Connecticut providers knowledge and attitudes towards use of extreme risk protection orders

Connecticut providers knowledge and attitudes towards use of extreme risk protection orders | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Connecticut providers knowledge and attitudes towards use of extreme risk protection orders Nishant Pandya, James Dodington, Joshua Jacob, Sarah Raskin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4743655/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Mar, 2025 Read the published version in Injury Epidemiology → Version 1 posted 4 You are reading this latest preprint version Abstract Background Extreme Risk Protection Orders (ERPOs) are a legislative tool that temporarily restrict firearm access in patients with higher suicide risk. ERPOs have reduced firearm suicide rates in Connecticut and are estimated to save one life per 10 orders filed. Connecticut medical providers can initiate this process, but less than 8% of 2020 ERPOs were filed by providers. This survey assesses provider knowledge and attitudes towards use of ERPOs. Methods This study electronically surveyed providers from six hospitals regarding their current knowledge of the Connecticut ERPO law, perceived barriers to the use of the law and procedures that might make use more likely. Results 114 providers completed the survey in 2022. 66 (57.8%) providers encountered more than 1 patient per year at risk for suicide with firearm access. Only 2 providers had ever initiated an ERPO, but both found it extremely helpful. Only 1 provider was extremely familiar with ERPO while 91 (83.4%) were not familiar. Barriers to using ERPO include negatively impacting the patient relationship, and not enough time to call and follow up. ERPO specific training, and trained on-site coordinators to help file and follow through were ways to encourage to ERPO utilization. Conclusion The majority of providers encounter at least one patient annually who may benefit from an ERPO. However, providers are largely unfamiliar with ERPO and the filing process. Time cost is the greatest barrier to its utilization. Provider training and trained coordinators to process ERPO were the two most requested supports to encourage providers to initiate ERPOs. Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction In 2020, there were 24,292 firearm-related suicides in the United States. Suicide is the 12th leading cause of death in the United States and suicide by firearms are responsible for nearly 54% of cases. 1 , 2 One approach to the prevention of suicide by firearm are extreme risk protection orders (ERPO). These laws create a legal process by which a court can order the removal of firearms from individuals who are deemed to be at risk of imminent harm to themselves or others, and when other alternatives for preventing access to the firearms have been exhausted. They are aimed at preventing suicides, as well as mass shootings, and interpersonal gun violence. Connecticut passed the United States’ first state-wide extreme risk protection order (ERPO) law in 1999 as a response to a mass shooting the previous year. Despite active concerns about the shooters’ mental health, there had been no legal means for the police to intervene 3 . The original Connecticut ERPO law permitted law enforcement to request permission from a judge to temporarily remove and prohibit the future acquisition of firearms for those deemed at “extreme risk” to themselves or others. As of August 2022, 18 additional states, California, Colorado., Delaware, Florida, Hawaii, Illinois, Indiana, Maryland, Massachusetts, Nevada, New Mexico, New Jersey, New York, Oregon, Rhode Island, Vermont, Virginia, Washington , and the District of Columbia in the US have enacted ERPO laws 4 . Since its creation, there have been 2,600 warrants granted in Connecticut with suicidality or risk for self-injury as the most common reason for firearm seizure. 5 It initially resulted in an estimated 1.6% reduction in suicide death that grew to a 13.7% reduction following high-profile mass shootings that resulted in increased utilization of the ERPO law. It is estimated 1 suicide death is prevented per every 10–20 gun removals. 6 7 . Historically, ERPOs have been primarily initiated by law enforcement. ERPO laws were implemented in King County, Washington in 2017. In its first year, 75 ERPO petitions were filed to limit the purchase or possession of firearms by individuals. Nearly all petitions were filed directly by law enforcement after being informed by family members that the individual was deemed at risk of suicide or harm to others. 8 California implemented ERPO laws in 2016. Similar to King County, over 90% of the 1076 petitions between 2016–2019 petitions were filed by law enforcement. Each year, the total number of petitions filed did increase but great variability exists in the social demographics of the individuals that petitions were filed against and citizen comfort with initiating an ERPO petition. 9 More recently, joining Maryland, Hawaii, and the District of Columbia, Connecticut has expanded its ERPO law in 2021 to allow for family members or medical professionals to petition directly to a law enforcement officer or a court to initiate a risk order protection investigation. This change allows for an additional route outside of law enforcement officers. Over 400 petitions were filed in the first 6 months following the expansion of who can file ERPO petitions in Connecticut. The increased efficiency of ERPO petitions has facilitated individuals outside law enforcement to file petitions but has come with administrative burdens and redundancies for those without possession or access to firearms. 10 As ERPO petitions can now be more easily filed by those outside of law enforcement, medical providers are in a privileged position to recognize periods of crisis, changes in mental health, or warning signs that an individual is at greater risk to themselves or others 11 . The American Medical Association, American Academy of Pediatrics, Psychological Society, and American Academy of Family Physicians all recognize gun violence as a public health crisis. 