The following is a summary of “Effect of an Emergency Department Process Improvement Package on Suicide Prevention: The ED-SAFE 2 Cluster Randomized Clinical Trial,” published in the May 17, 2023 issue of Psychiatry by Boudreaux, et al.

For a study, researchers sought to determine if an emergency department (ED) process improvement package, with a focus on improving the implementation of collaborative safety planning, reduces subsequent suicide-related behaviors.

The study, called the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial, was a stepped-wedge cluster randomized clinical trial conducted in 8 EDs across the US. It utilized an interrupted time series design with three 12-month sequential phases: baseline, implementation, and maintenance. A random sample of 25 patients per month per site aged 18 years and older who screened positive on the Patient Safety Screener, a validated suicide risk screener, were included. Data were collected from patients seeking care between January 2014 and April 2018, and the data analysis was conducted from April to December 2022. Each site underwent lean training and established a continuous quality improvement (CQI) team to assess the existing suicide-related workflow in the ED, identify areas for improvement, and implement strategies to enhance care. The sites aimed to increase universal suicide risk screening and implement collaborative safety planning for patients at risk of suicide who were discharged from the ED. Site teams received coaching from experienced engineers in lean CQI and suicide prevention specialists. The primary outcome was a composite measure consisting of death by suicide or suicide-related acute healthcare visits within a 6-month follow-up period.

A total of 2,761 patient encounters were included in the analysis across the three phases. Of these, 1,391 (50.4%) were male, and the mean age was 37.4 (14.5) years. Within the 6-month follow-up, 546 patients (19.8%) exhibited the suicide composite outcome (9 [0.3%] died by suicide and 538 [19.5%] had a suicide-related acute healthcare visit). There was a significant difference in the suicide composite outcome between the three phases (baseline: 216 of 1,030 [21%], implementation: 213 of 967 [22%], maintenance: 117 of 764 [15.3%]; P = .001). The adjusted odds ratios during the maintenance phase were 0.57 (95% CI, 0.43-0.74) compared with baseline and 0.61 (0.46-0.79) compared with the implementation phase, indicating a reduction of 43% and 39%, respectively, in the risk of the suicide composite outcome.

The implementation of a department-wide change in suicide-related practices, including the use of a safety plan intervention, through continuous quality improvement methods resulted in a significant decrease in suicide behaviors during the maintenance period of the study. This study highlights the effectiveness of such interventions in reducing suicide-related outcomes in the ED setting.

Source: jamanetwork.com/journals/jamapsychiatry/article-abstract/2804647