A Randomized Control Trial of a Digital Health Tool for Safer Firearm and Medication Storage for Patients with Suicide Risk.

Most patients with suicide risk do not receive recommendations to reduce access to lethal means due to a variety of barriers (e.g., lack of provider time, training). Determine if highly efficient population-based EHR messaging to visit the Lock to Live (L2L) decision aid impacts patient-reported storage behaviors. Randomized trial. Integrated health care system serving Denver, CO. Served by primary care or mental health specialty clinic in the 75-99.5th risk percentile on a suicide attempt or death prediction model. Lock to Live (L2L) is a web-based decision aid that incorporates patients' values into recommendations for safe storage of lethal means, including firearms and medications. Anonymous survey that determined readiness to change: pre-contemplative (do not believe in safe storage), contemplative (believe in safe storage but not doing it), preparation (planning storage changes) or action (safely storing). There were 21,131 patients randomized over a 6-month period with a 27% survey response rate. Many (44%) had access to a firearm, but most of these (81%) did not use any safe firearm storage behaviors. Intervention patients were more likely to be categorized as preparation or action compared to controls for firearm storage (OR = 1.30 (1.07-1.58)). When examining action alone, there were no group differences. There were no statistically significant differences for any medication storage behaviors. Selection bias in those who responded to survey. Efficiently sending an EHR invitation message to visit L2L encouraged patients with suicide risk to consider safer firearm storage practices, but a stronger intervention is needed to change storage behaviors. Future studies should evaluate whether combining EHR messaging with provider nudges (e.g., brief clinician counseling) changes storage behavior.ClinicalTrials.gov: NCT05288517.

Firearm leadership: Development, analysis, and application of a novel concept to message secure storage of firearms in the military.

Suicide remains a leading cause of death in the United States (U.S.) Armed Forces. Access to firearms increases the risk of death by suicide due to the high lethality of firearm-related injuries (~90% in suicide attempts) and the highly dynamic nature of suicide which includes rapid change from low- to high-risk states. Critical gaps remain in research, programming, and communication amongst scientists, Department of Defense (DoD) programmatic leaders, front-line commanders, and service members. To enhance communication and coordination, in June 2022, the first-ever national "Firearm Suicide Prevention in the Military: Messaging and Interventions Summit" was held, with discussion of Firearm Leadership, a concept that emphasizes the importance of communication about lethal means safety (LMS) among military leaders and service members. Through a discussion of scientific literature, the points identified during the Summit, as well as presenting illustrative case examples derived from suicide death reviews, we aim to provide a conceptual model for the benefits of Firearm Leadership and how some barriers can be overcome. Following the Summit, further discussions on "Firearm Leadership" led to the development of a Firearm Leadership Factsheet.

Acceptability of Long Versus Short Firearm Safety Education Videos in the Emergency Department: A Pilot Randomized Controlled Trial.

STUDY OBJECTIVE: Safe firearm storage is protective against pediatric firearm injuries. We sought to compare a 3-minute versus 30-second safe firearm storage video in terms of acceptability of video content and use in the pediatric emergency department (PED). METHODS: We conducted a randomized controlled trial in a large PED (from March to September 2021). Participants were English-speaking caregivers of noncritically ill patients. Participants were surveyed about child safety behaviors (including firearm storage), then shown 1 of 2 videos. Both videos described safe storage principles; the 3-minute video included temporary firearm removal and a survivor testimonial. The primary outcome was acceptability, measured by responses on a 5-point Likert scale (strongly disagree to strongly agree). A survey at 3 months evaluated information recall. Baseline characteristics and outcomes were compared between groups using Pearson chi-squared, Fisher exact, and Wilcoxon Mann Whitney tests as appropriate. Absolute risk difference for categoric variables and mean difference for continuous variables are reported with 95% confidence interval (CI). RESULTS: Research staff screened 728 caregivers; 705 were eligible and 254 consented to participate (36%); 4 withdrew. Of 250 participants, most indicated acceptability in terms of setting (77.4%) and content (86.6%), and doctors discussing firearm storage (78.6%), with no difference between groups. More caregivers viewing the longer video felt the length appropriate (99.2%) compared with the shorter video (81.1%, difference 18.1%, 95% CI 11.1 to 25.1). CONCLUSIONS: We show that video-based firearm safety education is acceptable among study participants. This can provide consistent education to caregivers in PEDs and needs further study in other settings.

