Updates in Firearms Access Screening

As the United States started to emerge from COVID-19 restrictions in early 2021, we witnessed a spate of mass shootings in cities across the country. While these searing images – 8 people dead at an Atlanta spa, hundreds terrorized while grocery shopping in Boulder, Colorado – so often frame the narrative of gun violence in America, suicide by firearm accounts for more than 60% of all deaths from gun violence across the United States and remains an under-recognized threat. Additionally, living in a home with a firearm increases an adolescent's risk of death. In our study “Screening for Access to Firearms by Pediatric Trainees in High-Risk Patients,” we reviewed screening for access to firearms by pediatric residents in patients with suicidal or homicidal ideation who presented to a pediatric emergency department. We found that this screening was documented in only 5% of these encounters. Furthermore, 5% of patients were discharged home without this potentially life-saving screening having been completed by any provider.¹ Because this low screening rate represented a critical missed opportunity to address a potentially modifiable risk factor, our team subsequently completed a quality improvement project after which the rate of screening increased to 34%.² While this was a positive change, it still left the majority of our patients unscreened and significant room for improvement.

Firearms and COVID-19

Following our initial publication, the COVID-19 pandemic emerged with wide-reaching consequences. During this global crisis, firearm purchases dramatically increased, and experts including Sacks and Bartels have raised concerns that, amidst a time of unprecedented isolation, financial stress, and widespread uncertainty, this trend may have important implications for the risk of suicide.³ Anestis et al found that those who purchased a firearm during the pandemic were more likely to have a history of suicidal ideation than either people who do not own firearms or those who already owned firearms but did not buy a new one during the COVID-19 pandemic.⁴ Given this potentially increased risk, screening efforts for access to firearms and lethal means counseling are now especially important. Additionally, as patients may be limiting interactions with the health care system during the pandemic, it is also important to redouble our efforts for firearms screening and counseling during any opportunity, whether in the outpatient clinic or the emergency department.

Firearms Screening in Other Health Care Settings

Since our initial study, research teams demonstrated that pediatric residents’ rates of screening for access to firearms was low in other settings, including inpatient wards⁵ and primary care clinics.⁶ However, similar to our follow-up study,² quality improvement methodology successfully increased the rate of screening.⁶ These quality improvement projects delineated multiple perceived barriers that had to be addressed to improve screening rates, including perceived stigma, time to complete screening, discomfort with responding to a positive screen, and failure to consider screening at the time of the patient interaction. In our own institution, training around firearms screening and counseling has been added to intern orientation for all trainees to help address these barriers, to call attention to the central importance of this issue as a basic tenet of routine care, and to help with sustainability of our quality improvement initiatives.

Parental Perceptions

Salhi et al surveyed parent-child dyads and built upon prior research demonstrating that children have greater access to firearms in the home than their parents realize.⁷ This finding highlights that parents may underestimate the risk a firearm in the home poses for their child and reinforces the importance of these conversations so that appropriate risk-reduction counseling can be provided.

Novel Interventions

Miller et al completed a large multi-site trial examining the impact of an emergency department intervention on parent-reported lethal means access restriction in the homes of children and adolescents who presented with behavioral health concerns. Families in the intervention group were twice as likely to adopt safe storage practices for their firearms as those in the control group.⁸ In the adult setting, Mueller et al completed a quality improvement project in which they successfully demonstrated that bedside counseling regarding safe storage of lethal means, including firearms, helps patients create a safe storage plan.⁹ These findings suggest that emergency department-based interventions can be successful in driving risk-reduction, and they represent important groundwork in addressing the concern by many residents in our cohort that they do not know how to respond if a family discloses access to firearms.

Future Work

Firearms research has been limited for many years due to federal funding restrictions put in place by the 1996 Dickey amendment. Promisingly, the December 2019 federal spending bill included $25 million for research on gun violence prevention through both the National Institute of Health and the Centers for Disease Control and Prevention.¹⁰ This much needed initial federal investment in research (recognizing that sustained funding will be critical) offers hope that work in the coming years will generate evidence-based interventions that will allow us to change the course of gun violence in America.