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The implementation of continuous quality improvement (CQI) teams focused on establishing new approaches and training for suicide intervention in the emergency department (ED) led to significant reductions in suicide behaviors during the maintenance phase of the cluster randomized ED-SAFE 2 trial.

Across three 12-month phases, EDs that implemented CQI methods saw a significant difference in a suicide composite outcome of death by suicide or suicide-related acute healthcare visits: 21% in the baseline phase and 22% in the implementation phase versus 15.3% during the maintenance phase (P=0.001), reported Edwin D. Boudreaux, PhD, of the University of Massachusetts Chan Medical School in Worcester, and co-authors.

The adjusted odds ratios of risk of the suicide composite outcome during the maintenance phase was 0.57 (95% CI 0.43-0.74) compared with baseline and 0.61 (95% CI 0.46-0.79) compared with the implementation phase, they noted in .

While the reduction in suicide outcomes was not shown during the implementation phase, they did see some improvements over the course of the 12-month period, suggesting slower ramp-up of the CQI team approach in this phase.

"With a continuous quality improvement type of approach, we were able to improve the suicide composite outcome ... but the effect was sort of a delayed effect, it really wasn't measurable or pronounced until the third phase of the trial," Boudreaux told 乌鸦传媒.

"It's not like a medication where you just deliver the medication and the patient either has the medicine or doesn't have the medicine," he added. "This is more of an iterative cycle of process to improve the care, and specifically what we were focused on was trying to improve the safety planning and lethal means restriction counseling."

Boudreaux explained that the safety planning focus involved speaking with the patient about their mental health and creating a plan to reduce the person's access to lethal means, such as firearms and ammunition. The approach was designed to help patients remove themselves from potentially dangerous situations, so they can continue to seek appropriate mental health therapy.

However, he noted that the implementation of the safety planning approach was slow and difficult at times for many of the ED sites involved in the trial.

"The actual intervention delivery itself was very labor intensive. It was very, very difficult to change the practices of clinicians," he said. "In this case, the most important reasons are that the clinicians who are tasked with delivering interventions are already overloaded."

One reason for this overload is a shortage of behavioral health providers in EDs, but these interventions also require more time than the typical ED physician can spend with one patient, Boudreaux said, adding that it takes time to conduct the patient evaluation, make a safety plan, and then decide to discharge or admit the patient.

"In the grand scheme of things, safety planning is a brief intervention," he noted. "It can take anywhere from 20 to 45 minutes to build a good safety plan. So when you look at the things we have to try to do to prevent people from [attempting suicide], that's a pretty brief intervention, but that's still a lot [of time] for an emergency department. And so training clinicians to do it, and then the amount of time it took was a real challenge."

In addition to training, each ED was expected to increase universal suicide risk screenings and conduct safety planning with patients at risk of suicide who were ready for discharge.

"This idea of a safety plan, where you come up with a plan with the patient in a collaborative way, then you reduce their access to lethal means, this is kind of basic building blocks of suicide prevention," Boudreaux said. "And that's part of what a clinician has to do, is become comfortable with being able to assess that and being able to manage suicide risk."

The ED-SAFE 2 (Emergency Department Safety Assessment and Follow-up Evaluation 2) study was conducted across eight U.S. EDs from January 2014 to April 2018. Each ED site received training and the resources needed to create a CQI team.

The study included 2,761 patient encounters across the three study phases; mean patient age was 37.4, 50.4% were men, and 71.5% were white. A majority of the patients (89.4%) had depression.

During the 6-month follow-up, 19.8% of patients exhibited the suicide composite outcome, including 0.3% who died by suicide and 19.5% who had an acute healthcare visit related to suicide.

Boudreaux and team noted that they were unable to detect differences in deaths by suicide or attempts, "an unavoidable problem in most suicide research because of the rarity of suicide death."

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