Views of voluntary, temporary out-of-home firearm storage among individuals living in a firearm-owning home: results from a qualitative study in two states.

INTRODUCTION: Firearms account for the majority of suicide deaths in the USA. A recommended approach for suicide prevention is reducing access to firearms by temporarily removing them from the home. We sought to understand how firearm owners and those who reside with them view and might use voluntary, temporary out-of-home firearm storage. METHODS: From July to November 2021, we interviewed English-speaking adults in Colorado and Washington who own firearms or reside with them, using semistructured interviews. We used a team-based mixed deductive and inductive approach to code transcripts and identify themes. RESULTS: Half of the 38 interviewees were men (53%) aged 35-54 years (40%); 92% identified as white. The average age that participants reported first having a firearm was 20.4 years; 16% reported never owning a firearm themselves, only living in homes with firearms. Qualitative findings fell into broad themes: (1) storage with family members/friends, (2) concerns/challenges with storing a firearm with a business/organization, (3) importance of trust (4) outreach methods for out-of-home storage programmes. CONCLUSION: Programmes for voluntary, temporary out-of-home firearm storage will not be impactful unless such storage is desired and used. Understanding views of potential storage users can help support development of acceptable and feasible programmes.

Correction: The Story of #GetMePPE and GetUsPPE.org to Mobilize Health Care Response to COVID-19 : Rapidly Deploying Digital Tools for Better Health Care.

[This corrects the article DOI: 10.2196/20469.].

Bystander intervention to prevent firearm injury: A qualitative study of 4-H shooting sports participants.

This qualitative study examines how youth and adult members of 4-H Shooting Sports clubs perceive firearm injury risk and risk reduction, and the applicability of a bystander intervention (BI) risk reduction framework in this community. Semistructured interviews were conducted with 11 youth and 13 adult members of 4-H Shooting Sports clubs across nine US states from March to December of 2021 until thematic saturation was reached. Deductive and inductive thematic qualitative analyses were performed. Six overarching themes emerged: (1) The tendency to view firearm injury as predominantly unintentional in nature; (2) Acknowledgment of a wide array of risks for firearm injury; (3) Perceived barriers to bystander action to prevent firearm injury including knowledge, confidence, and consequences of action; (4) Facilitators of bystander action including a sense of civic responsibility; (5) Direct and indirect strategies to address potential risks for firearm injury; and (6) Belief that BI skills training would be useful for 4-H Shooting Sports. Findings lay the groundwork for applying BI skills training as an approach to firearm injury prevention in 4-H Shooting Sports, similar to how BI has been applied to other types of injury (i.e., sexual assault). 4-H Shooting Sports club members' sense of civic responsibility is a key facilitator. Prevention efforts should attend to the broad array of ways in which firearm injury occurs, including suicide, mass shootings, homicide, and intimate partner violence, as well as unintentional injury.

Older Adults' Preferences Regarding Firearm Locking Device Use: Results of a National Survey.

OBJECTIVES: Use of firearm locking devices may reduce the risk of suicide and injury among older adults. This study describes older adults' preferences when choosing a firearm locking device. METHODS: We conducted a secondary analysis of a nationally representative survey of US adult firearm owners (N = 2,152). We compared older adults (≥65y) with relatively younger adults (<65y), stratified by self-reported gender. RESULTS: The top three factors cited as impacting firearm locking device selection included speed (53.6%) and ease of firearm access from device (52.4%), and cost of the device (28.7%). These top factors were comparable for all adults across genders. A larger proportion of older vs younger males reported that a primary preference was whether the device allows the firearm to remain loaded with ammunition; smaller proportions of older vs younger males reported strength of device (device durability) and costs. CONCLUSIONS: Preference among older adults, particularly older males, for locking devices that maintain the firearms easy to access - especially, loaded with ammunition - might impact firearm injury prevention efforts for this high-risk group. CLINICAL IMPLICATIONS: For harm reduction, use of any firearm locking device may reduce the risk of firearm injury or death. Clinicians are encouraged to explore reasons for locking device selection within motivational interviewing frameworks.

