine-relevant firearm injury research questions. Emergency medicine-specific data are limited for most of these questions. Funders and researchers should consider increasing their attention to firearm injury prevention and control, particularly to the questions identified here and in other recently developed research agendas.

Staff Views of an Emergency Department Intervention Using Safety Planning and Structured Follow-Up with Suicidal Veterans

The objective of this study is to summarize staff perceptions of the acceptability and utility of the safety planning and structured post-discharge follow-up contact intervention (SPI-SFU), a suicide prevention intervention that was implemented and tested in five Veterans Affairs Medical Center emergency departments (EDs). A purposive sampling approach was used to identify 50 staff member key informants. Interviews were transcribed and coded using thematic analysis. Almost all staff perceived the intervention as helpful in connecting SPI-SFU participants to follow-up services. A slight majority of staff believed SPI-SFU increased Veteran safety. Staff members also benefited from the implementation of SPI-SFU. Their comfort discharging Veterans at some suicide risk increased. SPI-SFU provides an appealing option for improving suicide prevention services in acute care settings.

Factors influencing the suicide intervention skills of emergency medical services providers

BACKGROUND

Lithuania currently has the highest suicide rate in Europe and the fifth highest worldwide.

AIMS

To identify the factors that influence the suicide intervention skills of emergency medical services (EMS) providers (doctors, nurses, paramedics).

METHOD

Two hundred and sixty-eight EMS providers participated in the research. The EMS providers were surveyed both prior to their training in suicide intervention and six months later. The questionnaire used for the survey assessed their socio-demographic characteristics, suicide intervention skills, attitudes towards suicide prevention, general mental health, strategies for coping with stress, and likelihood of burnout.

RESULTS

Better suicide intervention skills were more prevalent among EMS providers with a higher level of education, heavier workload, more positive attitudes towards suicide prevention, better methods of coping with stress, and those of a younger age. Six months after the non-continuous training in suicide intervention, the providers' ability to assess suicide risk factors had improved, although there was no change in their suicide intervention skills.

CONCLUSIONS

In order to improve the suicide intervention skills of EMS providers, particular attention should be paid to attitudes towards suicide prevention, skills for coping with stress, and continuous training in suicide intervention.

ABBREVIATIONS

EMS: Emergency medical services; SIRI: Suicide intervention response inventory.

LETHAL MEANS ACCESS AND ASSESSMENT AMONG SUICIDAL EMERGENCY DEPARTMENT PATIENTS

BACKGROUND

Reducing access to lethal means (especially firearms) might prevent suicide, but counseling of at-risk individuals about this strategy may not be routine. Among emergency department (ED) patients with suicidal ideation or attempts (SI/SA), we sought to describe home firearm access and examine ED provider assessment of access to lethal means.

METHODS

This secondary analysis used data from the Emergency Department Safety Assessment and Follow-up Evaluation, a three-phase, eight-center study of adult ED patients with SI/SA (2010-2013). Research staff surveyed participants about suicide-related factors (including home firearms) and later reviewed the ED chart (including documented assessment of lethal means access).

RESULTS

Among 1,358 patients with SI/SA, 11% (95% CI: 10-13%) reported ≥1 firearm at home; rates varied across sites (range: 6-26%) but not over time. On chart review, 50% (95% CI: 47-52%) of patients had documentation of lethal means access assessment. Frequency of documented assessment increased over study phases (40-60%, P < .001) but was not associated with state firearm ownership rates. Among the 337 (25%, 95% CI: 23-27%) patients discharged to home, 55% (95% CI: 49-60%) had no documentation of lethal means assessment; of these, 13% (95% CI: 8-19%; n = 24) actually had ≥1 firearm at home. Among all those reporting ≥1 home firearm to study staff, only half (50%, 95% CI: 42-59%) had provider documentation of assessment of lethal means access.

CONCLUSIONS

Among these ED patients with SI/SA, many did not have documented assessment of home access to lethal means, including patients who were discharged home and had ≥1 firearm at home.

Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm-Related Injury

Firearm injury is a leading cause of injury-related morbidity and mortality in the United States. We sought to systematically identify and summarize existing literature on clinical firearm injury prevention screening and interventions. We conducted a systematic search of PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycInfo, and ClinicalTrials.gov for English-language original research (published 1992-2014) on clinical screening methods, patient-level firearm interventions, or patient/provider attitudes on the same. Unrelated studies were excluded through title, abstract, and full-text review, and the remaining articles underwent data abstraction and quality scoring. Of a total of 3,260 unique titles identified, 72 were included in the final review. Fifty-three articles examined clinician attitudes/practice patterns; prior training, experience, and expectations correlated with clinicians' regularity of firearm screening. Twelve articles assessed patient interventions, of which 6 were randomized controlled trials. Seven articles described patient attitudes; all were of low methodological quality. According to these articles, providers rarely screen or counsel their patients-even high-risk patients-about firearm safety. Health-care-based interventions may increase rates of safe storage of firearms for pediatric patients, suicidal patients, and other high-risk groups. Some studies show that training clinicians can increase rates of effective firearm safety screening and counseling. Patients and families are, for the most part, accepting of such screening and counseling. However, the current literature is, by and large, not high quality. Rigorous, large-scale, adequately funded studies are needed.

