• Bibtex: @boudreaux2023
  • Bibliography: 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. (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

Example citation

Enhanced screening and safety planning reduced suicide-related events by 30% after visits to emergency departments

My notes

  • Large variation in TAU in one of their previous trials (n = 497). 40% were asked about lethal means, none had safety plan, <10% had a scheduled session with a behavioral health specialist.
  • Each emergency department had to implement screening and Safety Planning
  • The main composite outcome was (1) another ED visit or hospitalization related to suicidal ideation or attempt, or (2) death by suicide within 6 months of the index visit.
    • 2761 encounters in total, and 546 (19.8%) had one suicide-related event. 9 of these were suicides.
      • 21% during baseline phase
      • 22% during implementation phase
      • 15% during maintenance phase
  • Relative risk reduction of 30% from baseline to maintenance


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.To determine if an ED process improvement package, with a subfocus on improving the implementation of collaborative safety planning, reduces subsequent suicide-related behaviors.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.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.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.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.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.ClinicalTrials.gov Identifier: NCT02453243 PDF: boudreaux_2023_effect_of_an_emergency_department_process_improvement_package_on_suicide.pdf