Access to Firearms: Initiation of Firearm Screening Among Psychiatric Patients in a Pediatric Emergency Department.

OBJECTIVE: Increase provider screening rates for firearm access among patients presenting to the pediatric emergency department (PED) for a psychiatric chief complaint. METHODS: In this resident-driven quality improvement project, a retrospective chart review examined firearm access screening rates among patients presenting to the PED with the chief complaint of "psychiatric evaluation." After establishing our baseline screening rate, the first phase of our plan, do, study, act (PDSA) cycle included implementing Be SMART education for pediatric residents. We made Be SMART handouts available in the PED, created electronic medical record (EMR) templates to facilitate documentation, and emailed routine reminders to residents during their PED block. In the second PDSA cycle, the pediatric emergency medicine (PEM) fellows expanded our efforts to increase project awareness from a supervisory role. RESULTS: The baseline screening rate was 14.7% (50 of 340). After PDSA 1, a center line shift occurred, and screening rates increased to 34.3% (297 of 867). After PDSA 2, screening rates increased to 35.7% (226 of 632). In the intervention phase, providers who received training screened 39.5% (238 of 603) of encounters versus providers who did not receive training screened 30.8% (276 of 896) of encounters. Of all encounters screened, 39.2% (205 of 523) screened positive for in-home firearms. CONCLUSIONS: We improved firearm access screening rates in the PED using provider education, EMR prompts, and PEM fellow participation. Opportunities remain to promote firearm access screening and secure storage counseling in the PED.

Keto-Bezoar: Adverse Event Related to Initiation of Ketogenic Diet in an Infant.

The ketogenic diet is frequently used as part of the treatment regimen for pediatric patients with refractory epilepsy. This diet is generally well tolerated, with constipation being the most described side effect. This case highlights a previously undocumented severe complication of a "keto-bezoar" formation related to the initiation of the ketogenic diet in a young infant.

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.