The finding: In this secondary analysis of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study, the authors find that only 50% (95% CI: 47-52%) of suicidal emergency department (ED) patients had documentation of access to firearms – in spite of the fact that most suicide deaths in the US are by firearm. Documentation of lethal means access was not associated with actual gun ownership, and 13% of patients discharged without such documentation had one or more firearms at home. Suicide attempt by overdose is more common, but documentation was no better when expanded to include access to dangerous medications.

Strengths and weaknesses: The analysis is based on a large, multi-site study with longitudinal follow-up of a large cohort of suicidal emergency department patients. A chart review combined with a subsequent interview by study staff provide a level of detail rarely available for such a large ED cohort.
Less information is provided about documentation of access to lethal means other than firearms, and it would have been interesting to know if patients’ reported access to firearms was consistent across clinical and study encounters.

Relevance: Although many ED providers feel lethal means counseling is not effective, in fact, firearms counseling affects storage behaviors, and means restrictions is associated with lower rates of suicide and self-harm. Mitigating access to lethal means is fundamental to any ED safety intervention, and providers should document counseling as part of their safety assessment.