Extreme Risk Protection Orders in Older Adults in Six U.S. States: A Descriptive Study.

OBJECTIVES: Extreme Risk Protection Orders (ERPOs) allow a court to restrict firearm access for individuals ("respondents") at imminent risk of harm to self/others. Little is known about ERPOs use for older adults, a population with higher rates of suicide and dementia. METHODS: We abstracted ERPO cases through June 30, 2020, from California, Colorado, Connecticut, Florida, Maryland, and Washington. We restricted our analysis to petitions for older (≥65 years) respondents, stratified by documented cognitive impairment. RESULTS: Among 6,699 ERPO petitions, 672 (10.0%) were for older adults; 13.7% (n = 92) of these noted cognitive impairment. Most were white (75.7%) men (90.2%). Cognitively impaired (vs. non-impaired) respondents were older (mean age 78.2 vs 72.7 years) and more likely to have documented irrational/erratic behavior (30.4% vs 15.7%), but less likely to have documented suicidality (33.7% vs 55.0%). At the time of the petition, 56.2% of older adult respondents had documented firearm access (median accessible firearms = 3, range 1-160). CONCLUSIONS: Approximately 14% of ERPO petitions for older adults involved cognitive impairment; one-third of these noted suicide risk. Studies examining ERPO implementation across states may inform usage and awareness. CLINICAL IMPLICATIONS: ERPOs may reduce firearm access among older adults with cognitive impairment, suicidality, or risk of violence.

Voluntary, temporary out-of-home firearm storage: A survey of firearm retailers and ranges in two states.

Out-of-home storage of personal firearms is one recommended option for individuals at risk of suicide, and statewide online maps of storage locations have been created in multiple states, including Colorado and Washington. We sought to examine both the extent to which firearm retailers and ranges offer temporary, voluntary firearm storage and the perceived barriers to providing this service. We invited all firearm retailers and ranges in Colorado and Washington to complete an online or mailed survey; eligible sites had to have a physical location where they could provide storage. Between June-July 2021, 137 retailers/ranges completed the survey (response rate = 25.1%). Nearly half (44.5%) of responding firearm retailers/ranges in Colorado and Washington State indicated they had ever provided firearm storage. Among those who had ever offered storage, 80.3% currently offered storage while 19.7% no longer did. The majority (68.6%) of participants had not heard of the Colorado/Washington gun storage maps and 82.5% did not believe they were currently listed on the maps. Respondents indicated liability waivers would most influence their decision about whether to start or continue providing temporary, voluntary storage of firearms. Understanding current practices, barriers, and concerns about providing out-of-home storage by retailers and ranges may support development of more feasible approaches for out-of-home firearm storage during times of suicide risk.

A Qualitative study on diverse perspectives and identities of firearm owners.

OBJECTIVE: Research surrounding firearm ownership is often contextualised within the perspectives of older white men. We expand this description using the perceptions of a diverse group of firearm-owning stakeholders. METHODS: We conducted semistructured interviews from October 2020 to May 2021 with Colorado/Washington State stakeholders representing (1) firearm ranges/retailers; (2) law enforcement agencies or (3) relevant state/national firearm organisations. Data were analysed using standard qualitative techniques and included 25 participants, representing varied sociocultural groups including racial and ethnic minorities, political minorities and sexual minorities. RESULTS: Participants for this analysis were of different self-identified sociocultural groups including racial and ethnic minorities (African American, Hispanic and Asian), political minorities (liberal) and sexual minorities, defined as Lesbian, Gay, Bisexual, and Transgender (LGBT). Perspectives on firearm ownership included an idea of gun culture as a component of (1) personal identity, (2) an expression of full citizenship and (3) necessary for self-protection. A strong subtheme was the intersection of minority group and firearm owner identities, creating a need for divergent social communities because of ideas on traditional gun culture. These communities are a safe place for individuals belonging to minority groups to escape negative external and internal group associations with firearms. CONCLUSION: Perspectives on firearms and firearm ownership in the secondary analysis were heterogeneous and related to personal experiences, external and internal group pressures that influence individual behaviour. Understanding the breadth of perspectives on firearm ownership is imperative to engaging individuals for risk reduction. This study adds to the literature by expanding an understanding of the motivation for firearm ownership among diverse communities.

