Lethal Means Access and Assessment Among Suicidal Emergency Department Patients

Abstract

Background Reducing access to lethal means (especially firearms) might prevent suicide, but counseling of at-risk individuals about this strategy may not be routine. Among emergency department (ED) patients with suicidal ideation or attempts (SI/SA), we sought to describe home firearm access and examine ED provider assessment of access to lethal means. Methods This secondary analysis used data from the Emergency Department Safety Assessment and Follow-up Evaluation, a 3-phase, 8-center study of adult ED patients with SI/SA (2010-2013). Research staff surveyed participants about suicide-related factors (including home firearms) and later reviewed the ED chart (including documented assessment of lethal means access). Results Among 1358 patients with SI/SA, 11% (95%CI 10-13%) reported ≥1 firearm at home; rates varied across sites (range: 6% to 26%) but not over time. On chart review, 50% (95%CI 47-52%) of patients had documentation of lethal means access assessment. Frequency of documented assessment increased over study phases (40% to 60%, p<0.001) but was not associated with state firearm ownership rates. Among the 337 (25%, 95%CI 23-27%) patients discharged to home, 55% (95%CI 49-60%) had no documentation of lethal means assessment; of these, 13% (95%CI 8-19; n=24) actually had ≥1 firearm at home. Among all those reporting ≥1 home firearm to study staff, only half (50%, 95%CI 42-59) had provider documentation of assessment of lethal means access. Conclusions Among these ED patients with SI/SA, many did not have documented assessment of home access to lethal means, including patients who were discharged home and had ≥1 firearm at home.

Hospital Emergency Department Lethal Means Counseling for Suicidal Patients

“…Prior work, including the large ED-Safety Assessment and Follow-up Evaluation (ED-SAFE) trial, documents that ED clinicians often do not routinely counsel about lethal means 21,22,33–36 and their counseling can be improved. 37 Even with political sensitivities about guns, 38 patients are receptive to receiving guidance, 19,39–41 and counseling can improve storage practices.…”

“…17,19,42 ED-SAFE chart reviews found that although 11% of patients reported having firearms only 50% of those patients had medical record notes indicating lethal means counseling. 22 Other evidence indicates that providing safety devices with counseling enhances results. 43 Future research should examine the effectiveness of safety messages, with and without providing safety devices and also consider the effectiveness of new “extreme risk protection orders” for temporary removal of guns.…”

“…11–14 Limiting access to firearms during crises is an important strategy, 15,16 showing success through ED-based education with parents of suicidal youth. 17–19 Lethal means counseling may be underutilized by EDs, 20–22 as many providers do not routinely assess lethal means access, despite recommendations. 9,10,23–26 …”

A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research

“…61 As firearm suicide has a case fatality rate of 90%, versus 10% for all other methods combined, 4,62,63 reducing access to firearms and other lethal means among those with suicide risk may prevent suicide deaths, 64 and is part of the National Strategy for Suicide Prevention. 65 Lethal means screening and counseling (i.e., counseling about reducing access to lethal means) for suicidal ED patients is recommended, 66,67 and provider training adapted for EDs exists 68 , but there are gaps in current research to guide ED implementation 35,60,61,69 and efficacy 67,70 . Barriers to address include ED providers' unfamiliarity with options for safe firearm storage, inadequate provider training on counseling, 59 and unanswered questions about the best messages and messengers for the counseling.…”

Yes, You Can: Physicians, Patients, and Firearms

“…Screening and counseling about firearms is uncommon, whether as anticipatory guidance (46) or a selective intervention (47)(48)(49). For example, in a study of veterans who screened positive for suicidal thoughts, only 15% of providers documented whether patients had access to firearms (50).…”