9 ERPO laws are effective tools healthcare providers can use to help reduce firearm-related suicide and other deaths. Despite available legal means, physicians poorly utilize ERPO laws as only 8% of ERPOs are initiated by clinicians or employers In a survey in the state of Maryland, healthcare providers in the departments of psychiatry, pediatrics, and emergency medicine were sent a survey to determine what they knew about the state’s ERPO law and what the barriers and facilitators might be. 12 The current study is designed to replicate and extend this Maryland study with changes made due to the differences between the laws in these states. In addition, we will ask questions about the subjective data that people currently find important in determining the use of ERPO laws so that we can analyze the likelihood that the law is being used in a just and fair way. Swanson (2020) has pointed out ways in which individual racial bias may play a role in subjective decisions to invoke the law. Finally, we included questions about whether a history of neurologic illness plays a role in people’s likelihood to invoke ERPO restrictions. Given the opportunity to reduce firearm-related suicide, it would be beneficial to better understand healthcare providers’ attitudes towards ERPO laws and their perceived barriers to using them. This study surveyed medical providers in Connecticut in private practice and at four hospitals to assess knowledge, barriers, and facilitators to utilizing current ERPO laws in their clinical practice. Methods Participants A total of 114 individuals responded to our survey. Detailed information about the type of practice, area of specialty, and practice location can be seen in Fig. 1 . Years of practice ranged from less than one year to 40 years with a mean of 14.21 (s.d. 5.79). Area of practice for the respondents include providers specializing in pediatrics (37%), psychology (21%), psychiatry (15%), internal medicine (4%), emergency medicine (1%), gastroenterology (1%), OBGYN (1%) and undisclosed (25%). Materials This survey contained 16 questions. It queried the respondents about their current knowledge of the Connecticut ERPO law, perceived barriers to the use of the law and procedures that might make use more likely. We asked if prior diagnoses, such as brain injury, mental illness, or post-traumatic stress disorder, would increase the likelihood of using the law. Finally, we asked respondents about the demographic factors that might go into the likelihood of using ERPO (such as previous history of arrest). The full survey can be viewed in Appendix I. It took approximately 10 minutes to complete. Procedure The study was approved by the Institutional Review Board at Trinity College. The survey was created and distributed via Qualtrics software (Qualtrics, 2020). A survey link was sent to all members of the Connecticut Psychological Association via a listserv, and via individual emails to members of the departments of psychiatry, internal medicine, and pediatrics at four regional hospitals (Yale New Haven Hospital, Hartford Hospital, Connecticut Children’s Medical Center, and Trinity Health of New England). Despite this targeted distribution, we did receive responses from providers in other departments and chose to keep them in the results. Participants had the option of receiving a $ 10 gift card for their participation. All surveys were completed in 2022. Results Descriptive data were collected for all survey questions. Awareness of ERPO and policies Strikingly, when asked how familiar the participants were with the Connecticut ERPO law, only one said they were extremely familiar and five said they were very familiar. Seventeen were moderately familiar and 25 slightly familiar. Sixty-one (51% of respondents) reported that they were not at all familiar as seen in Fig. 2 . None of the respondents were familiar with any specific policies or procedures surrounding the ERPO law at their institution. Potential need to use an ERPO This lack of awareness does not seem to stem from a lack of situations where use of an ERPO could be considered. When asked “How often do you estimate you encounter a patient or client that is at extreme risk of violence, or suicide, has access to firearms, and who you would consider for an ERPO?” One respondent said daily, one weekly, and four monthly. Sixty respondents said a few times per year and 43 (49%) said never. Only two respondents had ever used an ERPO (one respondent five times and the other respondent once) and both said they found it definitely helpful. Current practice As shown in Fig. 3 , about 70% of the respondents reported that they counsel those at risk of suicide about lethal means always or most of the time. Sixteen percent do rarely or never. Of those who do discuss lethal means, 80% discuss access to firearms always or most of the time. Barriers to using ERPO The main barriers reported to using ERPO among these health professionals were concern that it might negatively affect their relationship with the patient (26%), not enough time to make the call and follow up (20%), and not feeling comfortable bringing the police into patient care (26%). Twenty-four percent of respondents marked “other” and most of the comments indicated that this was a lack of knowledge in how to file a report. When specifically asked if the change in Connecticut’s law allowing them to file a petition without directly involving police 26 respondents said this would make them more likely to do so, 52 said this would not change their likelihood, and 15 said it would make them less likely to file a petition. Suggestions to make it more likely to file an ERPO Respondents were asked to give the most important way that systems could be changed to make it more likely for them to file an ERPO. The largest number of respondents (83%) felt they needed training. Sixty-eight percent would like to see a trained coordinator at their institution to help with filing and follow through. In addition, respondents would like to have consultation with a legal expert (45%) or a specific internal policy at their institution (47%). See Fig. 1 . Impact of specific diagnoses In order to determine if any specific diagnostic categories are more or less likely to lead to a health care provider filing an ERPO we asked about depression, psychosis, traumatic brain injury, bipolar disorder, and post-traumatic stress disorder. Those data can be seen in Fig. 4 . Discussion Of the 114 surveyed providers, only two had ever filed ERPOs and more than half of providers were unfamiliar with the existence of ERPOs. Connecticut was the first state to introduce ERPO in 1999 but only recently expanded the ability for medical providers to directly petition to state courthouses in 2021. While the ability to directly file is fairly recent, the unfamiliarity with ERPO demonstrates a need to increase familiarity and awareness among medical providers in Connecticut who can use this tool to restrict firearm access in patients at risk for suicide. More than half of medical providers see at least one patient per year who may benefit from ERPO. This number however may be an underestimate. Over 30% of respondents did not regularly discuss lethal means when counseling patients at risk for suicide. Of those who did such counseling, only 60% always asked about access to firearms. This gap is likely attributed to time barrier when addressing all patient needs in the outpatient setting for both pediatric and adult primary care providers. 13 14 . Due to these time barriers, it is not feasible to screen every single patient at very visit. There were many providers who felt their use of an ERPO would be more likely in the case of specific mental health diagnoses or traumatic brain injury. Specific training that provides guidance for which of these diagnoses are more likely to lead to self-harm or harm of others and how to recognize the signs would be an important part of ERPO training. Patients with these diagnoses may better be served and screened for ERPO more regularly as on the one hand their risk for self-harm may be higher than the general population and on the other it would not be appropriate to assume that without adequate screening. Increasing ERPO use by medical providers can reduce suicide by firearm mortality in Connecticut. Similar to counseling on lethal means and firearm access, time to call and follow up remains a barrier for provider use of ERPO. Institutions can support providers by investing in ERPO specific trainings, hiring trained coordinators, and providing legal counseling. These requests commonly selected by respondents identifies a desire to engage with ERPO but logistical and time limiting the ability to engage. In addition, it might be helpful for specific data input to flag a reminder about ERPO in electronic medical records. Even with such investment, respondents expressed concern of harming their relationships with patients and actively involving law enforcement into patient care. Increasing familiarity with the ERPO process including the expectations and actions of law enforcement on investigation may help address provider concerns. Conclusion This study surveyed medical providers in Connecticut assessing their current knowledge of the Connecticut ERPO law, perceived barriers to the use of the law and procedures that might make use more likely. Connecticut providers are largely unaware of ERPO and very few had any experience utilizing this legislative tool as individuals or within their respective institutions. Despite their lack of familiarity, medical providers do encounter patients with higher risk for suicide with access to firearm who may benefit from ERPO. Additionally, the majority of providers do appropriately counsel for and screen for lethal means and firearm access in patients at risk for suicide. Providing institutional support with ERPO specific training and hiring support staff to facilitate ERPO along are ways institutions can support providers to utilize this tool to help prevent suicide by firearm. Declarations Ethics approval and consent to participate This survey was approved by the Yale University and Trinity College Institutional Review Boards. Each participant in the survey provided consent prior to completing the survey and allowed for their responses to be used in this study. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards Consent for publication Not applicable, no patient data is used in this publication Availability of data and material Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Competing interests The authors declare that they have no competing interests Funding This study did not receive funding Authors' contributions Sarah Raskin was responsible for creating the original survey and helping write parts of the manuscript. Jim Dodington helped distribute the survey and review the manuscript. Nishant Pandya helped distribute the survey, write the manuscript, and engage in data analysis. Joshua Jacob helped engage in data analysis of survey response. Each author engaged in editing the manuscript. Acknowledgements Not applicable References Klein, Joshua, et al. “Firearms: The Leading Cause of Years of Potential Life Lost.” Trauma Surgery & Acute Care Open , vol. 7, no. 1, 1 Feb. 2022, p. e000766, tsaco.bmj.com/content/7/1/e000766.citation-tools, https://doi.org/10.1136/tsaco-2021-000766. Accessed 11 May 2022. Gondi, Suhas, et al. “Extreme Risk Protection Orders.” Academic Medicine , vol. 94, no. 11, Nov. 2019, pp. 1649–1653, https://doi.org/10.1097/acm.0000000000002935. Kivisto, Aaron J, and Peter Lee Phalen. “Effects of Risk-Based Firearm Seizure Laws in Connecticut and Indiana on Suicide Rates, 1981-2015.” Psychiatric Services (Washington, D.C.) , vol. 69, no. 8, 2018, pp. 855–862, www.ncbi.nlm.nih.gov/pubmed/29852823, https://doi.org/10.1176/appi.ps.201700250. Heflin, Justin. “Are Red Flag Laws a Green Light to Save Lives?” ssrn.com , 19 July 2022, papers.ssrn.com/sol3/papers.cfm?abstract_id=4167250. Accessed 27 Sept. 2022. Keating, Christopher. “Gov. Lamont Touts Expansion of Connecticut’s “Red Flag” Gun Law – Used 2,600 Times – as Lawmakers Weigh