Do All Adult Psychiatric Patients Need Routine Laboratory Evaluation and an Electrocardiogram?

BACKGROUND: Acute psychiatric presentations account for a significant number of emergency department (ED) visits. These patients require assessment by the emergency physician and often need further evaluation by a psychiatrist, who may request routine laboratory evaluation and an electrocardiogram (ECG). CLINICAL QUESTION: Do all adult psychiatric patients need routine laboratory evaluation and an ECG? EVIDENCE REVIEW: Studies retrieved included 2 prospective, observational studies and 7 retrospective studies. These studies evaluate the utility of laboratory analysis in all patients presenting a psychiatric complaint and its impact on patient management and disposition. CONCLUSION: Based upon the available literature, routine laboratory analysis and ECG for all patients presenting with a psychiatric complaint are not recommended. Clinicians should consider the individual patient, clinical situation, and comorbidities when deciding to obtain further studies such as laboratory analysis. © 2022 Elsevier Inc.

'Gun shop projects' for suicide prevention in the USA: current state and future directions.

OBJECTIVES: To describe community-driven suicide prevention partnerships between firearm retailers and public health officials ('gun shop projects'), including common elements and challenges. METHODS: We conducted qualitative interviews with leaders from state-level and national-level partnerships to determine common features, challenges and strategies used by these groups. Data were coded via theme analysis; two independent coders followed a shared codebook developed in an iterative fashion and with high inter-rater reliability. RESULTS: Across 10 interviews, data revealed four main themes: (1) community building was a cornerstone of these efforts; (2) appropriate messaging and language were vital to successes; (3) groups employed various educational and outreach campaigns and (4) groups identified common challenges and obstacles. CONCLUSIONS: Gun shop project partnerships between firearm retailers and public health officials show promise, with thematic data demonstrating common trends and steps towards successful programme implementation. Evaluative data are needed to determine the impact of these efforts on suicide prevention in local communities.

"Firearm access in dementia: legal and logistic challenges for caregivers".

The prevalence of Alzheimer's disease and related dementias (ADRD) is increasing. In the United States, older adults are among those most likely to have firearms in the home. Addressing firearm access among persons with ADRD can be confusing and stressful for family caregivers, healthcare providers, firearm industry representatives and law enforcement. This study sought to examine key stakeholder perspectives concerning legal and logistic considerations for temporary firearm transfers when a person with ADRD owned firearms. A secondary analysis of 24 qualitative interviews conducted to inform the development of a firearm safety tool for ADRD caregivers revealed four types of barriers. These barriers were each associated with logistical challenges and legal ambiguities that hampered ADRD-related firearm transfers: (1) legal questions on firearm ownership and permitted transferees; (2) transfer logistics and duration; (3) issues of engaging law enforcement or retailers for transfers; and, (4) lack of information resources and guidance. Siloes between stakeholder groups persist and limit information sharing. Broad initiatives engaging caregivers, older adults, clinicians, aging service providers, law enforcement, and firearm outlets could inform the development of policies, programs, and practices to enhance the safety and well-being of people with ADRD and their caregivers.

Changes in Firearm and Medication Storage Practices in Homes of Youths at Risk for Suicide: Results of the SAFETY Study, a Clustered, Emergency Department-Based, Multisite, Stepped-Wedge Trial.

