TOP 63 - Lockboxes for Little Lives: Implementing Firearm Screening for Families of Toddlers in the Pediatric Inpatient Setting

Publication Number: 1822.TOP 63

Heather Hirsch, Emory University School of Medicine, Decatur, GA, United States; Sofia Chaudhary, Emory University School of Medicine, Decatur, GA, United States; Kiesha Fraser Doh, Children's Healthcare of Atlanta/Emory University, Atlanta, GA, United States; Amanda G. Kuhn, Emory University School of Medicine, Atlanta, GA, United States; Kelly Liu, Emory University School of Medicine, Atlanta, GA, United States; Sajani Patel, Emory University School of Medicine, Atlanta, GA, United States; Melissa C. Popkin, Children's Healthcare of Atlanta, Atlanta, GA, United States; Nitya Ramalingam, Emory University School of Medicine, Decatur, GA, United States; Jaquelin Solis Solis, Emory University School of Medicine, ATLANTA, GA, United States; Shelby Thomas, Children's Healthcare of Atlanta, Atlanta, GA, United States; Heather Xiao, Emory University School of Medicine, Marietta, GA, United States; Julia KW. Yarahuan, Children's Healthcare of Atlanta, Atlanta, GA, United States; Lori M. Singleton, Morehouse School of Medicine, Peachtree City, GA, United States

Background: Firearms currently surpass motor vehicle collisions as the leading cause of death for children and youth in the United States. Families often underestimate their child's access to firearms and fail to recognize that children as young as two years old may have enough strength to pull the trigger. Conversely, storing firearms locked or unloaded is approximately 70% protective. Provider guidance and safety device provision improves firearm secure storage rates, yet fewer than 3% of inpatient pediatricians discuss firearm safety despite two-thirds of parents, including 58% of firearm-owning parents, supporting such conversations.

Objective: We implemented a quality improvement initiative to address gaps in inpatient firearm screening. Our primary aim was to increase documentation of household firearm access among Pediatric Hospital Medicine (PHM) patients aged 2-5 years from < 2% to 40% by December 2025. The secondary aim was to distribute handgun lockboxes to 80% of families reporting unsecured firearms. The global aim was to increase parental knowledge of secure firearm storage strategies and reduce firearm injuries in toddlers.

Design/Methods: The project involved pediatric residents, PHM fellows, PHM faculty, and social workers. We collected baseline data through a randomized review of 20 charts per month from June 2024 to November 2024. A key driver diagram was completed to identify potential interventions including a screening tool embedded within the Electronic Medical Record system and educational sessions with physicians (residents, PHM fellows and faculty) and social workers. The hospital's parental advisory committee provided input on screening questions. From June 2025 to December 2025, we conducted plan-do-study-act cycles. The monthly percentage of patients with documentation of firearm access was tracked using an annotated run chart. Upon discharge, families who endorsed access to firearms received written firearm safety guidance and watched a secure firearm storage video. Families who owned an unsecured firearm were educated on lockbox use by a social worker and offered a lockbox. We plan to contact families regarding lockbox usage if consented.

To date, we have completed 5 months of post-intervention data and have found an average screening rate of 11.4%, improved from a baseline screening rate of 1.7%. We've distributed 13 lockboxes with a lockbox distribution rate of 70% for eligible families. We plan to implement additional interventions to reach our 40% screening goal, focusing on identified barriers such as provider confidence and forgetfulness.

Figure 1. Key Driver Diagram for Lockbox for Little Lives Project
Key drivers were identified that correlate to the project's SMART aims. There are interventions that tie to each. Some interventions can be coupled as you will see in Figure 2.

PHM Toddler- Admitted Firearm Screening Rates
Figure 2. Process control chart demonstrating firearm storage screening for PHM-admitted toddler patients (ages 2-5 yp). Baseline data is from June 2024 to November 2024. Interventions start in June 2025. Interventions: A- Launched EMR screen June 5th 2025 + AVS information for those screened. B- Intern-only Firearm Safe storage Didactics (July 10th) + Launched lockbox distribution for eligible patients July 17th C- August 19th- Case Based Lecture with residents/learners on PHM service . D- Oct 13th-Smarttext that was previously restricted to only inpt units was updated to include ED units (so those admitted pts were notes started in ED were able to access screen in H&P template).