One Step Closer to Safer: Counseling Outcomes from American Academy of Pediatrics Firearm Safe Storage Education Training.

OBJECTIVE: To assess pre and postself-reported counseling outcomes for Safer: Storing Firearms Prevents Harm, an American Academy of Pediatrics universal firearm safe storage counseling training for pediatric clinicians providing health maintenance in outpatient settings. STUDY DESIGN: Safer was developed by a national multidisciplinary committee of firearm injury prevention experts with input from firearm-owning families and launched in June 2021. Pediatric clinicians completed baseline and 1-month posttraining surveys after signing up for the Pedialink course from February through June 2022. Primary outcomes included self-reported measures of counseling self-efficacy and frequency. Wilcoxon matched-pairs signed-rank tests compared outcome distributions at baseline and follow-up. Two adjusted, multilevel mixed-effects regression models were conducted. RESULTS: Of 230 clinicians who completed baseline surveys, 146 (64%) completed 1-month postsurveys. Regional representation included Southeast = 67 (46%), Northeast = 24 (16%), Midwest = 21 (14%), Pacific = 15 (10%), Southwest = 11 (8%), and Rocky Mountain = 8 (5%). At follow-up, there was significant improvement in both the distribution of self-efficacy (median [first Quartile-third Quartile = 50 [20-70] at baseline and 80 [60-85] at follow-up; P < .001) and self-reported counseling frequency (median [first Quartile-third Quartile] = 10 [0-50] at baseline and 50 [10-80] at follow-up; P < .001). Adjusted regression model results suggested that self-efficacy significantly improved from baseline to follow-up (time coefficient 25.3; 95% CI = [21.0, 29.5]; P < .001) as did counseling frequency (time coefficient 13.6; 95% CI = [9.2, 18.0]; P < .001). CONCLUSIONS: Significant improvement in self-reported counseling self-efficacy and frequency was demonstrated 1 month following Safer training.

Critical examination of resilience and resistance in African American families: Adaptive capacities to navigate toxic oppressive upstream waters.

African American families navigate not only everyday stressors and adversities but also unique sociocultural stressors (e.g., "toxic upstream waters" like oppression). These adverse conditions are consequences of the historical vestiges of slavery and Jim Crow laws, often manifested as inequities in wealth, housing, wages, employment, access to healthcare, and quality education. Despite these challenges, African American families have developed resilience using strength-based adaptive coping strategies, to some extent, to filter these waters. To advance the field of resilience research, we focused on the following questions: (1) what constitutes positive responses to adversity?; (2) how is resilience defined conceptually and measured operationally?; (3) how has the field of resilience evolved?; (4) who defines what, when, and how responses are manifestations of resilience, instead of, for example, resistance? How can resistance, which at times leads to positive adaptations, be incorporated into the study of resilience?; and (5) are there case examples that demonstrate ways to address structural oppression and the pernicious effects of racism through system-level interventions, thereby changing environmental situations that sustain toxic waters requiring acts of resilience to survive and thrive? We end by exploring how a re-conceptualization of resilience requires a paradigm shift and new methodological approaches to understand ways in which preventive interventions move beyond focusing on families' capacity to navigate oppression and target systems and structures that maintain these toxic waters.

Health Care Utilization After Nonfatal Firearm Injuries.

OBJECTIVES: Despite the high incidence of firearm injuries, little is known about health care utilization after nonfatal childhood firearm injuries. This study aimed to describe health care utilization and costs after a nonfatal firearm injury among Medicaid and commercially insured youth using a propensity score matched analysis. METHODS: We conducted a propensity score matched cohort analysis using 2015 to 2018 Medicaid and Commercial Marketscan data comparing utilization in the 12-months post firearm injury for youth aged 0 to 17. We matched youth with a nonfatal firearm injury 1:1 to comparison noninjured youth on demographic and preindex variables. Outcomes included inpatient hospitalizations, emergency department (ED) visits, and outpatient visits as well as health care costs. Following propensity score matching, regression models estimated relative risks of the health care utilization outcomes, adjusting for demographic and clinical covariates. RESULTS: We identified 2110 youth with nonfatal firearm injury. Compared with matched noninjured youth, firearm injured youth had a 5.31-fold increased risk of inpatient hospitalization (95% confidence interval [CI] 3.93-7.20), 1.49-fold increased risk of ED visit (95% CI 1.37-1.62), and 1.06-fold increased risk of outpatient visit (95% CI 1.03-1.10) 12-months postinjury. Adjusted 12-month postindex costs were $7581 (95% CI $7581-$8092) for injured youth compared with $1990 (95% CI $1862-2127) for comparison noninjured youth. CONCLUSIONS: Youth who suffer nonfatal firearm injury have a significantly increased risk of hospitalizations, ED visits, outpatient visits, and costs in the 12 months after injury when compared with matched youth. Applied to the 11 258 US youth with nonfatal firearm injuries in 2020, estimates represent potential population health care savings of $62.9 million.