STUDY OBJECTIVE: We evaluate whether a counseling intervention implemented at the hospital level resulted in safer firearm and medication storage by caregivers of youths aged 10 to 17 years after their child's evaluation in the emergency department (ED) for a behavioral health concern. METHODS: We used a stepped-wedge clustered design rolled out at 4 hospital sites to assess primary preregistered outcomes (self-reported storage changes caregivers made to household firearms and medications), assessed by survey 2 weeks after the ED visit. Three logistic models provided estimates of the intervention effect: an unadjusted model, a model with hospital-level fixed effects, and a model that further adjusts for time. RESULTS: Of the 575 caregiver participants, 208 were firearm owners (123 in usual care, 85 in the intervention). Baseline (pre-ED visit) characteristics did not differ between usual care and intervention phases. During the 2-year study period, twice as many caregivers whose child visited the ED after (compared with before) a hospital adopted the intervention improved firearm storage and 3 times as many improved medication storage (odds ratio [OR]=2.1 [95% confidence interval {CI} 1.0 to ∞] and OR=3.0 [95% CI 2.2 to ∞], respectively). After adjusting for time, the intervention effect for medications persisted (OR=2.0 [95% CI 1.0 to ∞]); the effect on firearms did not (OR=0.7 [95% CI 0.1 to ∞]). CONCLUSION: To our knowledge, this study is the first controlled trial to estimate the effectiveness of an intervention on firearm and medication storage in homes of youths at elevated risk of suicide. We found evidence that caregivers' medication storage improved after their child's ED visit, with evidence suggestive of improvement for firearm storage.

Lessons learned in conducting youth suicide prevention research in emergency departments.

INTRODUCTION: To address youth suicide, we recruited seven emergency departments (EDs) for what we believe is the first controlled trial of an intervention to promote safer firearm and medication storage after a child was seen in an ED by a behavioural health clinician. We provided training and a common protocol that required behavioural health clinicians to counsel about reducing access to household firearms and medication and provide locking devices. This paper examines how we addressed implementation challenges and considers how lessons learnt might inform future studies and interventions. METHODS: We tracked enrolment numbers and documented, through project records, the challenges in recruiting and developing partnerships with hospitals, as well as implementing the intervention and carrying out data collection. RESULTS: We encountered challenges identifying hospitals with sufficient patient volumes to meet our analytic requirements, obtaining contact information from families in the ED and providing supplies to the sites. These challenges were compounded by lack of uniformity in data systems, making it difficult to estimate total ED encounters meeting our eligibility criteria, and by differences in patterns of behavioural healthcare delivery across sites. The strategies we devised to address these challenges included creating visual materials that appealed to parents' altruistic desire to help other families, laminated 'cheat sheets' and hang tags for clinician badges reminding them of the key points of the intervention and contracting with a distribution centre to coordinate shipping. DISCUSSION: Despite the challenges noted, we found that the behavioural health clinicians in the EDs followed the protocol and found it useful in engaging families in discussions about both firearm and medication storage. Several hospitals intend to continue the intervention on their own as the new usual care, suggesting that the challenges encountered can be and are worth tackling.

ED recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature.

INTRODUCTION: Caring for suicidal patients can be challenging, especially in emergency departments without easy access to mental health specialists. The American College of Emergency Physicians and the American Foundation for Suicide Prevention appointed a working group to create an easy-to-use suicide prevention tool for ED providers. METHODS: The writing group created an easy-to-use mnemonic for the care of adult patients as a way of organizing sequential steps, accompanied by a systematic review of available ED-based suicide prevention literature. The systematic review was performed both to ensure that all relevant evidence was taken into account as well as to evaluate the strength of evidence for each recommendation. Levels of evidence were assigned utilizing the ACEP level of evidence classification. RESULTS: The writing group created the mnemonic ICAR2E, which stands for Identify suicide risk; Communicate; Assess for life threats and ensure safety; Risk assessment (of suicide); Reduce the risk (of suicide); and Extend care beyond the ED. 31 articles were identified in the search, and were included in the systematic review. CONCLUSIONS: The ICAR2E mnemonic may be a feasible way for practicing ED clinicians to provide evidence-based care to suicidal patients. However, further research is needed.

Preventing Firearm-Related Death and Injury.

Deaths and injuries from firearms are significant public health problems, and clinicians are in a unique position to identify risk among their patients and discuss the importance of safe firearm practices. Although clinicians may be ill-prepared to engage in such discussions, an adequate body of evidence is available for support, and patients are generally receptive to this type of discussion with their physician. Here, we provide an overview of existing research and recommended strategies for counseling and intervention to reduce firearm-related death and injury.

The Story of #GetMePPE and GetUsPPE.org to Mobilize Health Care Response to COVID-19 : Rapidly Deploying Digital Tools for Better Health Care.

