Firearms Screening in the Pediatric Inpatient Setting

Discussion

Firearms were the cause of death in 88% of teenaged homicides and 41% of teenaged suicides in 2014.¹⁷ And, although nonfirearm injuries result in death in only 1 of every 760 cases, almost 1 in 4 youth firearm injuries is fatal.¹⁸ Access to in-home firearms is an independent risk factor for suicide.¹⁹ Adolescents with risk factors for suicide were just as likely to report in-home firearm access as those without risk factors,¹⁹ and in a nationally representative survey of US adults, the presence of self-harm risk factors in a child did not impact caregivers’ report of in-home firearm presence or storage practices.²⁰ Only 1 in 3 parents who owned guns stored all guns locked and unloaded regardless of whether their child had self-harm risk factors.²⁰ Yet, studies have shown that parent education and counseling on firearms can assist in preventing further gun injuries.^21–23

To our knowledge, this is the first study to specifically examine the prevalence of firearm screening in the pediatric inpatient setting. Inpatient screening for home firearms occurred infrequently in our study. Although still <5%, we found that firearm screening was highest in 2012 and 2013, with the greatest rate increase seen between 2010 and 2011: 0.7%. It is difficult to accurately identify the factors that might have led to this clinically small difference in screening rates. However, in 2012, the AAP released a policy statement about firearm screening that may have impacted results. The AAP guidelines included several recommendations: pediatricians should include questions about the presence and availability of firearms into their initial patient history taking, urge parents to prevent access to guns, and promote safer storage of guns.⁴ It is also noteworthy that the tragedies at Sandy Hook Elementary School in Newtown, Connecticut, and what was then known as the Century 16 movie theater in Aurora, Colorado, both occurred in 2012 and may have led to more intentional and unintentional physician focus on firearm safety and injury prevention.

Speculation as to why subsequent years (2014 and 2015) showed a decline in screening may be related to distance in time from AAP policy statement release and multiple concurrent state attempts to regulate firearm screening conversations between physicians and the patient or patient’s guardian. In addition, knowledge of the Florida Firearm Owners’ Privacy Act, which was signed into law in 2011, upheld in 2014, and ultimately struck down by a federal appeals court in 2017 as infringing on the First Amendment rights of doctors, may have biased providers against firearms screening even though it was from a different state than the current study.²⁴ This law explicitly prevented physicians from discussing routine firearm screening and/or anticipatory guidance regarding firearm safety. Additionally, the law subjected physicians to harsh penalties for violating this law. Although in a different state from where our study took place, this may have biased providers against firearm screening. Some variability is also potentially attributable to the transience of housing officers, who perform the bulk of social history taking and documentation, and in a given year, there may have been residents with a greater zeal for firearm advocacy. Overall low rates may be related to some physicians’ preference for targeted rather than universal firearm screening²⁵ as well as low perceived self-efficacy in firearm counseling.²⁶ Nonetheless, no federal or state statute prohibits physicians from screening for firearms or providing counseling when such information is relevant to the health of the patient or others.²⁷

Yet, even when screening is performed, follow-up counseling may either not be performed or not documented. In a 2014 retrospective study of behavioral health patients in a pediatric emergency department, 25% of the patients reported having access to lethal means; however, only 4% of patients received lethal-means–reduction counseling.⁹ This is consistent with the findings in our study and highlights the gap between the practice of screening for firearms and the goal of that practice: to reduce intentional and unintentional injury from firearms in the home. Perhaps more disappointing than the low rates of screening overall in our study was the low rate of action when a positive screen result was obtained, particularly in the setting of unstable psychiatric disease with the highest risk of self-harm. In our study, only 19.8% of the gun-owning families identified in screening received specific anticipatory guidance about mitigating this risk. The vast majority of these families had a child with unstable psychiatric disease.

The pediatric inpatient setting presents its own potential challenges, which may explain why screening rates were so low in our study. Understandably, providers may choose to focus on the admitting diagnosis and be less interested in screening and counseling on what are felt to be unrelated topics. Screening rates were higher in our study for encounters with an admission diagnosis of mood disorder, but even in that case, only 37% of the encounters were screened. However, compared with ambulatory and emergency department encounters, inpatient encounters are longer and may afford more opportunities for family and provider interactions. Although a minority of children interact with the inpatient pediatric sphere, other successful initiatives (ie, reducing rates of secondhand tobacco smoke exposure) have used this setting as an opportunity to provide screening and anticipatory guidance with families in a less time-pressured environment than the outpatient sphere.^28,29

There are several limitations of this study. There may be other terminology that could have been used to document firearm screening that we did not include. Similarly, we chose to examine the top general pediatric admitting diagnoses to obtain a broad view of common screening practices and avoid selection bias, but it is possible that more frequent screening may have occurred with other higher-risk diagnoses not included (such as traumatic injuries). It is also possible that screening was performed without documentation; however, the medical record review study designs, such as that in our study, are less prone to recall bias when compared with self-reported physician screening behavior. In addition, on the basis of our chart review, we found that 3.4% of the charts were falsely identified as having evidence of screening. This would suggest that our true screening percentage may be closer to 2.84% instead of 2.94%. Missing data in large data sets is a known limitation³⁰; however, it is 1 we aimed to mitigate with a large sample size. Lastly, gun ownership varies regionally, so it is unclear if screening and counseling rates would be similar in other settings.