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ImportanceSuicide 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.ObjectiveTo 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 ParticipantsThe 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.InterventionsEach 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 MeasuresThe primary outcome was a composite comprising death by suicide or suicide-related acute health care visits, measured over a 6-month follow-up window.ResultsAcross 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 RelevanceIn 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 RegistrationClinicalTrials.gov Identifier: NCT02453243

Objectives: To determine if an emergency department Early Goal Directed Therapy (EGDT) protocol differentially affects in-hospital mortality when controlling for severity of illness using Mortality in Emergency Department Sepsis (MEDS) score. Methods:This study is a retrospective chart review of 243 patients, conducted at an urban tertiary care center, after implementing an EGDT protocol on January 1, 2008. This study compares differences in in-hospital mortality and length of stay (LOS) in the ICU and the ED between the 126 septic patients who were hospitalized the year prior to implementation of an EGDT protocol (control group) and the postimplementation study group (117 septic patients from 7/2008-6/2009), using MEDS score as a risk stratification tool. In-hospital mortality was compared between our pre-and post EGDT groups and adjusted for MEDS score using logistic regression with accompanying odds ratios and 95% confidence intervals. Median ED and ICU LOS were also compared. Results:The mean age and comorbidities were similar between the two groups. (p=0.27 and p=0.87 respectively). Reduction in absolute mortality was 9.9% when EGDT is used (control = 30.4%, study = 20.5%, p=0.08). When controlling for illness severity using MEDS score, the relative risk (RR) of death with EGDT was about half that of the control group (RR=0.52, 95% CI [0.27-0.960]). Also, by applying MEDS to risk stratify patients into various groups of illness severity, we found no specific groups where EGDT was more efficacious at reducing the Predicted Probability of death. EGDT lead to a 39.1% reduction in the median LOS in ICU (control=124 hours, study = 75.5 hours, p=0.03), without increasing LOS in ED (control = 6 hours, study = 7 hours, p=0.69).Conclusions: EGDT is beneficial in septic patients regardless of their MEDS score. Our data suggests that risk stratification tools such as MEDS score should not be used to determine which patients should or should not receive EGDT.