Peer-reviewed article
Improving Pediatric Emergency Department Lethal Means Safety Documentation Rates for Adolescents with Mental Health Concerns.
Stegall CL, McGill AM, Fanton J, Mullan PC ·
Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001This quality improvement study examined how to better document conversations about access to lethal means (firearms, sharp objects, medications) with adolescents presenting to a pediatric emergency department for mental health concerns. The team implemented two interventions: first by adding screening questions to clinical notes, then by creating an electronic form in the health records system. Documentation rates for lethal means safety counseling increased dramatically from baseline 3% to 90% by the end of the study.
Key points
- Baseline rates of any lethal means safety counseling documentation were extremely low at 3%, with complete documentation of all three means at only 1%
- First intervention using open-ended screening questions in clinical notes increased any lethal means documentation to 81% and complete documentation to 68%
- Second intervention using an electronic health record form further increased documentation to 90% for any means, though complete documentation plateaued at 66%
- Firearm/gun access was documented most consistently (90%), while sharps (68%) and medication (69%) access were documented less frequently
- The study achieved its target of exceeding 75% for any lethal means documentation and nearly met its 50% target for complete documentation
Limitations
The study was conducted in a single tertiary children's hospital and does not provide information about whether documentation improved clinical outcomes, actual counseling quality, or whether the intervention was sustained beyond the study period. It is unclear whether improved documentation translates to better safety for adolescents or reduced suicide risk.
Abstract
Introduction Lethal means safety counseling (LMSC) is recommended for children presenting to the emergency department (ED) for a mental health (MH) evaluation. Currently, no gold-standard guidelines exist for documenting LMSC in the ED. Methods This quality improvement project was conducted in the ED of a tertiary children's hospital. Baseline data were analyzed for access to any LMSC documentation (ALD) for "firearms/guns," "sharps," or "medication," and for complete LMSC documentation (CLD) if access to all 3 types was documented. The first intervention period added open-ended screening questions about access to lethal means to the MH-licensed clinical social worker note template. Intervention period 2 implemented an electronic health record "PowerForm" in Cerner PowerChart. We aimed to increase ALD and CLD to exceed 75% and 50%, respectively, during a 6-month period, with sustained success. Statistical process control p-charts with standardized special-cause rules were used to determine performance over time. Results Baseline ALD and CLD rates were 3% and 1%, respectively. During intervention 1, the ALD and CLD rates increased to 81% and 68%, respectively, with special-cause variation noted for both rates. During intervention 2, ALD increased to 90%, but CLD rates did not change significantly (66%). For intervention 2, the documentation of firearm/gun access (90%) was higher than documentation of access to sharps (68%) or medication (69%). Conclusions We achieved a significant increase in ALD and CLD for MH evaluations in our ED. Lessons learned may generalize to other ED settings.
Findings the Hub has extracted
Each claim below is labelled by its type of design and links back to this report.
- Intervention
- Two sequential quality improvement interventions: (1) adding open-ended screening questions about lethal means access to mental health clinical notes, and (2) implementing an electronic health record PowerForm to systematically document access to firearms, sharps, and medications
- Population
- Adolescents presenting to a tertiary children's hospital emergency department for mental health evaluation
Key finding
Baseline any lethal means documentation: 3%; baseline complete documentation: 1%