Firearm injuries in children: a missed opportunity for firearm safety education

Emergency department utilization by youth before and after firearm injury

BACKGROUND

Emergency department (ED) visits may serve as opportunities for firearm injury prevention and intervention efforts. Our objective was to determine ED utilization by youth before and after firearm injury.

METHODS

We performed a retrospective cohort study of ED encounters by youth (0-18 years old) with firearm injury from eight states using the 2019 State ED and Inpatient Databases. Our primary outcome was an ED encounter (1) 90 days before or (2) 90 days after index injury. We used generalized estimating equations, accounting for hospital clustering, to determine associations between ED utilization and ED type (pediatric vs. general), youth age, sex, race and ethnicity, urbanicity, and insurance status.

RESULTS

We identified 1035 ED encounters for firearm injury (median [IQR] age 17 (15-18) years, 85.3% male, 63.3% non-Hispanic Black, 68.6% publicly insured, 90.5% living in a metropolitan area, 52.8% general ED). In the 90 days before an index injury, 12.8% of youth had an ED encounter; of these, 68.2% occurred in general EDs, and 18.2% were for trauma. In the 90 days after an index injury, 22.1% of youth had an ED encounter; of these, 50.0% occurred in general EDs, and 22.6% were for trauma. We found no significant association between ED type and ED utilization patterns. Few youths changed ED type across longitudinal encounters.

CONCLUSIONS

Youth have high rates of ED utilization before and after firearm injury. Half of firearm-injured youth receive their emergency care exclusively in general EDs. Implementing firearm injury prevention and intervention efforts in all ED settings is critical.

Which Types of Providers Have Firearm Discussions in a Pediatric Primary Care Clinic?

OBJECTIVE

Safe firearm storage decreases self-inflicted and unintentional firearm injury in youth. Medical providers are well-positioned to discuss safe firearm storage with families. The primary objective of this study was to determine which providers are most likely to discuss firearms with their patients. Our secondary objective was to determine whether providers were more likely to discuss firearms with patients at elevated suicide risk.

METHODS

This was a retrospective chart review of primary care well-child visits occurring January to December 2019 in a large, urban academic clinic. We documented provider type and training level (exposure); any documentation of firearms in the chart (counseling, screening) was considered as having a firearm discussion (outcome). We also collected demographics, patient mental health history, and Patient Health Questionnaire-9 scores and assessed suicide risk.

RESULTS

Of the 743 charts reviewed, firearms were discussed in 9% (n = 66). Medical students were most likely to discuss firearms (15%), and attending physicians were least likely (1%, P < 0.001). Providers did not discuss firearms more frequently among youth at elevated suicide risk.

CONCLUSIONS

Though providers do not frequently discuss and document firearm discussions overall, the higher rates among medical students are promising. Given the lethality of firearms in a suicide attempt, the lack of firearm safety discussions with those at elevated suicide risk was concerning. Further study should evaluate factors that facilitate discussions in this cohort and identify strategies to improve counseling among more senior providers.

Promoting Firearm Injury Prevention and Advocacy as Pediatric Surgeons: A Call to Action From the APSA/AAP Advocacy Committee

Firearm injuries have become the leading cause of death among American children. Here we review the scope of the problem, and the pivotal role pediatric surgeons have in preventing pediatric firearm injury. Specific methods for screening and counseling are reviewed, as well as how to overcome barriers. Community and hospital resources as well as organizational efforts are discussed. Finally, a path for surgeon advocacy is outlined as is a call to action for the pediatric surgeon, as we are uniquely poised to identify pediatric patients and deliver timely interventions to reduce the impact of firearm violence. LEVEL OF EVIDENCE: Level IV.

Child Firearm Injury Circumstances and Associations With Violence Intervention Program Enrollment

INTRODUCTION

Pediatric firearm injuries are the leading cause of death among American children. While assault is the most commonly cited cause, few studies have investigated circumstances surrounding such injuries. Violence intervention programs (VIPs) have been utilized to combat firearm violence, though a similar lack of knowledge exists regarding possible associations between firearm injury circumstances and youth VIP enrollment.

METHODS

This cross-sectional study included children aged 6-17 y who presented to an urban level 1 pediatric trauma center with firearm injuries from 2014 to 2017. Victim demographics and enrollment in a VIP were obtained from medical records, as well as circumstances surrounding the injuries based on account of the victim, victim's family/friends, and/or police present at the hospital. Circumstances included location of the shooting, if the shooter was known to the victim, and if the shooting was confirmed by the victim or their contacts to have been accidental or an intentional assault. Medical record numbers were used to locate victims in our trauma registry in order to obtain their assigned international classification of disease codes. Wilcox-rank sum, Pearson's chi-squared and Fisher's exact tests were used to detect associations between demographics, VIP enrollment, and shooting circumstances.

