• Research Highlight
Suicide is a leading cause of death in the United States, but opportunities exist to intervene and save lives. Many people who die by suicide visit an emergency room in the weeks or months beforehand, making them critical places to reach people at risk. Addressing suicide risk in these fast-paced, urgent care settings is challenging, but research funded by the National Institute of Mental Health showed it is possible. The study, known as the Emergency Department Safety Assessment and Follow-up 2 (ED-SAFE 2) significantly reduced suicidal behaviors among people at risk for suicide.
What is the ED-SAFE suicide risk intervention?
ED-SAFE is a randomized clinical trial designed to improve suicide risk screening and detection in emergency departments. The trial differs from similar studies because routine clinical staff, rather than researchers, deliver the suicide risk intervention. This approach increases the likelihood that suicide prevention strategies can be reliably implemented and maintained in the real world. ED-SAFE is also the largest practical clinical trial of best practices related to suicide in emergency departments.
He original ED-SAFE study showed that universal suicide risk screening and a Multicomponent intervention for adults at risk of suicide. could be implemented in emergency services. The intervention consisted of safety planning to help patients identify early warning signs and access resources and support, and was followed by telephone communication after leaving care. It doubled the number of patients identified as at risk for suicide and reduced subsequent suicidal behaviors by 20%.
What did the researchers do in the current study?
The current study was the next step in this research effort. Edwin Boudreaux, Ph.D. , from the University of Massachusetts Chan School of Medicine, led a multidisciplinary team to examine whether a package of suicide prevention efforts focused on improving clinical workflow across the department could reduce suicide-related behaviors. Having established that the suicide risk intervention was feasible and effective, the researchers wanted to see if it could be improved further using a scientific approach focused on quality improvement.
The multisite study was conducted in eight demographically diverse emergency departments in the United States. Participants were adults seen for emergency care between January 2014 and April 2018.
Quality improvement experts and suicide prevention specialists trained site staff to assess their current suicide-related workflow, identify gaps and opportunities for growth, and design solutions to incrementally improve care. Clinical staff implemented these efforts in a phased manner in three 12-week phases.
- Initial phase: Continue the enhanced suicide prevention efforts adopted in the original ED-SAFE study, including universal suicide risk screening.
- Implementation phase: Introduce improvements in suicide-related care, including collaborative safety planning between clinicians and patients to help manage future suicidal crises.
- Maintenance phase: Maintain progress in the implementation phase, periodically evaluate workflow and make continuous improvements in care.
During each month of the study, researchers randomly selected 25 patients at each site from the pool of all patients who tested positive on a validated suicide risk screener. Although all patients at risk for suicide received the ED-SAFE suicide risk intervention, researchers reviewed the medical records of only selected patients to see if they received care for suicidal ideation or suicide attempt or if they died by suicide within the 6 months. of your initial emergency visit.
Did ED-SAFE 2 improve suicide-related care?
Analyzing data from nearly 7,000 medical records, researchers observed a significant change in suicide risk across phases of the study. The likelihood of suicidal ideation, attempts, or behavior in the 6 months following an emergency visit was significantly lower during the maintenance phase compared to the baseline phase, reflecting a 30% decrease. These results showed that implementation of best practices for suicide care, including universal screening and collaborative safety planning, and their ongoing evaluation effectively improved suicide-related outcomes after emergency discharge.
The current investigators improved on the suicide risk reduction observed in the original ED-SAFE study achieved through comprehensive suicide prevention efforts. They did this by adding quality improvement methods to help emergency department staff regularly monitor and adjust their clinical practices over time. These findings highlight the benefits of incorporating brief anti-suicide interventions into routine emergency care to save lives. Importantly, clinical staff in real-world emergency departments could feasibly and consistently provide this care. If applied more widely, these suicide prevention strategies could improve clinical care, decrease the risk of suicide, and save lives.
If you or someone you know is struggling or having suicidal thoughts, call or text the Suicide and Crisis Lifeline 988 at 988 or chat on 988lifeline.org. In life-threatening situations, call 911.
Reference
Boudreaux, ED, Larkin, C., Sefair, AV, Ma, Y., Li, Y.F., Ibrahim, AF, Zeger, W., Brown, GK, Pelletier, L., Miller, I., and ED-SAFE investigators 2 . (2023). Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster randomized clinical trial. JAMA Psychiatry, 80(7), 665-674. https://doi.org/10.1001/jamapsychiatry.2023.1304
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