Disparities in Pharmacologic Restraint for Children Hospitalized in Mental Health Crisis.

BACKGROUND AND OBJECTIVES: Children hospitalized with a mental health crisis often receive pharmacologic restraint for management of acute agitation. We examined associations between pharmacologic restraint use and race and ethnicity among children admitted for mental health conditions to acute care nonpsychiatric children's hospitals. METHODS: We performed a retrospective cohort study of children (aged 5-≤18 years) admitted for a primary mental health condition from 2018 to 2022 at 41 US children's hospitals. Pharmacologic restraint use was defined as parenteral administration of medications for acute agitation. The association of race and ethnicity and pharmacologic restraint was assessed using generalized linear multivariable mixed models adjusted for clinical and demographic factors. Stratified analyses were performed based on significant interaction analyses between covariates and race and ethnicity. RESULTS: The cohort included 61 503 hospitalizations. Compared with non-Hispanic Black children, children of non-Hispanic White (adjusted odds ratio [aOR], 0.81; 95% confidence interval [CI], 0.72-0.92), Asian (aOR, 0.82; 95% CI, 0.68-0.99), or other race and ethnicity (aOR, 0.68; 95% CI, 0.57-0.82) were less likely to receive pharmacologic restraint. There was no significant difference with Hispanic children. When stratified by sex, racial/ethnic differences were magnified in males (aORs, 0.49-0.68), except for Hispanic males, and not found in females (aORs, 0.83-0.93). Sensitivity analysis revealed amplified disparities for all racial/ethnic groups, including Hispanic youth (aOR, 0.65; 95% CI, 0.47-0.91). CONCLUSIONS: Non-Hispanic Black children were significantly more likely to receive pharmacologic restraint. More research is needed to understand reasons for these disparities, which may be secondary to implicit bias and systemic and interpersonal racism.

Intravenous antibiotics for urinary tract infections in children with neurologic impairment.

BACKGROUND: Children with high-intensity neurologic impairment (HINI) have an increased risk of urinary tract infection (UTI) and prolonged intravenous (IV) antibiotic exposure. OBJECTIVE: To determine the association between short (≤3 days) and long (>3 days) IV antibiotic courses and UTI treatment failure in hospitalized children with HINI. METHODS: We performed a retrospective cohort study examining UTI hospitalizations at 49 hospitals in the Pediatric Health Information System from 2016 to 2021 for children (1-18 years) with HINI. The primary outcome was UTI readmission within 30 days. Our secondary outcome was the association of hospital-level variation in short IV antibiotic course use with readmission. Readmission rates were compared between short and long courses using multivariable regression. RESULTS: Of 5612 hospitalizations, 3840 (68.4%) had short IV antibiotic courses. In our adjusted model, children with short IV courses were less likely than with long courses to have a 30-day UTI readmission (4.0%, 95% CI [3.6%, 4.5%] vs. 6.3%, 95% CI [5.1%, 7.8%]). Despite marked hospital-level variation in short IV course use (50.0%-87.5% of hospitalizations), there was no correlation with readmissions. CONCLUSIONS: Children with HINI hospitalized with UTI had low UTI readmission rates, but those who received long IV antibiotic courses were more likely to experience UTI readmission versus those receiving short courses. While residual confounding may influence our results, we did not find that short IV courses impacted readmission at the hospital level despite variation in use across institutions. Long IV antibiotic courses are associated with risks and may not confer benefit in this population.

Firearm Injury Prevention.

Firearms are the leading cause of death for US youth, overtaking motor vehicle collisions in 2020. Approximately 65% are due to homicide, 30% are due to suicide, 3.5% are due to unintentional injuries, 2% are undetermined intent, and 0.5% are from legal interventions. In homes with firearms, the likelihood of unintentional death, suicide, and homicide is three to four times higher than those without firearms. Secure storage of firearms, having them locked, unloaded, and separate from ammunition can prevent unintentional firearm injuries.

