Adapting the Zero Suicide Framework to the Adult Emergency Department Setting: Strategies for Nurse Leaders

Abstract

The ED has been increasingly recognized as a key setting for suicide prevention. Zero Suicide (ZS) is an aspirational goal to eliminate suicide for all patients within a health care system through utilization of best practices. However, there has been limited exploration of ZS implementation within the ED. As ED nurses play an important role in suicide prevention through their close contact with patients at risk for suicide, ZS implementation would benefit from tailored strategies for ED nurse leadership. We describe the ZS framework and provides strategies for nurse leaders to adapt each ZS component in the adult ED.

Suicide is a serious public health problem. Suicide rates increased by roughly 30% in the United States between 2000 and 2018 (Centers for Disease Control and Prevention, 2023a). Following declines between 2018 and 2020, rates increased by roughly 4.5% in 2021. Provisional data suggest additional increases in 2022 (Curtin, Garnett, & Ahmad, 2023). Suicide remains within the top 10 leading causes of death for those ages 10 to 64 (Centers for Disease Control and Prevention, 2023b). Many at risk for suicide may not be detected, limiting opportunities to mitigate both acute and chronic risk. In the United States, emergency department (ED) visits related to suicidal ideation and suicide attempts increased for all age groups between 2008 and 2017; over 2 million self-harm- and suicide-related ED visits occurred in 2020 (Agency for Healthcare Research and Quality, n.d.; Owens et al., 2020). Over 30% of individuals who die by suicide visit the ED within the year prior (Schaffer et al., 2016; Vasiliadis et al., 2015). The majority of these visits (~60%) are for non-mental health concerns (Ahmedani et al., 2014). Of those who die by suicide within a year of an ED visit as their last health care contact, nearly one third die within the first month (Vasiliadis et al., 2015). At the same time, research suggests that suicide risk often remains undetected in the ED (Boudreaux et al., 2016).

In response to these trends, hospital-based psychiatric emergency departments, sometimes referred to as Comprehensive Psychiatric Emergency Programs (CPEPs), have emerged over the past decade with promising evidence for stabilizing high-acuity psychiatric needs and alleviating ED system strain (Zeller, Calma, & Stone, 2014; Kim et al., 2022). However, they are not yet widely available throughout the United States. Consequently, ED visits remain a key opportunity to identify and address suicide risk (D’Onofrio et al., 2010; The Joint Commission, 2019).

In response, the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study tested several interventions for enhancing usual care among ED patients. The study included universal and secondary suicide risk screening, outpatient suicide prevention discharge resources, and structured follow-up (Boudreaux et al., 2013). Results showed a significant reduction in suicide attempts one year after ED discharge, pointing to the importance of additional support following screening (Miller et al., 2017). The ED-SAFE study validated tools and procedures within the adult ED context for use in suicide prevention approaches such as the Zero Suicide framework.

Zero Suicide

The Zero Suicide (ZS) framework was developed by the National Action Alliance for Suicide Prevention and the Suicide Prevention Resource Center based on prior approaches that showed significant decreases in suicide, such as the Perfect Depression Care model within the Henry Ford Health System (Coffey, 2007; Coffey et al., 2013; Knox et al., 2010). The framework advocates system-wide implementation of evidence-based practices to eliminate suicide within a heath care system (Zero Suicide Institute, n.d.-b). Since its development, ZS has been implemented across several health care systems (Boudreaux et al., 2022; Labouliere et al., 2018; Turner et al., 2021; Zero Suicide Institute, n.d.-d). The framework includes seven major components for enhancing suicide prevention efforts: Lead, Train, Identify, Engage, Treat, Transition, and Improve (see Table 1; Zero Suicide Institute, n.d.-b). While ZS is designed for system-wide implementation, most of the extant literature focuses on primary care and behavioral health settings; there has been limited exploration of strategies for adapting ZS to the adult ED (Boudreaux et al., 2022; Turner et al., 2021). In addition, strategies for outpatient behavioral health settings may not be feasible in the ED. As such, there is a need to explore tailoring ZS implementation to the ED context and the needs of ED staff.

Table 1.

