Quality Improvement Program reduces Suicide Outcomes in the ED

In the maintenance phase of the trial, there was a significantly lower incidence of suicide behaviors as a result of employing continuous quality improvement (CQI) methodologies to achieve a department-wide change in suicide-related practices, including the deployment of a safety plan intervention, says an article published in Journal of American Medical Association.

Despite being a suitable site, the emergency department (ED)-initiated interventions are still immature and under researched. In order to ascertain if an ED process improvement package, with a sub focus on enhancing the execution of collaborative safety planning, lowers subsequent suicide-related behaviors, Edwin Boudreaux and colleagues conducted this study.

The Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) experiment utilized a time-series interrupted design with three 12-month sequential phases: implementation, baseline, and maintenance. It was a stepped-wedge cluster randomized clinical trial performed in eight EDs throughout the US. Patients who tested positive on the Patient Safety Screener, a validated suicide risk screener, who were 18 years of age and older made up a random sample of 25 patients each month per location. Secondary analyses focused on all patients who tested positive, regardless of disposition, whereas primary analysis focused on those who were released from the ED. Data on patients who sought medical attention between January 2014 and April 2018 were gathered, and from April to December 2022, the data were analyzed.

To assess the present process linked to suicide in the ED, identify opportunities for improvement, and carry out improvement activities, each hospital created a continuous quality improvement team and underwent lean training. Each site was required to enhance the number of patients at risk for suicide who receive home discharge from the ED and to adopt collaborative safety planning. 

The key findings of this study were:

1. 2761 patient contacts from 3 periods were included in the analysis.

2. The mean (SD) age of these was 37.4 (14.5) years, and there were 1391 (50.4%) males.

3. During the 6-month follow-up, a total of 546 patients (19.8%) displayed the suicide composite.

4. Between the three stages, there was a significant change in the suicide composite result (baseline: 216 of 1030 [21%]; implementation: 213 of 967 [22%]; maintenance: 117 of 764 [15.3%]; P =.001).

5. The adjusted odds ratios of the suicide composite risk during the maintenance phase were 0.57 compared to baseline and 0.61 (0.46-0.79) compared to the implementation phase, respectively, and they indicate a 43% and 39% reduction.

Reference: 

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., Arias, S. A., Betz, M. E., Boyle, K., … Manton, A. (2023). Effect of an Emergency Department Process Improvement Package on Suicide Prevention. In JAMA Psychiatry. American Medical Association (AMA). https://doi.org/10.1001/jamapsychiatry.2023.1304