Pharmacologic restraint use for children experiencing mental health crises in pediatric hospitals.

BACKGROUND: Children in mental health crises are increasingly admitted to children's hospitals awaiting inpatient psychiatric placement. During hospitalization, patients may exhibit acute agitation prompting pharmacologic restraint use. OBJECTIVE: To determine hospital-level incidence and variation of pharmacologic restraint use among children admitted for mental health conditions in children's hospitals. DESIGN, SETTING, AND PARTICIPANTS: We examined data for children (5 to ≤18 years) admitted to children's hospitals with a primary mental health condition from 2018 to 2020 using the Pediatric Health Information System database. Hospital rates of parenteral pharmacologic restraint use per 1000 mental health bed days were determined and compared after adjusting for patient-level and demographic factors. Cluster analysis (k-means) was used to group hospitals based on overall restraint use (rate quartiles) and drug class. Hospital-level factors for pharmacologic restraint use were compared. RESULTS: Of 29,834 included encounters, 3747 (12.6%) had pharmacologic restraint use. Adjusted hospital rates ranged from 35 to 389 pharmacologic restraint use days per 1000 mental health bed days with a mean of 175 (standard deviation: 72). Cluster analysis revealed three hospitals were high utilizers of all drug classes. No significant differences in pharmacologic restraint use were found in the hospital-level analysis. CONCLUSIONS: Children's hospitals demonstrate wide variation in pharmacologic restraint rates for mental health hospitalizations, with a 10-fold difference in adjusted rates between highest and lowest utilizers, and high overall utilizers order medications across all drug classes.

Pediatric Firearm Injury Mortality Epidemiology.

Firearm injury is a leading and preventable cause of death for youth in the United States. The Centers for Disease Control and Prevention web-based injury statistics query and reporting system was queried to examine changes in firearm injury mortality among youth aged 0 to 19 from 2001 to 2019. This includes assessment of overall mortality rates, mortality rates based on intent and race/ethnicity, and the proportion of deaths due to homicide, suicide, and unintentional shootings among different age groups. Regression analysis was used to identify significant differences in mortality rate over time between Black and White youth. Deaths due to firearm injury were compared with deaths due to motor vehicle traffic collisions. In 2019, firearm injuries surpassed motor vehicle collisions to become the leading cause of death for youth aged 0 to 19 years in the United States. Homicide is the most common intent across all age groups, but suicide represents a large proportion of firearm deaths in 10- to 19-year-old youth. In 2019, Black youth had a firearm mortality rate 4.3 times higher than that of White youth and a firearm homicide rate over 14 times higher than that of White youth. For each additional year after 2013, the mortality rate for Black youth increased by 0.55 deaths per 100 000 compared with White youth (time by race interaction effect P < .0001). These data indicate the growing burden of firearm injuries on child mortality and widening racial inequities with Black youth disproportionately affected by firearm violence. This public health crisis demands physician advocacy to reduce these preventable deaths among youth.

Improving the Frequency and Documentation of Gun Safety Counseling in a Resident Primary Care Clinic.

OBJECTIVE: Increase the frequency and documentation of gun safety discussions during well-child checks in the pediatric primary care resident clinic to 50% within 6 months. METHODS: This is a quality improvement study in a pediatric resident continuity clinic. Before implementing any interventions, a survey was conducted to understand residents' attitudes and practices regarding gun safety screening and counseling. Interventions included a parent safety survey, Be SMART materials in clinic, and a prompt embedded into Electronic Health Record templates. Chart reviews were conducted to determine frequency of gun safety discussion. Resident self-reported comfort with gun safety counseling was also evaluated. RESULTS: A statistical process control chart was generated to track documentation and found the baseline mean rate of gun safety discussions during well-child checks was 3%. Rates increased following the addition of the Electronic Health Record prompt, with the mean further increased to 84% in July 2019. A sustained rate of over 75% was achieved through February 2020. Over 4 study months, the proportion of trainees reporting feeling very uncomfortable/uncomfortable with gun safety counseling decreased from 22% to 15%. The Be SMART program was identified as a key intervention increasing gun safety counseling. CONCLUSIONS: Our study identified an effective approach to improving the frequency and documentation of gun safety discussions in an academic primary care setting, providing a unique blueprint for firearm screening and safe storage counseling success. Ultimately, we believe this will increase safe storage behaviors in the home and reduce risks of child death from firearms.