Knowledge and Practice of Emergency Medicine Healthcare Teams Regarding the ASK Campaign and Firearm Safety

Unintentional firearm injuries are a preventable problem within the pediatric population, and many of these could be avoided with proper firearm storage.

The Asking Saves Kids (ASK) campaign recommends that parents ask adults in whose homes their children spend time about the presence and storage of firearms.

No known studies have examined emergency providers’ comfort level and knowledge on these topics. The goal of this study was to describe emergency healthcare providers’ (HCPs) knowledge and behaviors regarding the ASK campaign and firearm safety and to measure the benefits of providing an ASK education.

METHODS: This study took place at an urban hospital ED. Participants were EM physicians and RNs, who were chosen voluntarily. HCPs completed a pre-intervention survey, an intervention, and a post-intervention survey. The intervention consisted of sharing ASK pamphlets and providing a 5-minute verbal training. The post-intervention survey was completed typically within 1-2 days of the intervention. Data were compiled, and statistical analysis was performed.

RESULTS: 86.8% of providers initially reported that they rarely or never discussed firearm safety. 50.5% of pre-survey participants and 81.6% of post-survey participants felt comfortable discussing firearm safety.  Similarly, the average percentage of correct responses to the knowledge questions increased from pre- to post-survey: 36.8% to 76.2%, respectively.

CONCLUSIONS: This intervention was sufficient to improve HCP knowledge in firearm safety and comfort in discussing firearms. Universal firearm training would allow more caregivers to receive proper information on how to safely store their firearms and minimize accidental pediatric injuries.

INTRODUCTION
Firearm safety has become a growing concern in the U.S., yet it is not a common point of discussion in an average clinical visit, with only 25% of physicians surveyed reported discussing firearm safety often or very often with patients.^1,9 The Asking Saves Kids (ASK) campaign was promoted with the intent that parents or caregivers should ask if there is an unlocked firearm where their children will be playing.⁸ A study conducted by Dr. Agarwal, et al in NYC found that 96% of caregivers felt that physicians should provide ASK education, and 85% of caregivers who received ASK training felt comfortable asking if there is a firearm where their child plays.² Another study reported that 75% of parents agreed that pediatricians should advise them regarding the safe storage of firearms within the home.³ These studies demonstrate that caregivers are willing to discuss firearm safety, but no studies have examined emergency healthcare providers’ comfort level and knowledge on these topics. Intervention in the ED has previously been shown to be effective in increasing patient awareness. Specifically, a study has shown that ED providers were able to effectively deliver smoking cessation counseling to their patients in a time-efficient manner.⁴ Our study hypothesizes that the same concept could apply to increase firearm safety counseling and awareness in the ED setting.

Nearly 1300 children die and 5790 are treated for gunshot wounds each year.¹² From analyzing all patient data from the U.S. National Trauma Data Bank, years 2009 to 2014, Cutler, et al. found that, of 466,403 pediatric ED visits, 21,416 (4.6%) resulted from a firearm injury.¹³ Additionally, from their analysis, patients visiting EDs for firearm-related injuries had more than 7 times mortality compared to other injuries, and firearm injuries were responsible for more than a quarter of the total pediatric deaths.¹³ Thus, emergency medicine providers are often the front line for treating patients that have been injured by firearms, and the likelihood of severe injury and mortality is higher when associated with firearms.

The purpose of this study was to describe emergency department healthcare providers’ (HCP) knowledge and behaviors when it comes to the ASK campaign and firearm safety before and after a brief educational intervention about the ASK campaign. Additionally, this study aimed to assess if there was a difference in comfort discussing the ASK campaign within varying HCP demographics.

METHODS 
Emergency medicine physicians and nurses were recruited at an urban level 1 trauma center hospital emergency department. This entire study and intervention took place pre-COVID pandemic from August to October 2018. HCPs completed a voluntary pre-intervention survey, and afterward, a brief educational intervention was performed, sharing ASK pamphlets with HCPs and providing a 5-minute verbal training based on the Asking Saves Kids campaign website.⁸ The HCPs were then asked to complete a voluntary post-intervention survey, typically within two days of the intervention.

The surveys were designed to assess HCP knowledge about firearm prevalence and safe storage practices as well as HCP comfort level presenting the information to caregivers of children. The knowledge questions included: the percentage of homes with kids that have guns (33%), the percentage of parents who keep a gun loaded (25%), the percentage of unintentional firearm deaths of kids that occur in a home (80%), whether providers are comfortable discussing firearm safety with caregivers during ED visit, and whether the HCPs consider themselves familiar with proper firearm storage practices. Additionally, the first survey asked whether the HCP: discusses firearm safety with adult patients, discusses firearm safety with caregivers of pediatric patients, and whether they are familiar with ASK. The post-survey asked providers if they are comfortable discussing firearm safety with caregivers of pediatric patients after receiving training, if they think this information is valuable for all HCPs, and if they are willing to share ASK information with the caregiver of every pediatric patient.

Data were compiled using RedCap software, and statistical analysis was performed. Descriptive statistics were reported for pre-and post-survey responses. The statistical significance of differences in responses by participant characteristics was performed using chi-square or Fisher’s exact tests as appropriate. This study was approved by the IRB and all investigators completed appropriate CITI training. Patients and the public were not involved in the design, conduct, reporting, or dissemination plans of our research.

RESULTS
91 healthcare providers participated in the pre-survey and 49 of those participated in the post-survey over the course of three months. Emergency HCP knowledge of ASK campaign statistics was significantly improved after the five-minute verbal intervention. Specifically, the correct responses to knowledge questions increased from pre- to post-survey: 42.7% vs 73.5% knew that one in three homes with kids have at least one gun, 44.9% vs 69.4% knew that one-quarter of parents with guns keep one loaded, and 22.7% vs 85.7% knew that four in five unintentional firearm deaths of kids occur in a home.

