Emergency Physician Survey on Firearm Injury Prevention

Where Can We Improve?

David A. Farcy, MD; Nicole Doria, MD; Lisa Moreno-Walton, MD, MS, MSCR; Hannah Gordon, MD, MPH; Jesus Sánchez, PhD; Luigi X. Cubeddu, MD, PhD; Megan L. Ranney, MD, MPH

Disclosures

Western J Emerg Med. 2021;22(2):257-265. 

In This Article

Abstract and Introduction

Abstract

Introduction: Firearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention. The aim of this study was to describe EPs' beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED).

Methods: We conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons' Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate.

Results: A total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home.

Conclusions: Among respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed.

Introduction

Firearm injury in the United States is a continuing epidemic.[1,2] In 2017 alone, there were 39,773 firearm-related deaths: 23,854 suicides; 14,542 homicides; 486 resulting from unintentional discharge of a firearm; and 338 of undetermined origin.[3] The rate of firearm death has increased 20% in the last five years.[4] Although firearm injury statistics are unreliable, the best available data estimates that in the last five years there were more than twice as many nonfatal firearm injuries seen in emergency departments (ED).[5] In 2018 and 2019, medical organizations joined together to assert the need for a public health approach to firearm injury, highlighting the need for research and describing ways in which the medical community could design and implement clinically-based firearm injury prevention initiatives.[6,7]

Physicians effectively risk stratify and counsel patients regarding preventive health including tobacco and alcohol cessation, correct use of infant car seats, the importance of wearing seatbelts and helmets, drowning prevention, and vaccinations.[8–10] Evidence suggests that similar risk stratification and counseling discussions may be effective for preventing firearm injury and its consequences.[11] Physicians can identify at-risk patients, provide factual information about firearm injury risk and, if needed, refer patients to resources that may reduce risk.[12–14] Contrary to the myth that patients resent being counseled on firearm safety by their doctors, the literature shows that patients are receptive to discussing firearm injury prevention with physicians, as long as counseling is delivered in a respectful manner.[15,16] While physicians who own firearms may be more likely to discuss firearm injury prevention with patients than those that don't,[17] in general, few physicians raise the subject with patients. This is true despite physicians in general believing they have the right to discuss firearm safety, and medical leadership groups and patients concurring and encouraging such discussions.[18]

There are approximately 150 million ED visits each year in the US.[3] Emergency physicians (EP) are not only the first (and sometimes only) physicians to treat patients with firearm injuries, we also have a well-documented role in identification and implementation of injury prevention strategies in general.[19] However, a recent study found that the charts of only 3% of patients presenting with suicidal ideation documented whether or not the patient had access to a firearm,[20] and according to a small, non-scientific survey in 2016, few EPs discussed risk of firearm injury with victims of domestic violence, assault, or other high-risk categories.[21] A survey of EPs in 22 states reported that although two-thirds of respondents had encountered a firearm in the ED, fewer than half felt at all confident in their ability to safely handle the situation.[22] These missed opportunities may be related to the paucity of education on this topic in medical schools, or due to other unmeasured factors.[1,2]

Prior work conducted by the American College of Surgeons described attitudes, beliefs, and practices of US surgeons regarding firearms and firearm injury prevention, and was used to develop consensus recommendations on surgeons' roles in firearm injury prevention.[23] Given EPs' critical role in injury prevention, a similar assessment of EPs is warranted. The aims of this study were to assess EPs' knowledge, attitudes, and self-reported practice regarding firearm injury prevention, and to evaluate their perceived personal vulnerability to firearm injury in the workplace.

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