National Law.” Hartford Courant , 14 June 2022, www.courant.com/2022/06/14/gov-lamont-touts-expansion-of-connecticuts-red-flag-gun-law-used-2600-times-as-lawmakers-weigh-national-law/. Accessed 17 Apr. 2023. Nielsen, David. “Disarming Dangerous Persons: How Connecticut’s Red Flag Law Saves Lives without Jeopardizing Constitutional Protections.” Quinnipiac Health Law Journal , vol. 23, 2020, p. 253, org/HOL/LandingPage?handle=hein.journals/qhlj23&div=16&id=&page=. Accessed 17 Apr. 2023. Klein, Joshua, et al. “Firearms: The Leading Cause of Years of Potential Life Lost.” Trauma Surgery & Acute Care Open , vol. 7, no. 1, 1 Feb. 2022, p. e000766, tsaco.bmj.com/content/7/1/e000766.citation-tools, https://doi.org/10.1136/tsaco-2021-000766. Accessed 11 May 2022. Frattaroli, Shannon, et al. “Extreme Risk Protection Orders in King County, Washington: The Epidemiology of Dangerous Behaviors and an Intervention Response.” Injury Epidemiology , vol. 7, no. 1, 22 July 2020, https://doi.org/10.1186/s40621-020-00270-1. Accessed 3 Oct. 2021. Pallin, Rocco, et al. “Assessment of Extreme Risk Protection Order Use in California from 2016 to 2019.” JAMA Network Open , vol. 3, no. 6, 18 June 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7303810/, https://doi.org/10.1001/jamanetworkopen.2020.7735. Accessed 5 Nov. 2020. Altmari, Dave, et al. “CT Police: Updated “Red Flag” Law Used Largely for Suicide Threats.” Journal Inquirer , 5 Dec. 2022, journalinquirer.com/crime_and_courts/ct-police-updated-red-flag-law-used-largely-for-suicide-threats/article_d32be3be-749b-11ed-a129-e30a1d027004.html. Accessed 17 Apr. 2023. Hollo A, VanderStoep A, Frattaroli S. Physicians’ perspectives on Extreme Risk Protection Orders (ERPOs) in the clinical setting: Challenges and opportunities for gun violence prevention. West JC, ed. PLOS ONE . 2022;17(9):e0274489. doi:https://doi.org/10.1371/journal.pone.0274489 Frattaroli S, Hoops K, Irvin NA, et al. Assessment of Physician Self-reported Knowledge and Use of Maryland’s Extreme Risk Protection Order Law. JAMA Network Open . 2019;2(12):e1918037. doi:https://doi.org/10.1001/jamanetworkopen.2019.18037 Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the Time Needed to Provide Adult Primary Care. Journal of General Internal Medicine . Published online July 1, 2022. doi:https://doi.org/10.1007/s11606-022-07707-x Diamond, Guy S., et al. “Attitudes, Practices, and Barriers to Adolescent Suicide and Mental Health Screening.” Journal of Primary Care & Community Health , vol. 3, no. 1, 8 Nov. 2011, pp. 29–35, https://doi.org/10.1177/2150131911417878. Additional Declarations No competing interests reported. Supplementary Files AppendixISurvey.pdf Cite Share Download PDF Status: Published Journal Publication published 19 Mar, 2025 Read the published version in Injury Epidemiology → Version 1 posted Editorial decision: Revision requested 06 Aug, 2024 Editor assigned by journal 01 Aug, 2024 Submission checks completed at journal 30 Jul, 2024 First submitted to journal 15 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4743655","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":336869285,"identity":"2ef123f2-eca6-4e47-b441-aef357fe0001","order_by":0,"name":"Nishant 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1","display":"","copyAsset":false,"role":"figure","size":29267,"visible":true,"origin":"","legend":"\u003cp\u003eHome institution of each provider respondent\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4743655/v1/41f47bc83aae9301ac91a3d9.jpg"},{"id":63832887,"identity":"6d580175-2c56-4099-9514-329d1cad8611","added_by":"auto","created_at":"2024-09-02 19:23:45","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":27452,"visible":true,"origin":"","legend":"\u003cp\u003eProvider familiarity with Connecticut Extreme Risk Protection Law\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4743655/v1/cde867b952cad027420294f1.jpg"},{"id":63832289,"identity":"d663a1e0-3cb7-456f-9a0a-edc59be6fa06","added_by":"auto","created_at":"2024-09-02 19:15:45","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":204324,"visible":true,"origin":"","legend":"\u003cp\u003eHow many providers counseling on lethal means to patients at risk for suicide\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4743655/v1/7955ffbbb03fd691cb1599e5.jpg"},{"id":63832290,"identity":"a77000b1-14c9-4fac-b6be-de41cceeb1c7","added_by":"auto","created_at":"2024-09-02 19:15:45","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":178499,"visible":true,"origin":"","legend":"\u003cp\u003eWhat effect does certain psychiatric disorders have on provider likelihood to file an ERPO\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4743655/v1/da74bda0472e535157d951b2.jpg"},{"id":79120543,"identity":"cfa088b7-d3b8-4718-928f-b5429800b8e3","added_by":"auto","created_at":"2025-03-24 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suicides in the United States. Suicide is the 12th leading cause of death in the United States and suicide by firearms are responsible for nearly 54% of cases. \u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/span\u003e, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e One approach to the prevention of suicide by firearm are extreme risk protection orders (ERPO). These laws create a legal process by which a court can order the removal of firearms from individuals who are deemed to be at risk of imminent harm to themselves or others, and when other alternatives for preventing access to the firearms have been exhausted. They are aimed at preventing suicides, as well as mass shootings, and interpersonal gun violence.\u003c/p\u003e \u003cp\u003eConnecticut passed the United States\u0026rsquo; first state-wide extreme risk protection order (ERPO) law in 1999 as a response to a mass shooting the previous year. Despite active concerns about the shooters\u0026rsquo; mental health, there had been no legal means for the police to intervene \u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e. The original Connecticut ERPO law permitted law enforcement to request permission from a judge to temporarily remove and prohibit the future acquisition of firearms for those deemed at \u0026ldquo;extreme risk\u0026rdquo; to themselves or others.