Lethal Means Counseling for Parents of Youth Seeking Emergency Care for Suicidality

INTRODUCTION

A youth's emergency department (ED) visit for suicidal behaviors or ideation provides an opportunity to counsel families about securing medications and firearms (i.e., lethal means counseling).

METHODS

In this quality improvement project drawing on the Counseling on Access to Lethal Means (CALM) model, we trained 16 psychiatric emergency clinicians to provide lethal means counseling with parents of patients under age 18 receiving care for suicidality and discharged home from a large children's hospital. Through chart reviews and follow-up interviews of parents who received the counseling, we examined what parents recalled, their reactions to the counseling session, and actions taken after discharge.

RESULTS

Between March and July 2014, staff counseled 209 of the 236 (89%) parents of eligible patients. We conducted follow-up interviews with 114 parents, or 55% of those receiving the intervention; 48% of those eligible. Parents had favorable impressions of the counseling and good recall of the main messages. Among the parents contacted at follow up, 76% reported all medications in the home were locked as compared to fewer than 10% at the time of the visit. All who had indicated there were guns in the home at the time of the visit reported at follow up that all were currently locked, compared to 67% reporting this at the time of the visit.

CONCLUSION

Though a small project in just one hospital, our findings demonstrate the feasibility of adding a counseling protocol to the discharge process within a pediatric psychiatric emergency service. Our positive findings suggest that further study, including a randomized control trial in more facilities, is warranted.

Change in emergency department providers' beliefs and practices after use of new protocols for suicidal patients

OBJECTIVE

The study examined changes in self-reported attitudes and practices related to suicide risk assessment among providers at emergency departments (EDs) during a three-phase quasi-experimental trial involving implementation of ED protocols for suicidal patients.

METHODS

A total of 1,289 of 1,828 (71% response rate) eligible providers at eight EDs completed a voluntary, anonymous survey at baseline, after introduction of universal suicide screening, and after introduction of suicide prevention resources (nurses) and a secondary risk assessment tool (physicians).

RESULTS

Among participants, the median age was 40 years old, 64% were female, and there were no demographic differences across study phases; 68% were nurses, and 32% were attending physicians. Between phase 1 and phase 3, increasing proportions of nurses reported screening for suicide (36% and 95%, respectively, p<.001) and increasing proportions of physicians reported further assessment of suicide risk (63% and 80%, respectively, p<.01). Although increasing proportions of providers said universal screening would result in more psychiatric consultations, decreasing proportions said it would slow down clinical care. Increasing proportions of nurses reported often or almost always asking suicidal patients about firearm access (18%-69%, depending on the case), although these numbers remained low relative to ideal practice. Between 35% and 87% of physicians asked about firearms, depending on the case, and these percentages did not change significantly over the study phases.

CONCLUSIONS

These findings support the feasibility of implementing universal screening for suicide in EDs, assuming adequate resources, but providers should be educated to ask suicidal patients about firearm access.

Understanding the service needs of assault-injured, drug-using youth presenting for care in an urban Emergency Department

BACKGROUND

Violence is a leading cause of injury among youth 15-24years and is frequently associated with drug use. To inform optimal violence interventions, it is critical to understand the baseline characteristics and intent to retaliate of drug-using, assault-injured (AI) youth in the Emergency Department (ED) setting, where care for violent injury commonly occurs.

METHODS

At an urban ED, AI youth ages 14-24 endorsing any past six-month substance use (n=350), and a proportionally-sampled substance-using comparison group (CG) presenting for non-assault-related care (n=250), were recruited and completed a baseline assessment (82% participation). Medical chart review was also conducted. Conditional logistic regression was performed to examine correlates associated with AI.

RESULTS

Over half (57%) of all youth met the criteria for drug and/or alcohol use disorder, with only 9% receiving prior treatment. Among the AI group, 1 in 4 intended to retaliate, of which 49% had firearm access. From bivariate analyses, AI youth had poorer mental health, greater substance use, and were more likely to report prior ED visits for assault or psychiatric evaluation. Based on multivariable modeling, AI youth had greater odds of being on probation/parole (AOR=2.26; CI=1.28, 3.90) and having PTSD (AOR=1.88; CI=1.01, 3.50) than the CG.

CONCLUSIONS

AI youth may have unmet needs for substance use and mental health treatment, including PTSD. These characteristics along with the risk of retaliation, increased ED service utilization, low utilization of other health care venues, and firearm access highlight the need for interventions that initiate at the time of ED visit.