Zero Suicide Framework Components with Example Strategies for Nursing Leaders and Staff

Component	Strategies
Lead system-wide culture change committed to reducing suicides	Participate in multidisciplinary implementation team Lead and support organizational self-study Disseminate information on best practices Messaging to support culture change (e.g., email campaigns) Organize task- and role-specific workgroups, including involvement of behavioral health colleagues
Train a competent, confident, and caring workforce	Facilitate initial and ongoing evidence-based trainings based on organizational self-study results and local workflows Collaborate with behavioral health colleagues to provide training support and evaluation
Identify individuals with suicide risk via comprehensive screening and assessment	Implement evidence-based suicide risk screening and assessments Supplement as needed with telepsychiatry and crisis line services
Engage all individuals at-risk of suicide using a suicide care management plan	Implement safety planning, involving supportive others as applicable Implement lethal means assessment and counseling Support timely and complete documentation of suicide risk and appropriate engagement measures Consider implications of local and state laws pertaining to mental health crises and firearm access on lethal means discussions
Treat suicidal thoughts and behaviors directly using evidence-based treatment	Implement safety procedures (e.g., 1-to-1 observation) Utilize telepsychiatry services as appropriate to facilitate access to medication management and therapeutic intervention services Implement patient engagement and care transitions procedures, including timely follow-up for newly prescribed medications
Transition individuals through care with warm hand-offs and supportive contacts	Support centralized, regularly updated documentation of local resources to support discharge planning Advocate for developing relationships with local outpatient and community resources Utilize service referral lines as needed Involve supportive others and existing and receiving providers when possible Obtain and document multiple contacts Perform post-discharge outreach
Improve policies and procedures through continuous quality improvement	Support ongoing data collection to assess fidelity, identify growth areas Utilize strategies from the Lead component to support continuous quality improvement Participate in incident reviews and guide process change outcomes Support implementation of staff support programs, including staff peer support

Emergency nurse leaders and their staff play key roles in the implementation and improvement of ED suicide prevention efforts through their involvement in clinical care and close contact with patients (e.g., triage, patient safety, crisis management, discharge; Antai-Otong, 2016). In turn, ED nurses are in a strong position to shape ZS implementation in their settings. However, ED nursing staff face numerous barriers to effectively identifying and addressing suicide risk, including time pressure (e.g., limited time to build rapport), high patient volumes, limited privacy, gaps in timely follow-up resources, and gaps in education, training, and extant procedures (Antai-Otong, 2016; Bolster et al., 2015; Petrik et al., 2015). As such, implementation of a system-wide approach for suicide prevention in the ED requires developing tailored strategies that can be implemented by ED nurse leaders and their staff.

In light of the urgent need for enhancing suicide prevention in the ED and limited guidance involving the ZS framework, this paper aims to review each of the framework’s components within the context of ED needs and explore strategies for ED nurses to adapt ZS practices to their adult ED settings. We also outline gaps in the literature that may inform future ZS research.

Lead

The Lead component focuses on systems-level culture change with the goal of increasing motivation to reduce suicide at every organizational level (Zero Suicide Institute, n.d.-b). Specifically, the Lead component emphasizes the need for creating a blame-free environment, also known as a just culture, to support sustainable quality improvement. A restorative just culture lens with greater emphasis on factors including but not limited to ongoing collaboration (e.g., between patients, providers, organizations, community) and providers’ needs (e.g., for support, healing), has been applied to the ZS framework as well (Turner, Stapelberg, et al., 2020; Turner, Sveticic, et al., 2022). These cultural changes have particular bearing on incident review processes (see Improve below). ZS implementation requires a multidisciplinary implementation team to provide centralized leadership and communication (Zero Suicide Institute, n.d.-e). Due to their key roles in suicide prevention, involvement of emergency nursing leadership and staff in implementation planning is recommended. ZS recommends conducting an initial organizational self-study to determine current strengths and weaknesses related to existing suicide prevention efforts. This self-study generally consists of objective data (e.g., number of suicidal patients seen regularly) in combination with staff perceptions of strengths and challenges with suicide prevention (e.g., Allison et al., 2022). ED nurse leaders can support these efforts both by leading these projects (e.g., staff surveys, group discussions) as well as more broadly providing feedback on extant barriers and needs during the self-study (e.g., Porter et al., 2022). These self-study activities can identify key next steps for ED nurse leaders to support subsequent ZS components and cultural changes. For example, there may be a need to provide tailored messaging to other nurses and providers (e.g., that suicide is preventable, that lethal means restriction is effective; Betz, Brooks-Russell, et al., 2018; Betz, Miller, et al., 2013). Communication strategies can include identification of champions and e-mail campaigns. Disseminating information on local incidences and the perspectives of patients who experience suicidal ideation may promote positive attitudes toward ZS activities. Also in line with the Lead component, ED nurse leaders can serve as frontline champions for ZS implementation. For example, ED nurse leaders can organize workgroups focused on specific aspects of ZS implementation (e.g., suicide risk screening) or their workflows (e.g., triage, discharge; Allison et al., 2022). ED nurse leaders may consider how to best collaborate with existing initiatives to prevent duplicate efforts while also identifying what unique aspects of ED suicide prevention (e.g., ED boarding) require additional advocacy.