Physicians, nurses, and other health care providers initiated the #GetMePPE movement on Twitter to spread awareness of the shortage of personal protective equipment (PPE) during the coronavirus disease (COVID-19) pandemic. Dwindling supplies, such as face masks, gowns and goggles, and inadequate production to meet increasing demand have placed health care workers and patients at risk. The momentum of the #GetMePPE Twitter hashtag resulted in the creation of a petition to urge public officials to address the PPE shortage through increased funding and production. Simultaneously, the GetUsPPE.org website was launched through the collaboration of physicians and software engineers to develop a digital platform for the donation, request, and distribution of multi-modal sources of PPE. GetUsPPE.org and #GetMePPE were merged in an attempt to combine public engagement and advocacy on social media with the coordination of PPE donation and distribution. Within 10 days, over 1800 hospitals and PPE suppliers were registered in a database that enabled the rapid coordination and distribution of scarce and in-demand materials. One month after its launch, the organization had distributed hundreds of thousands of PPE items and had built a database of over 6000 PPE requesters. The call for action on social media and the rapid development of this digital tool created a productive channel for the public to contribute to the health care response to COVID-19 in meaningful ways. #GetMePPE and GetUsPPE.org were able to mobilize individuals and organizations outside of the health care system to address the unmet needs of the medical community. The success of GetUsPPE.org demonstrates the potential of digital tools as a platform for larger health care institutions to rapidly address urgent issues in health care. In this paper, we outline this process and discuss key factors determining success.

An Interactive Web-Based Lethal Means Safety Decision Aid for Suicidal Adults (Lock to Live): Pilot Randomized Controlled Trial.

BACKGROUND: Counseling to reduce access to lethal means such as firearms and medications is recommended for suicidal adults but does not routinely occur. We developed the Web-based Lock to Live (L2L) decision aid to help suicidal adults and their families choose options for safer home storage. OBJECTIVE: This study aimed to test the feasibility and acceptability of L2L among suicidal adults in emergency departments (EDs). METHODS: At 4 EDs, we enrolled participants (English-speaking, community-dwelling, suicidal adults) in a pilot randomized controlled trial. Participants were randomized in a 13:7 ratio to L2L or control (website with general suicide prevention information) groups and received a 1-week follow-up telephone call. RESULTS: Baseline characteristics were similar between the intervention (n=33) and control (n=16) groups. At baseline, many participants reported having access to firearms (33/49, 67%), medications (46/49, 94%), or both (29/49, 59%). Participants viewed L2L for a median of 6 min (IQR 4-10 min). L2L also had very high acceptability; almost all participants reported that they would recommend it to someone in the same situation, that the options felt realistic, and that L2L was respectful of values about firearms. In an exploratory analysis of this pilot trial, more participants in the L2L group reported reduced firearm access at follow-up, although the differences were not statistically significant. CONCLUSIONS: The L2L decision aid appears feasible and acceptable for use among adults with suicide risk and may be a useful adjunct to lethal means counseling and other suicide prevention interventions. Future large-scale studies are needed to determine the effect on home access to lethal means. TRIAL REGISTRATION: ClinicalTrials.gov NCT03478501; https://clinicaltrials.gov/ct2/show/NCT03478501.

Law Enforcement Agencies' Perceptions of the Benefits of and Barriers to Temporary Firearm Storage to Prevent Suicide.

OBJECTIVES: To examine the perceived benefits of and barriers to law enforcement agencies providing increased access to voluntary and temporary firearm storage. METHODS: We surveyed 448 police chiefs and sheriffs in 8 US Mountain West states about firearm storage practices, benefits of and barriers to storage, and related attitudes and beliefs. Data collection occurred during the spring and summer of 2016. RESULTS: Nearly three quarters of agencies reported that they are already providing storage and perceive relatively few barriers in doing so. Agency characteristics were not associated with current provision of firearm storage. Among the barriers identified included state laws, limited space, training needs, and community perceptions. Benefits of storage included being perceived positively by the community and supporting health care workers. CONCLUSIONS: Engaging with law enforcement agencies in suicide prevention efforts and addressing their perceived barriers to providing temporary firearm storage have promise as part of a comprehensive suicide prevention approach.