\u003c/p\u003e \u003cp\u003eAs of August 2022, 18 additional states, California, Colorado., Delaware, Florida, Hawaii, Illinois, Indiana, Maryland, Massachusetts, Nevada, New Mexico, New Jersey, New York, Oregon, Rhode Island, Vermont, Virginia, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eWashington\u003c/span\u003e, and the District of Columbia in the US have enacted ERPO laws \u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSince its creation, there have been 2,600 warrants granted in Connecticut with suicidality or risk for self-injury as the most common reason for firearm seizure. \u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e It initially resulted in an estimated 1.6% reduction in suicide death that grew to a 13.7% reduction following high-profile mass shootings that resulted in increased utilization of the ERPO law. It is estimated 1 suicide death is prevented per every 10\u0026ndash;20 gun removals. \u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e6 7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHistorically, ERPOs have been primarily initiated by law enforcement. ERPO laws were implemented in King County, Washington in 2017. In its first year, 75 ERPO petitions were filed to limit the purchase or possession of firearms by individuals. Nearly all petitions were filed directly by law enforcement after being informed by family members that the individual was deemed at risk of suicide or harm to others.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e California implemented ERPO laws in 2016. Similar to King County, over 90% of the 1076 petitions between 2016\u0026ndash;2019 petitions were filed by law enforcement. Each year, the total number of petitions filed did increase but great variability exists in the social demographics of the individuals that petitions were filed against and citizen comfort with initiating an ERPO petition.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMore recently, joining Maryland, Hawaii, and the District of Columbia, Connecticut has expanded its ERPO law in 2021 to allow for family members or medical professionals to petition directly to a law enforcement officer or a court to initiate a risk order protection investigation. This change allows for an additional route outside of law enforcement officers. Over 400 petitions were filed in the first 6 months following the expansion of who can file ERPO petitions in Connecticut. The increased efficiency of ERPO petitions has facilitated individuals outside law enforcement to file petitions but has come with administrative burdens and redundancies for those without possession or access to firearms.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAs ERPO petitions can now be more easily filed by those outside of law enforcement, medical providers are in a privileged position to recognize periods of crisis, changes in mental health, or warning signs that an individual is at greater risk to themselves or others \u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe American Medical Association, American Academy of Pediatrics, Psychological Society, and American Academy of Family Physicians all recognize gun violence as a public health crisis. \u003csup\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/span\u003e\u003c/sup\u003e ERPO laws are effective tools healthcare providers can use to help reduce firearm-related suicide and other deaths. Despite available legal means, physicians poorly utilize ERPO laws as only 8% of ERPOs are initiated by clinicians or employers\u003c/p\u003e \u003cp\u003eIn a survey in the state of Maryland, healthcare providers in the departments of psychiatry, pediatrics, and emergency medicine were sent a survey to determine what they knew about the state\u0026rsquo;s ERPO law and what the barriers and facilitators might be.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e The current study is designed to replicate and extend this Maryland study with changes made due to the differences between the laws in these states.\u003c/p\u003e \u003cp\u003eIn addition, we will ask questions about the subjective data that people currently find important in determining the use of ERPO laws so that we can analyze the likelihood that the law is being used in a just and fair way. Swanson (2020) has pointed out ways in which individual racial bias may play a role in subjective decisions to invoke the law. Finally, we included questions about whether a history of neurologic illness plays a role in people\u0026rsquo;s likelihood to invoke ERPO restrictions.\u003c/p\u003e \u003cp\u003eGiven the opportunity to reduce firearm-related suicide, it would be beneficial to better understand healthcare providers\u0026rsquo; attitudes towards ERPO laws and their perceived barriers to using them. This study surveyed medical providers in Connecticut in private practice and at four hospitals to assess knowledge, barriers, and facilitators to utilizing current ERPO laws in their clinical practice.\u003c/p\u003e"},{"header":"Methods","content":" \u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eA total of 114 individuals responded to our survey. Detailed information about the type of practice, area of specialty, and practice location can be seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Years of practice ranged from less than one year to 40 years with a mean of 14.21 (s.d. 5.79). Area of practice for the respondents include providers specializing in pediatrics (37%), psychology (21%), psychiatry (15%), internal medicine (4%), emergency medicine (1%), gastroenterology (1%), OBGYN (1%) and undisclosed (25%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMaterials\u003c/p\u003e \u003cp\u003eThis survey contained 16 questions. It queried the respondents about their current knowledge of the Connecticut ERPO law, perceived barriers to the use of the law and procedures that might make use more likely. We asked if prior diagnoses, such as brain injury, mental illness, or post-traumatic stress disorder, would increase the likelihood of using the law. Finally, we asked respondents about the demographic factors that might go into the likelihood of using ERPO (such as previous history of arrest). The full survey can be viewed in Appendix I. It took approximately 10 minutes to complete.