• Research Highlights
Suicide is the leading cause of death in the United States, but there are opportunities to intervene and save lives. Many people who die by suicide visit an emergency room in the weeks or months before, 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 has shown that it is possible. The study, known as the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) significantly reduced suicidal behaviors among those at risk of suicide.
What is the ED-SAFE Suicide Risk Intervention?
ED-SAFE is a randomized clinical trial designed to improve screening and detection of suicidal risk in emergency department settings. The trial differs from similar studies because routine clinical staff – rather than researchers – delivered 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 suicide-related best practices in emergency departments.
The original ED-SAFE study showed that universal suicide risk screening and one multicomponent intervention for adults at risk of suicide could be applied to emergency departments. The intervention consisted of safety planning to help patients identify early warning signs and access resources and support and was followed by telephone follow-up after discharge. It doubled the number of patients identified as at risk of suicide and reduced subsequent suicidal behaviors by 20%.
What did the researchers do in the current study?
The present study was the next step in this research effort. Edwin Boudreaux, Ph.D. , at the University of Massachusetts Chan School of Medicine, led a multidisciplinary team in examining whether a package of suicide prevention efforts focused on improving department-wide clinic workflow 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 further improved using a scientific approach focused on quality improvement.
The multisite study was conducted in eight demographically diverse emergency departments across the United States. Participants were adults seen for emergency care between January 2014 and April 2018.
Quality improvement experts and suicide prevention specialists trained staff at the facilities to assess their current suicide workflow, identify gaps and opportunities for growth, and design solutions to incrementally improve care. Clinical staff implemented these efforts in a staggered fashion over three 12-week phases.
- Basic phase: Continuation of the enhanced suicide prevention efforts adopted in the original ED-SAFE study, including universal suicide risk screening
- Implementation phase: Introducing improvements in suicide-related care, including collaborative safety planning between clinicians and patients to manage future suicidal crises
- Maintenance phase: Sustaining gains from the implementation phase, regular assessment of workflow and continuous improvements in care
During each month of the study, the researchers randomly selected 25 patients in each region from the pool of all patients who tested positive on a validated suicide risk screening. Although all patients found to be at risk of 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 attempt or died by suicide within 6 months of baseline. their urgent visit.
Did ED-SAFE 2 improve suicide-related care?
Analyzing data from nearly 7,000 medical records, the researchers observed a significant change in suicide risk during the study phases. The likelihood of suicidal ideation, attempt, or behavior at 6 months after an emergency visit was significantly lower during the maintenance phase compared to the baseline phase, reflecting a 30% reduction. These results showed that implementing best practices for suicide care, including universal screening and collaborative safety planning, and evaluating them on an ongoing basis effectively improved suicide-related outcomes after emergency discharge.
The current researchers improved on the reduction in suicide risk seen in the original ED-SAFE study achieved using comprehensive suicide prevention efforts. They did so by adding quality improvement methods to help emergency department staff regularly monitor and adapt their clinical practices over time. These findings highlight the life-saving benefits of incorporating brief suicide interventions into routine emergency care. Importantly, clinical staff in real-world emergency departments could provide this care feasibly and consistently. If more widely implemented, these suicide prevention strategies could enhance clinical care, reduce suicide risk, and save lives.
If you or someone you know is struggling or having suicidal thoughts, call or text the 988 Suicide and Crisis Lifeline at 988 or chat at 988lifeline.org. In life-threatening situations, call 911.
Report
Boudreaux, ED, Larkin, C., Sefair, AV, Ma, Y., Li, YF, Ibrahim, AF, Zeger, W., Brown, GK, Pelletier, L., Miller, I. & ED-SAFE 2 Investigators . (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