RESULTS

156 victims of firearm injury were described, including primarily Black adolescent males. 72% of victims were shot outdoors by an unknown shooter, the motivation of which was unknown in 93% of cases. 36% of these shootings were "drive-by". The majority of victims received international classification of disease codes for assault, though shootings that were confirmed by the victim to have been intentional assaults were relatively uncommon (13.4%). Most children lived in the same zip code in which they were shot (71%), and three particular zip codes accounted for 40% of shootings. 26% of victims chose to enroll in the VIP, and those that were victims of confirmed assaults (odds ratio 3.5) as well as those admitted to the hospital (odds ratio 2.4) were significantly more likely to enroll.

CONCLUSIONS

Based on victim account, children living in an urban setting are more frequently victims of unclearly motivated, outdoor neighborhood shootings rather than intentional assaults. More accurate understanding of the causes of pediatric firearm injuries should inform both recruitment into VIPs, as well as a balancing of VIPs with community-level interventions to address firearm violence.

Unintended Consequences of COVID-19 on Pediatric Falls From Windows: A Multicenter Study

INTRODUCTION

In attempts to quell the spread of COVID-19, shelter-in-place orders were employed in most states. Increased time at home, in combination with parents potentially balancing childcare and work-from-home duties, may have had unintended consequences on pediatric falls from windows. We aimed to investigate rates of falls from windows among children during the first 6 mo of the COVID-19 pandemic.

METHODS

Patients <18 y old admitted to three pediatric trauma centers (two - level 1, one - level 2) between 3/19/20 and 9/19/20 (COVID-era) were compared to a pre-COVID cohort (3/19/19 to 9/19/19). The primary outcome was the rate of falls from windows. Secondary outcomes included injury severity score (ISS), injuries sustained, and mortality.

RESULTS

Of 1011 total COVID-era pediatric trauma patients, 36 (3.6%) sustained falls from windows compared to 23 of 1108 (2.1%) pre-COVID era patients (OR 1.7, P = 0.05). The median ISS was seven pre-COVID versus four COVID-era (P = 0.43). The most common injuries sustained were skull fractures (30.5%), extremity injuries (30.5%), and intracranial hemorrhage (23.7%). One-fifth of patients underwent surgery (21.7% pre-COVID versus 19.4% COVID-era, P = 1.0). There was one mortality in the COVID-era cohort and none in the pre-COVID cohort (P = 1.0).

CONCLUSIONS

Despite overall fewer trauma admissions during the first 6 mo of the COVID-19 pandemic, the rate of falls from windows nearly doubled compared to the prior year, with substantial associated morbidity. These findings suggest a potential unintended consequence of shelter-in-place orders and support increased education on home safety and increased support for parents potentially juggling multiple responsibilities in the home.

Firearm Safety Counseling for Patients: An Interactive Curriculum for Trauma Providers

INTRODUCTION

Firearm injuries are a major public health concern. Safe firearm storage is recommended by multiple medical organizations. However, rates of firearm safety counseling are particularly low among trauma providers. Educational initiatives for other provider groups have proven to be effective. We hypothesized that educating trauma providers to offer safety counseling would be similarly effective.

METHODS

We developed a didactic session around safe firearm storage counseling for trauma providers consisting of a lecture followed by an interactive session with standardized patients. Session participants completed pre- and postsurveys evaluating their knowledge about firearm storage, self-efficacy in providing firearm storage counseling, and attitudes towards firearm safety. We compared differences between pre- and postsurvey data using chi-square tests.

RESULTS

The didactic session was delivered to target trauma providers: three trauma nurse practitioners, 42 general surgery residents, and 26 emergency medicine residents. After the session, participants were more likely to know the optimal way to safely store a firearm and to be confident in effectively counseling patients about safe firearm storage. Learners were not more likely to believe that providers have a responsibility to counsel patients on firearm safety.

DISCUSSION

A didactic session on safe firearm storage counseling was associated with increased rates of knowledge and self-efficacy. The session did not change attitudes among trauma providers, although, prior to the session, most providers already believed they had a responsibility to counsel patients on safe firearm storage. Similar curricula should be piloted at other trauma centers.

The Important Role for Physicians as Advocates for Firearm and Road Traffic Injury Prevention

The purpose of this article is to discuss the important role for physicians in advocating for the prevention of road traffic and firearm injuries. Physicians have shown to be effective advocates for a variety of injuries, and this needs to continue and be enhanced for these injury categories. Road traffic and firearm injuries are among the leading causes of death across the lifespan. The influence and credibility of physicians enhance the messages they provide in advocacy efforts. It is important that physicians educate and counsel patients in a variety of healthcare settings along with joining advocacy efforts of professional associations. Recommendations are provided for advocacy components related to these injuries. Also, it is very important that physicians receive training in medical school and/or residency about injuries and how to successfully advocate for evidence-based injury prevention strategies.