Additionally, HCP comfort in relaying this information to patients significantly increased. The percent who felt comfortable discussing firearm safety with caregivers during ED visits increased from 50.5% among pre-survey participants to 81.6% among post-survey participants.

Prior to the intervention, most reported that they rarely (n=27, 29.7%) or never (n=52, 57.1%) discussed firearm safety with adult patients or with caregivers of pediatric patients.  Frequency of and comfort with a discussion of firearm safety did not differ by respondent age, gender, role, or parenthood (p>0.05 for all comparisons, data not shown).

Following the intervention, 87.8% (n=43) indicated a willingness to share ASK information with the caregiver of every pediatrics patient. HCPs self-reported to find the ASK information useful to them in practice, with 91.8% believing that this info is valuable for all HCPs. Comfort in talking about proper firearm safety and storage was reported as improved after receiving the intervention, with 87.8% willing to share ASK information with the caregiver of every pediatric patient.

Of physicians and nursing staff in the level 1 trauma center emergency department approached, 91 completed a pre-intervention survey.  The majority of respondents to the pre-survey were less than 45 years old (n=67, 74%), female (n=74, 81.3%) and nurses (n=73, 81.1%).  Nearly half were parents of children under 18 (n=42, 46.2%) and one fifth (n=19, 20.9%) owned a firearm. 

DISCUSSION
With this brief intervention in the ED, this study hoped to empower HCPs to ask guardians about proper firearm storage and spread the message of the ASK campaign in hopes of reducing accidental firearm-related incidents in the community.

According to multiple prior studies, 80% of unintentional firearm deaths involving children under the age of 15 occur in a home.^7,8  This campaign was promoted with the intent that parents or caregivers should ask if there is an unlocked firearm where their children will be playing. There is ample evidence that clinical interventions can be efficacious in preventing injuries when they combine an array of health education and behavior change strategies such as counseling, demonstrations, and reinforcement.¹⁰ Prior studies demonstrated that ASK education provided by pediatricians is effective in increasing caregivers' comfort level in asking if there is a gun where their child plays and additionally that caregivers feel that pediatricians should provide ASK education.⁵ The question of whether pediatrics providers are comfortable providing firearm education also looks promising, with 87% of pediatric residents believing that it is a “good idea” to ask about guns in a home.⁹ However, there is limited research on the ASK campaign as it relates to emergency medicine providers.

From the results, we found that 91 HCPs participated in the pre-survey and 49 in the post-survey, with the demographics remaining similar and consistent between the two. Additionally, the correct responses to the knowledge-based questions improved from pre- to post-survey (Figures 1, 2). Also, the HCP confidence in being aware of proper firearm storage to counsel patients increased from 42% to 82%. Post-intervention, 88% of HCPs felt comfortable discussing firearm safety with caregivers of pediatric patients, demonstrating a significant difference. Finally, the frequency of and comfort with discussing firearm safety did not differ by respondent age, gender, role, or parenthood (p>0.05). Thus, this intervention was sufficient to improve HCP knowledge in firearm safety and comfort in discussing firearm storage with their patients.

Additionally, although this study was performed pre-COVID, some study limitations include that the study was performed at a single, level 1 trauma center in a racially and socioeconomically diverse area. The number of respondents to the follow-up survey (n=49) was substantially less than the primary survey (n=91), which could contribute to selection bias, however, the demographic information from Figure 1 remained overall equivalent, and the total number of firearm owners was 20.9% in the first survey vs 24.5% in the second survey. The fact that providers are more comfortable with counseling doesn’t preclude the possibility that long-term education of parents regarding the ASK campaign ceases to occur, and it is insufficient to say whether parents are implementing this specific advice from this clinical context. Finally, the challenge remains of the efficacy of this intervention in the long-term prevention of accidental firearm injuries.

Overall, this short intervention within the ED was sufficient to improve HCP knowledge in firearm safety and comfort in discussing firearm storage with their patients. This information was also well-received by the HCPs. This study indicated that the information will lead to increased patient exposure to the ASK campaign from HCPs and will be an important step in reducing accidental firearm injuries among children. There are still challenges, such as performing longitudinal studies on the long-term effectiveness of such a study in preventing pediatric firearm injuries, particularly in the context of the COVID pandemic as the amount of data strongly skews in favor of those individuals who are available to participate.

Future study directions include replicating the study in the context of COVID as children are more frequently found at home – making firearm safety even more critical. Involving the newer Act, Ask, Talk, Learn from Brady United and completing a follow-up survey several months later to assess if the providers feel they have begun to incorporate ASK and firearm safety into their patient care could also be appropriate directions.¹¹ Additionally, it would be valuable to assess accidental pediatric firearm injury pre-and post-intervention to assess efficacy, assess whether pediatric caregivers are following the guidelines provided by the HCP, and/or expand this training to other sites in the community.

CONCLUSION
Unintentional firearm injuries are a significant problem within the pediatric population and many of these incidents could be avoided with proper firearm storage. Exposing HCPs on the front line of patient care in the Emergency Department to the Asking Saves Kids campaign could help disseminate necessary information to firearm owners whose children come into the ED. If this training became widespread, many more caregivers of pediatric patients would receive the information they need to properly store their firearms, and, hopefully, these interventions would be able to help prevent accidental firearm injuries in the pediatric population in future studies. Additional longitudinal research is still required to determine if the use of the Asking Saves Kids educational campaign in the Emergency Department reduces gun injuries amongst children.

Acknowledgments: We want to express sincere gratitude and appreciation to Cara Joyce, PhD, Director, Biostatistics Core at Loyola University Chicago for completing the statistical analysis of this project.

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