CoChat
Sign Up
Cited by 46Suicide and Self-Harm StudiesEmergency and Acute Care StudiesPsychiatric care and mental health services

Effect of an Emergency Department Process Improvement Package on Suicide Prevention: The ED-SAFE 2 Cluster Randomized Clinical Trial

Open access
Boudreaux, Edwin D., Larkin, Celine, Vallejo Sefair, Ana, Ma, Yunsheng, Li, You Fu, Ibrahim, Ameer F., Zeger, Wesley, Brown, Gregory K. +16 more·2023·JAMA Psychiatry
DOI 10.1001/jamapsychiatry.2023.1304PMC PMC10193260
Open this paper in CoChat — free accountOpen PDF

Abstract

Importance: Suicide is a leading cause of deaths in the US. Although the emergency department (ED) is an opportune setting, ED-initiated interventions remain underdeveloped and understudied. Objective: To determine if an ED process improvement package, with a subfocus on improving the implementation of collaborative safety planning, reduces subsequent suicide-related behaviors. Design, Setting, and Participants: The Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial, a stepped-wedge cluster randomized clinical trial conducted in 8 EDs across the US, used 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 18 years and older who screened positive on the Patient Safety Screener, a validated suicide risk screener, were included. The primary analyses focused on those who were discharged from the ED, while secondary analyses focused on all patients who screened positive, regardless of disposition. Data were collected on patients who presented for care from January 2014 to April 2018, and data were analyzed from April to December 2022. Interventions: Each site received lean training and built a continuous quality improvement (CQI) team to evaluate the current suicide-related workflow in the ED, identify areas of improvement, and implement efforts to improve. Each site was expected to increase their universal suicide risk screening and implement collaborative safety planning for patients at risk of suicide who were discharged home from the ED. Site teams were centrally coached by engineers experienced in lean CQI and suicide prevention specialists. Main Outcomes and Measures: The primary outcome was a composite comprising death by suicide or suicide-related acute health care visits, measured over a 6-month follow-up window. Results: Across 3 phases, 2761 patient encounters were included in the analyses. Of these, 1391 (50.4%) were male, and the mean (SD) age was 37.4 (14.5) years. A total of 546 patients (19.8%) exhibited the suicide composite during the 6-month follow-up (9 [0.3%] died by suicide and 538 [19.5%] of a suicide-related acute health care visit). A significant difference was observed for the suicide composite outcome between the 3 phases (baseline, 216 of 1030 [21%]; implementation, 213 of 967 [22%]; maintenance, 117 of 764 [15.3%]; P = .001). The adjusted odds ratios of risk of the suicide composite during the maintenance phase was 0.57 (95% CI, 0.43-0.74) compared with baseline and 0.61 (0.46-0.79) compared with the implementation phase, which reflect a 43% and 39% reduction, respectively. Conclusions and Relevance: In this multisite randomized clinical trial, using CQI methods to implement a department-wide change in suicide-related practices, including the implementation of a safety plan intervention, yielded a significant decrease in suicide behaviors in the maintenance period of the study. Trial Registration: ClinicalTrials.gov Identifier: NCT02453243

Integrity signals

Registry

Crossref · 10.1001/jamapsychiatry.2023.1304

Cites

32 of 32 references verified0 citation errors · 0 not checkable

Statistics

Recomputing p-values needs the paper’s full text.

Claims the paper makes

The text we found for this paper looks like another document, so its claims and self-check weren’t run. The registry and citation checks still apply.

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The text we found for this paper looks like another document, so the self-check wasn’t run.

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Zwald ML, Holland KM, Annor FB, Kite-Powell A, Sumner SA, Bowen DA, et al. Syndromic surveillance of suicidal ideation and self-directed violence -United States, January 2017-December 2018. Morbidity and Mortality Weekly Report. 2020;69:103-8.

Cited by

Sorted by citations

Related

Authors
Boudreaux, E. D., Larkin, C., Vallejo Sefair, A., Ma, Y., Li, Y. F., Ibrahim, A. F., Zeger, W., Brown, G. K., Pelletier, L., Miller, I., ED-SAFE 2 Investigators, Arias, S. A., Betz, M. E., Boyle, K., Camargo, C. A., Caterino, J., Eastin, C., Johnson, S., LoVecchio, F., Manton, A., Mattocks, K., Stanley, B., Uebelacker, L., & Wang, B.
Affiliations
  • University of Massachusetts Chan Medical School (US)
  • Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester
  • Independent consultant, Boylston, Massachusetts
  • University of Nebraska Medical Center (US)
  • University of Pennsylvania (US)
  • Connecticut Children's Medical Center (US)
  • Brown University (US)
  • for the ED-SAFE 2 Investigators
Corresponding author
Boudreaux, Edwin D.
ORCID
Venue
JAMA Psychiatry
Publisher
American Medical Association (AMA)
Published
2023-07-01
Volume
80
Issue
7
Pages
665
ISSN
2168-622X (ISSN-L)
DOI
10.1001/jamapsychiatry.2023.1304
PMC
PMC10193260
OpenAlex
W4376872135
Semantic Scholar
ac0ac9d8c929f2bbafc79c7018387875d6948e84
Cited by
46
References
32
Citations by year
2026: 12 · 2025: 22 · 2024: 10 · 2023: 2
FWCI
13.41
Type
journal article
Language
en
Open access
Locations
  • JAMA Psychiatry (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
National Institute of Mental Health (R01MH106726, P50MH129701)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
  • Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
Keywords
suicide prevention, emergency department, suicide risk screening, process improvement, suicide mortality, workflow improvement, discharge planning, stepped-wedge cluster randomized trial, interrupted time series
MeSH terms
Suicide Prevention, Adult, Emergency Service, Hospital, Female, Humans, Male, Suicide, Suicidal Ideation

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review