Suicide is the 12^th leading cause of death in the United States, and the 3^rd leading cause of death for people ages 15-24.¹ More than 4% of all emergency department visits are attributed to psychiatric conditions² and 3–8% of all patients have suicidal ideation when screened in the ED.³ In addition, there are approximately 420,000 ED visits every year for intentional self-harm.⁴ The emergency department (ED) is an ideal place to implement interventions designed to reduce suicidal behavior. However, there have been few trials conducted in clinical settings to reduce suicidal behavior.

Brown University and Butler Hospital created the Emergency Department Safety Assessment and Follow-Up Evaluation (ED-SAFE) innovation to reduce suicidal behavior among patients who present to the ED with suicidal ideation. They published the results from the initial clinical trial, ED-SAFE 1, a multicenter study of eight EDs that assessed the ED-SAFE innovation. The ED-SAFE 1 innovation provided participants with a standard universal suicide risk screening (any standard universal screening tool can be applied) plus a secondary suicide risk screening by an ED physician. It also included discharge resources (including a self-administered safety plan) and post-ED telephone calls based on the Coping with Long Term Active Suicide Program (CLASP)⁵ focused on reducing suicide risk.⁶ In ED-SAFE 1, there was a 5% absolute reduction in suicide attempts between the treatment as usual and intervention phases.⁶ During the intervention phase, participants had 30% fewer total suicide attempts than participants in the treatment as usual phase.⁶ The study found that universal screening alone did not reduce suicide attempts, and therefore, the reduction is most likely tied to the innovation itself.⁶

The ED-SAFE 2 trial implemented two key elements that built on ED-SAFE 1: a Lean continuous quality improvement (CQI) approach and collaborative safety planning between patients and caregivers. Data were collected from 2014 to 2018 and analyzed from April 2022 to December 2022.³ The trial included three phases: baseline (retrospective), implementation, and maintenance.³ During implementation, each of the eight EDs formed a Lean team consisting of staff, management, information technology (IT), patient safety, and quality assurance members. The teams attended a one-day training and monthly followup meetings on Lean principles with an industrial engineering Lean expert with doctoral training.³ The teams evaluated their workflows, identified gaps in care, designed solutions to close these gaps, and oversaw the implementation of ED-SAFE 2.³ Additionally, the innovators implemented collaborative safety planning. Collaborative safety planning involved six-step safety plans created by clinicians and patients to help patients manage their individual suicidal crises.³ In addition to these changes, teams were expected to increase the number of suicide risk screenings for patients.³ The primary outcome measured was a suicide composite measure. The measure included 1) an ED visit or hospitalization due to suicidal ideation/behavior or 2) death by suicide in the six months after the index visit.³ The composite measure improved over the three phases (baseline by 21%; implementation by 22%; and maintenance by 15.3%; p=.001).³

Although the National Action Alliance for Suicide Prevention and The Joint Commission both identify EDs as an essential setting for suicide prevention, suicide prevention interventions in EDs remain underdeveloped and understudied.³ The Joint Commission identifies suicide within 72 hours of discharge from a healthcare setting that provides around-the-clock care, including the ED, as a sentinel event (a patient safety event that results in death, permanent harm, or severe temporary harm).³

When implementing this innovations, organizations should consider the following:

• Buy-in from hospital leadership and all staff involved in the continuum of care.
• Staff to conduct post-visit phone calls.
• Physicians willing to conduct secondary suicide prevention screenings.
• Physicians to serve as treatment advisers for the post-visit phone calls.
• Time and resources to train staff on the intervention.
• Staff to conduct data analysis.
• Leaders to train multidisciplinary teams on the Lean CQI strategy.
• Staff to participate in the Lean teams and create collaborative safety plans with patients.
• Clinicians with the bandwidth to create collaborative safety plans with patients. These clinicians must attend at least one training related to collaborative safety planning and they must demonstrate competency in collaborative safety planning through observation or other work samples.
• Staff to champion the maintenance stage of the innovation.
• Staff to measure and report results: at least one person with data related skills who can use the EHR for reporting per site; 40-80 hours are needed as an initial investment for setting up reports followed by one to two hours per month after the initial investment per site.

The innovator has received regular inquiries from other EDs about their ED-SAFE innovation. Much of the ED-SAFE innovation aligns with the Zero Suicide model, an emerging model for suicide prevention in healthcare.⁷

This pilot study aimed to enhance the formal reporting of incivility events directed at nursing staff by patients and visitors. The CIVIC Duty program included an educational session for nursing staff to improve their ability to identify incivility behaviors and understand organizational policies, along with nurse leader support to promote the use of the electronic incident reporting system for such incidents.