\u003c/p\u003e \u003cp\u003eProcedure\u003c/p\u003e \u003cp\u003e The study was approved by the Institutional Review Board at Trinity College. The survey was created and distributed via Qualtrics software (Qualtrics, 2020). A survey link was sent to all members of the Connecticut Psychological Association via a listserv, and via individual emails to members of the departments of psychiatry, internal medicine, and pediatrics at four regional hospitals (Yale New Haven Hospital, Hartford Hospital, Connecticut Children\u0026rsquo;s Medical Center, and Trinity Health of New England). Despite this targeted distribution, we did receive responses from providers in other departments and chose to keep them in the results. Participants had the option of receiving a \u003cspan\u003e$\u003c/span\u003e10 gift card for their participation. All surveys were completed in 2022.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDescriptive data were collected for all survey questions.\u003c/p\u003e \u003cp\u003eAwareness of ERPO and policies\u003c/p\u003e \u003cp\u003eStrikingly, when asked how familiar the participants were with the Connecticut ERPO law, only one said they were extremely familiar and five said they were very familiar. Seventeen were moderately familiar and 25 slightly familiar. Sixty-one (51% of respondents) reported that they were not at all familiar as seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. None of the respondents were familiar with any specific policies or procedures surrounding the ERPO law at their institution.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePotential need to use an ERPO\u003c/p\u003e \u003cp\u003eThis lack of awareness does not seem to stem from a lack of situations where use of an ERPO could be considered. When asked \u0026ldquo;How often do you estimate you encounter a patient or client that is at extreme risk of violence, or suicide, has access to firearms, and who you would consider for an ERPO?\u0026rdquo; One respondent said daily, one weekly, and four monthly. Sixty respondents said a few times per year and 43 (49%) said never. Only two respondents had ever used an ERPO (one respondent five times and the other respondent once) and both said they found it definitely helpful.\u003c/p\u003e \u003cp\u003eCurrent practice\u003c/p\u003e \u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, about 70% of the respondents reported that they counsel those at risk of suicide about lethal means always or most of the time. Sixteen percent do rarely or never. Of those who do discuss lethal means, 80% discuss access to firearms always or most of the time.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBarriers to using ERPO\u003c/p\u003e \u003cp\u003eThe main barriers reported to using ERPO among these health professionals were concern that it might negatively affect their relationship with the patient (26%), not enough time to make the call and follow up (20%), and not feeling comfortable bringing the police into patient care (26%). Twenty-four percent of respondents marked \u0026ldquo;other\u0026rdquo; and most of the comments indicated that this was a lack of knowledge in how to file a report. When specifically asked if the change in Connecticut\u0026rsquo;s law allowing them to file a petition without directly involving police 26 respondents said this would make them more likely to do so, 52 said this would not change their likelihood, and 15 said it would make them less likely to file a petition.\u003c/p\u003e \u003cp\u003eSuggestions to make it more likely to file an ERPO\u003c/p\u003e \u003cp\u003eRespondents were asked to give the most important way that systems could be changed to make it more likely for them to file an ERPO. The largest number of respondents (83%) felt they needed training. Sixty-eight percent would like to see a trained coordinator at their institution to help with filing and follow through. In addition, respondents would like to have consultation with a legal expert (45%) or a specific internal policy at their institution (47%). See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eImpact of specific diagnoses\u003c/p\u003e \u003cp\u003eIn order to determine if any specific diagnostic categories are more or less likely to lead to a health care provider filing an ERPO we asked about depression, psychosis, traumatic brain injury, bipolar disorder, and post-traumatic stress disorder. Those data can be seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOf the 114 surveyed providers, only two had ever filed ERPOs and more than half of providers were unfamiliar with the existence of ERPOs. Connecticut was the first state to introduce ERPO in 1999 but only recently expanded the ability for medical providers to directly petition to state courthouses in 2021. While the ability to directly file is fairly recent, the unfamiliarity with ERPO demonstrates a need to increase familiarity and awareness among medical providers in Connecticut who can use this tool to restrict firearm access in patients at risk for suicide.\u003c/p\u003e \u003cp\u003eMore than half of medical providers see at least one patient per year who may benefit from ERPO. This number however may be an underestimate. Over 30% of respondents did not regularly discuss lethal means when counseling patients at risk for suicide. Of those who did such counseling, only 60% always asked about access to firearms. This gap is likely attributed to time barrier when addressing all patient needs in the outpatient setting for both pediatric and adult primary care providers. \u003csup\u003e13 14\u003c/sup\u003e. Due to these time barriers, it is not feasible to screen every single patient at very visit. There were many providers who felt their use of an ERPO would be more likely in the case of specific mental health diagnoses or traumatic brain injury. Specific training that provides guidance for which of these diagnoses are more likely to lead to self-harm or harm of others and how to recognize the signs would be an important part of ERPO training. Patients with these diagnoses may better be served and screened for ERPO more regularly as on the one hand their risk for self-harm may be higher than the general population and on the other it would not be appropriate to assume that without adequate screening.