Improving Firearm Screening and Anticipatory Guidance During Well-child Checks: A Resident-led Quality Improvement Project

Purpose/Objectives: Firearms are the leading cause of death in American children and adolescents. The American Academy of Pediatrics (AAP) recommends that pediatricians ask about the presence of firearms in the home at well-child visits and advises that homes without firearms provide the most effective measure to prevent firearm-related injuries. The AAP recommends safe storage for homes with guns. Despite these recommendations, pediatrician firearm screening remains low. A recent randomized control trial found a significant increase in safe firearm storage when pediatricians provided free firearm locks and counseled on firearm removal and safe storage. Increase firearm screening (asking about home firearms) from roughly 40% to 70% and also increase counseling on firearm removal, safe storage and provision of free firearm locks during pediatric well-child checks over eight months. Design/Methods: This quality improvement project (QIPR #1389) used the plan-do-study-act (PDSA) methodology and included two sequential interventions: First, the entire department received didactic training on firearm safety and evidence-based recommendations for firearm screening and anticipatory guidance, and clinics received free firearm locks. Thereafter, clinics received Be SMART© posters and educational cards from the national educational campaign for firearm safety. To assess the project, pediatric residents, PAs/APRNs and attendings in the General Pediatrics Division at the University of Florida received three anonymous, electronic, six-question surveys spaced three to four months after each PDSA intervention to evaluate firearm screening and anticipatory guidance practices from 10/2020-6/2021. Results: Response rates overall were 43.8% (survey 1: 58.4% (n=52); survey 2: 47.2% (n=42); survey 3: 25.8% (n=23). At baseline, pediatric providers cited firearm screening during a third (37.8%) of well-child checks. If a parent/caregiver reported a firearm in the home, only half (53.1%) at baseline counseled that the safest home for a child is one without firearms. Most pediatricians (88.0%) reported counseling that firearms should be stored unloaded, locked, and separate from ammunition. Firearm locks were offered only at 9.6% of visits. After two PDSAs, reports of firearm screening significantly improved (37.8% to 72.4%) as did free firearm lock provision (9.6% to 79.3%), exceeding our 70% goal (see Tables 1 and 2). Anticipatory guidance also improved: counseling that the safest home is one without firearms increased (53.1% to 66.2%) and counseling on safe firearm storage remained high (increasing from 88.0% to 93.1%). Increased screening significantly improved across all pediatric provider types (resident, PA/APRN, attending). Conclusion/Discussion: At baseline, pediatricians infrequently screened for home firearms, consistent with previous studies. After PDSA interventions, this quality improvement study demonstrated that department-wide training on firearm safety and screening recommendations, free firearm locks, and Be SMART© materials are effective ways to improve firearm screening and anticipatory guidance during well-child checks in an academic primary care center. Future studies will measure the sustainability of these interventions.