Using Quality Improvement Methods to Improve Lethal Means Counseling for Adolescents

Kristyn Jeffries, MD, MPH
Conor Smith, MD
Melissa Wood-Katz, MD
Imani T. Hasan, MHA
Valerie Harfield, MHSA
Jason Williams, PsyD, MSEd

Suicide is the second leading cause of death for adolescents age 15-19 years in the United States.?Evidence-based?suicide prevention strategies - such as lethal means counseling (LMC) with families at risk of suicide – can help reduce access to firearms and other highly lethal means during an acute crisis period. Our primary aim was to increase documentation of LMC?in the emergency department from baseline of 26% to goal of 46% within 12 months.

This QI project was part of the AAP’s?Improving Mental Health Processes, Workflows, and Responses (IMPWR) project. The results presented are from a single-center, tertiary children’s hospital with a multidisciplinary behavioral health team. Patients?aged?12-17 years who presented to the emergency department with a mental health complaint were included. Patients with autism, developmental delay, and eating disorders were excluded. The primary outcome was percentage of patients with documented LMC. Baseline data were obtained from April 2023-March 2024. We used Plan-Do-Study-Act (PDSA) cycle?methodology?to?identify?barriers and implement improvements during the intervention period of April 2024-March?2025. Interventions included providing?LMC?education to social workers,?adjusting?the social work note?template and?implementing?a standardized safety plan.??Statistical process control charts were used to identify special cause variation.

Data were obtained from 2475 charts of adolescents presenting with mental?health complaints: 859 in the baseline period and?1616?in the intervention period. The?mean percentage of patients receiving LMC?increased from?26% to?56% after interventions, meeting special cause variation (Figure 1). ?This increase in LMC documentation was sustained for the following 5 months after project completion. Despite this overall improvement, sub-analysis identified a persistent equity gap in which White patients disproportionately received LMC more often than Black patients (45% vs 35%, p< 0.01).

Using QI methodology to standardize note templates and safety planning resources, we achieved our goal to increase documentation of LMC in the emergency department. These strategies may be helpful to other hospitals to improve the care provided to this at-risk population. Future interventions at our institution will aim to reduce the racial disparities identified in our LMC documentation.

1) Describe baseline gaps and disparities in lethal means counseling for pediatric patients presenting to the emergency department with mental health complaints.
2) Discuss barriers and facilitators to implementing standardized lethal means counseling workflows in acute care environments.
3) Identify key quality improvement interventions used to increase rates of lethal means counseling in the pediatric ED setting.