\u003c/p\u003e \u003cp\u003eIncreasing ERPO use by medical providers can reduce suicide by firearm mortality in Connecticut. Similar to counseling on lethal means and firearm access, time to call and follow up remains a barrier for provider use of ERPO. Institutions can support providers by investing in ERPO specific trainings, hiring trained coordinators, and providing legal counseling. These requests commonly selected by respondents identifies a desire to engage with ERPO but logistical and time limiting the ability to engage. In addition, it might be helpful for specific data input to flag a reminder about ERPO in electronic medical records. Even with such investment, respondents expressed concern of harming their relationships with patients and actively involving law enforcement into patient care. Increasing familiarity with the ERPO process including the expectations and actions of law enforcement on investigation may help address provider concerns.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study surveyed medical providers in Connecticut assessing their current knowledge of the Connecticut ERPO law, perceived barriers to the use of the law and procedures that might make use more likely. Connecticut providers are largely unaware of ERPO and very few had any experience utilizing this legislative tool as individuals or within their respective institutions. Despite their lack of familiarity, medical providers do encounter patients with higher risk for suicide with access to firearm who may benefit from ERPO. Additionally, the majority of providers do appropriately counsel for and screen for lethal means and firearm access in patients at risk for suicide. Providing institutional support with ERPO specific training and hiring support staff to facilitate ERPO along are ways institutions can support providers to utilize this tool to help prevent suicide by firearm.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis survey was approved by the Yale University and Trinity College Institutional Review Boards. Each participant in the survey provided consent prior to completing the survey and allowed for their responses to be used in this study.\u003c/p\u003e\n\u003cp\u003eThe study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable, no patient data is used in this publication\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSarah Raskin was responsible for creating the original survey and helping write parts of the manuscript. Jim Dodington helped distribute the survey and review the manuscript. Nishant Pandya helped distribute the survey, write the manuscript, and engage in data analysis. Joshua Jacob helped engage in data analysis of survey response. Each author engaged in editing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKlein, Joshua, et al. \u0026ldquo;Firearms: The Leading Cause of Years of Potential Life Lost.\u0026rdquo; \u003cem\u003eTrauma Surgery \u0026amp; Acute Care Open\u003c/em\u003e, vol. 7, no. 1, 1 Feb. 2022, p. e000766, tsaco.bmj.com/content/7/1/e000766.citation-tools, https://doi.org/10.1136/tsaco-2021-000766. Accessed 11 May 2022.\u003c/li\u003e\n\u003cli\u003eGondi, Suhas, et al. \u0026ldquo;Extreme Risk Protection Orders.\u0026rdquo; \u003cem\u003eAcademic Medicine\u003c/em\u003e, vol. 94, no. 11, Nov. 2019, pp. 1649\u0026ndash;1653, https://doi.org/10.1097/acm.0000000000002935.\u003c/li\u003e\n\u003cli\u003eKivisto, Aaron J, and Peter Lee Phalen. \u0026ldquo;Effects of Risk-Based Firearm Seizure Laws in Connecticut and Indiana on Suicide Rates, 1981-2015.\u0026rdquo; \u003cem\u003ePsychiatric Services (Washington, D.C.)\u003c/em\u003e, vol. 69, no. 8, 2018, pp. 855\u0026ndash;862, www.ncbi.nlm.nih.gov/pubmed/29852823, https://doi.org/10.1176/appi.ps.201700250.\u003c/li\u003e\n\u003cli\u003eHeflin, Justin. \u0026ldquo;Are Red Flag Laws a Green Light to Save Lives?\u0026rdquo; \u003cem\u003essrn.com\u003c/em\u003e, 19 \u003cbr /\u003e July 2022, papers.ssrn.com/sol3/papers.cfm?abstract_id=4167250. Accessed 27 Sept. 2022.\u003c/li\u003e\n\u003cli\u003eKeating, Christopher. \u0026ldquo;Gov. Lamont Touts Expansion of Connecticut\u0026rsquo;s \u0026ldquo;Red Flag\u0026rdquo; Gun Law \u0026ndash; Used 2,600 Times \u0026ndash; as Lawmakers Weigh National Law.\u0026rdquo; \u003cem\u003eHartford Courant\u003c/em\u003e, 14 June 2022, www.courant.com/2022/06/14/gov-lamont-touts-expansion-of-connecticuts-red-flag-gun-law-used-2600-times-as-lawmakers-weigh-national-law/. Accessed 17 Apr. 2023.\u003c/li\u003e\n\u003cli\u003eNielsen, David. \u0026ldquo;Disarming Dangerous Persons: How Connecticut\u0026rsquo;s Red Flag Law Saves Lives without Jeopardizing Constitutional Protections.\u0026rdquo; \u003cem\u003eQuinnipiac Health Law Journal\u003c/em\u003e, vol. 23, 2020, p. 253, \u003cbr /\u003eorg/HOL/LandingPage?handle=hein.journals/qhlj23\u0026amp;div=16\u0026amp;id=\u0026amp;page=. Accessed 17 Apr. 2023.\u003c/li\u003e\n\u003cli\u003eKlein, Joshua, et al. \u0026ldquo;Firearms: The Leading Cause of Years of Potential Life Lost.\u0026rdquo; \u003cem\u003eTrauma Surgery \u0026amp; Acute Care Open\u003c/em\u003e, vol. 7, no. 1, 1 Feb. 2022, p. e000766, tsaco.bmj.com/content/7/1/e000766.citation-tools, https://doi.org/10.1136/tsaco-2021-000766. Accessed 11 May 2022.\u003c/li\u003e\n\u003cli\u003eFrattaroli, Shannon, et al. \u0026ldquo;Extreme Risk Protection Orders in King County, Washington: The Epidemiology of Dangerous Behaviors and an Intervention Response.\u0026rdquo; \u003cem\u003eInjury Epidemiology\u003c/em\u003e, vol. 7, no. 1, 22 July 2020, https://doi.org/10.1186/s40621-020-00270-1. Accessed 3 Oct. 2021.