Lethal Means Counseling Implementation in a Community Pediatric Emergency Department: A Quality Improvement Initiative

Sofia Chaudhary, MD
Hannah Thummel, BSIE
Marcus Graham, LCSW
John Constantino, MD
Bolanle Akinsola, MD

Suicide is a leading cause of death among US youth ages 10-17, firearms being the most lethal means. Pediatric emergency departments (PEDs) are often first point of contact for youth in mental health crisis and offer opportunities for suicide prevention. Lethal means counseling (LMC), where a provider counsels families on restricting access to firearms, medications, and other lethal means, improves secure storage practices but is inconsistently implemented in PEDs. At our PED (59,000 annual visits), with 24-hour behavioral mental health (BMH) social work coverage, LMC documentation was inconsistent and firearm locking devices were not offered. We aimed to increase LMC documentation for PED patients/caregivers presenting with BMH concerns and increase the percentage of caregivers with access to firearms who are offered a firearm safety device to 80% by October 31, 2025.

Our QI initiative targeted patients <18 years and their caregivers presenting to the PED with BMH concerns. Interventions included Counseling on Access to Lethal Means program in-person LMC training and virtual firearm education, development and integration of an LMC screening and documentation tool within the electronic medical record (EMR), creation of conversational scripts and educational handouts, and group and individual feedback sessions. Our aims primarily focused on our process measures: the percentage of eligible ED visits with documented LMC in the EMR and percentage of families with firearm access offered a lockbox. The outcome measure was the percentage of families screened for firearm access. Balancing measures included ED length of stay for BMH patients and provider workflow burden. Data was analyzed using statistical process control (SPC) charts.

From May 2025 to Feb 2026, 1,395 youth presented to the PED with BMH concerns. LMC documentation in the EMR was achieved in 86% (1,199/1,395) of eligible encounters (Figure 1). SPC analysis demonstrated a shift with special cause variation sustained after intervention implementation. Among screened families, 181/1,199 (15%) reported firearm access; of these, 29% reported storing firearms loaded or unsure, 13% reported storing firearms unlocked or unsure, highlighting counseling opportunities. Among families with firearm access, 73% (131/181) were offered firearm locking devices, and 28% accepted a device (50 lockboxes,1 trigger lock) (Figure 2). SPC analysis demonstrated improvement over time, though uptake of devices remained variable. 988/1,199 reported medications at home, of which 50% (498/988) did not store medications locked. Educational handouts were distributed to all families with BMH concerns.

Standardized LMC training with integration of LMC screening into the EMR behavioral health assessments workflow was associated with improved, sustained documentation of LMC and increased firearm safety device offering to BMH patients in a community PED. While project’s aim for LMC documentation was achieved, lockbox offering showed meaningful progress toward the stated aim (73%), supporting the feasibility and scalability of this approach.

1-How a lethal means counseling initiative can be implemented in a community pediatric emergency department for youth at high risk for suicide.
2-How to identify quality improvement opportunities to improve the consistency and fidelity of lethal means counseling delivery.
3-How caregiver-reported medication and firearm access and storage practices can inform future emergency department–based suicide and injury prevention interventions.

From Wishes to Washington: Crafting Your Advocacy Message

Amelia Bray-Aschenbrenner, MD
Sofia Chaudhary, MD, MPH
Lindsay Clukies, MD

As injuries remain the leading cause of death of people 1-44 years of age, injury prevention advocates must have the tools to discuss evidence-based public health strategies with policymakers to reduce the burden of injuries, particularly among children and adolescents. This 90-minute interactive workshop will provide participants with practical skills for engaging in nonjudgmental, nonpartisan advocacy conversations with non-medical policy makers focused on shared goals and meaningful engagement.

The session will begin with a 30-minute didactic overview of effective advocacy communication strategies. Participants will learn how to clearly and concisely articulate positions on child injury and public health issues, develop memorable advocacy “why” statements, translate clinical and community experiences into compelling advocacy messages, and frame conversations in ways that resonate with diverse audiences. The session will also address strategies for engaging policymakers across differing viewpoints, building and sustaining professional relationships with legislative offices, and navigating emotionally and politically sensitive discussions. Real-world examples from injury prevention and child health advocacy will be incorporated throughout.

The remainder of the workshop will focus on hands-on experiential skill-building activities. Participants will be given 15-minutes to individually craft their “why” statement. They will be given 30-minutes to practice delivering their message in facilitated small groups. Attendees will receive feedback on how to make their messaging clear, compelling, concise, and audience-focused. For the remaining 15-minutes, small groups will choose 1-2 attendees to lead mock meetings with policymakers, portrayed by workshop facilitators, to practice applying the conversational and relationship-building techniques discussed during the lecture portion. Other group members will observe and provide feedback. By the end of the session, participants will leave with tangible tools and greater confidence to engage in injury prevention and child advocacy at the local, state, and national levels.

- Craft and confidently deliver a memorable personal advocacy “why” statement
- Develop effective communication strategies for engaging with legislators and policymakers
- Practice navigating challenging or emotionally charged policy conversations
- Apply newly acquired advocacy skills through interactive small-group breakout sessions