\u003c/li\u003e\n\u003cli\u003ePallin, Rocco, et al. \u0026ldquo;Assessment of Extreme Risk Protection Order Use in California from 2016 to 2019.\u0026rdquo; \u003cem\u003eJAMA Network Open\u003c/em\u003e, vol. 3, no. 6, 18 June 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7303810/, https://doi.org/10.1001/jamanetworkopen.2020.7735. Accessed 5 Nov. 2020.\u003c/li\u003e\n\u003cli\u003eAltmari, Dave, et al. \u0026ldquo;CT Police: Updated \u0026ldquo;Red Flag\u0026rdquo; Law Used Largely for Suicide Threats.\u0026rdquo; \u003cem\u003eJournal Inquirer\u003c/em\u003e, 5 Dec. 2022, journalinquirer.com/crime_and_courts/ct-police-updated-red-flag-law-used-largely-for-suicide-threats/article_d32be3be-749b-11ed-a129-e30a1d027004.html. Accessed 17 Apr. 2023.\u003c/li\u003e\n\u003cli\u003eHollo A, VanderStoep A, Frattaroli S. Physicians\u0026rsquo; perspectives on Extreme Risk Protection Orders (ERPOs) in the clinical setting: Challenges and opportunities for gun violence prevention. West JC, ed. \u003cem\u003ePLOS ONE\u003c/em\u003e. 2022;17(9):e0274489. doi:https://doi.org/10.1371/journal.pone.0274489\u003c/li\u003e\n\u003cli\u003eFrattaroli S, Hoops K, Irvin NA, et al. Assessment of Physician Self-reported Knowledge and Use of Maryland\u0026rsquo;s Extreme Risk Protection Order Law. \u003cem\u003eJAMA Network Open\u003c/em\u003e. 2019;2(12):e1918037. doi:https://doi.org/10.1001/jamanetworkopen.2019.18037\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"13\"\u003e\n\u003cli\u003ePorter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the Time Needed to Provide Adult Primary Care. \u003cem\u003eJournal of General Internal Medicine\u003c/em\u003e. Published online July 1, 2022. doi:https://doi.org/10.1007/s11606-022-07707-x\u003c/li\u003e\n\u003cli\u003eDiamond, Guy S., et al. \u0026ldquo;Attitudes, Practices, and Barriers to Adolescent Suicide and Mental Health Screening.\u0026rdquo; \u003cem\u003eJournal of Primary Care \u0026amp; Community Health\u003c/em\u003e, vol. 3, no. 1, 8 Nov. 2011, pp. 29\u0026ndash;35, https://doi.org/10.1177/2150131911417878.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"injury-epidemiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inep","sideBox":"Learn more about [Injury Epidemiology](https://injepijournal.biomedcentral.com)","snPcode":"40621","submissionUrl":"https://submission.nature.com/new-submission/40621/3","title":"Injury Epidemiology","twitterHandle":"@InjuryEpi","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4743655/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4743655/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eExtreme Risk Protection Orders (ERPOs) are a legislative tool that temporarily restrict firearm access in patients with higher suicide risk. ERPOs have reduced firearm suicide rates in Connecticut and are estimated to save one life per 10 orders filed. Connecticut medical providers can initiate this process, but less than 8% of 2020 ERPOs were filed by providers. This survey assesses provider knowledge and attitudes towards use of ERPOs.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study electronically surveyed providers from six hospitals regarding their current knowledge of the Connecticut ERPO law, perceived barriers to the use of the law and procedures that might make use more likely.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e114 providers completed the survey in 2022. 66 (57.8%) providers encountered more than 1 patient per year at risk for suicide with firearm access. Only 2 providers had ever initiated an ERPO, but both found it extremely helpful. Only 1 provider was extremely familiar with ERPO while 91 (83.4%) were not familiar. Barriers to using ERPO include negatively impacting the patient relationship, and not enough time to call and follow up. ERPO specific training, and trained on-site coordinators to help file and follow through were ways to encourage to ERPO utilization.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe majority of providers encounter at least one patient annually who may benefit from an ERPO. However, providers are largely unfamiliar with ERPO and the filing process. Time cost is the greatest barrier to its utilization. Provider training and trained coordinators to process ERPO were the two most requested supports to encourage providers to initiate ERPOs.\u003c/p\u003e","manuscriptTitle":"Connecticut providers knowledge and attitudes towards use of extreme risk protection orders","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-02 19:15:40","doi":"10.21203/rs.3.rs-4743655/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-06T20:08:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-01T17:13:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-30T09:33:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Injury Epidemiology","date":"2024-07-15T14:42:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"injury-epidemiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"inep","sideBox":"Learn more about [Injury Epidemiology](https://injepijournal.biomedcentral.com)","snPcode":"40621","submissionUrl":"https://submission.nature.com/new-submission/40621/3","title":"Injury Epidemiology","twitterHandle":"@InjuryEpi","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1ca3ca47-ebca-40fe-a4ff-749843253fe1","owner":[],"postedDate":"September 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-24T16:04:13+00:00","versionOfRecord":{"articleIdentity":"rs-4743655","link":"https://doi.org/10.1186/s40621-025-00565-1","journal":{"identity":"injury-epidemiology","isVorOnly":false,"title":"Injury Epidemiology"},"publishedOn":"2025-03-19 15:58:16","publishedOnDateReadable":"March 19th, 2025"},"versionCreatedAt":"2024-09-02 19:15:40","video":"","vorDoi":"10.1186/s40621-025-00565-1","vorDoiUrl":"https://doi.org/10.1186/s40621-025-00565-1","workflowStages":[]},"version":"v1","identity":"rs-4743655","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4743655","identity":"rs-4743655","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}