Train

The Train component involves disseminating information on ZS, assessing current training needs, and providing staff training. Trainings should be research-informed, ongoing (e.g., yearly), and accompanied by regular evaluations to maintain suicide prevention skills. Specific areas of emphasis and training priorities can be informed by organizational self-study results. Evidence-based, suicide-specific training for emergency nurses may improve confidence in caring for suicidal patients and protect against burnout (Muehlenkamp et al., 2023). Additionally, overall staff readiness to implement ZS practices may be improved by training and education (Allison et al., 2022).

Within the ED context, consideration of local workflows can aid identification of appropriate trainings for specific staff. For example, emergency nurse leaders working to implement suicide screening can advocate for or facilitate gatekeeper trainings focused on improving comfort with asking about suicide and promoting help-seeking (Burnette et al., 2015). Such trainings would not be sufficient for other staff, as they provide limited information on stratifying and addressing suicide risk. Examination of organizational self-study results and local workflows may indicate the need for training all ED staff on ZS practices to best support ZS implementation and fidelity.

ED nurse leaders may also wish to consider additional training areas for ED nurses in support of ZS implementation. For example, past studies show that safety planning (see Engage below) training can be completed via self-guided videos and review of materials without being overly burdensome on ED staff (B. Stanley et al., 2015). Additional trainings and education materials for ZS practices (e.g., screening, risk assessment, and lethal means counseling) are available online (Education Development Center, 2020; Zero Suicide Institute, n.d.-a). Collaboration with behavioral health colleagues within the health care system can aid in identifying and facilitating relevant trainings.

Identify

The Identify component focuses on implementation of suicide screening and risk evaluation. The Emergency Nurses Association identifies universal screening as a vital component in emergency nursing practice (Zaleski et al., 2018). The ZS toolkit recommends establishing written policies and procedures for screening and assessing risk. Several brief screening and risk assessment instruments have been validated for use in the ED. Primary screeners initially identify suicide risk while secondary screeners inform risk stratification of those with positive primary screens. For example, the ED-SAFE Patient Safety Screener (PSS-3) is a primary, 3-item interview tool developed for identifying depression and suicidality in the emergency department (Boudreaux et al., 2015). The Columbia-Suicide Severity Rating Scale (C-SSRS) is a 3- to 6-item secondary screener assessing the severity and intensity of suicidal ideation and the presence and lethality of suicide-related behaviors (Interian et al., 2017; Posner et al., 2011). An alternative is the ED-SAFE Secondary Screener (ESS; Boudreaux et al., 2020). Several studies suggest tools such as these are feasible to implement in emergency departments and contribute minimally, if at all, to overall length of stay (Betz et al., 2015; Horowitz et al., 2010; Syndergaard et al., 2022).

ED nurse leaders can provide key input on integrating screening practices into nursing workflows, such as when to perform primary and secondary screening (e.g., during triage or the primary nursing assessment). Notably, screening tools alone are insufficient for determining risk stratification and disposition and require additional supplementation (Stewart & Lees-Deutsch, 2021). ED nurse leaders should consider local resources to ensure adequate screening and evaluation (e.g., overflow procedures). For example, telepsychiatry and crisis line services may provide additional assessment support and are generally available 24/7 (Suicide Prevention Resource Center, 2015).

Engage

The next step is to Engage patients in care by developing case management and safety plans, including plans for lethal means safety. Throughout this process, collaboration and open communication with patients promotes adherence to discharge plans.

Safety plans are crisis management plans developed collaboratively with patients and focus on decreasing acute suicide risk. Modules include helping patients identify warning signs, coping strategies, resources, and clear indicators for seeking additional care (B. Stanley et al., 2018; B. Stanley & Brown, 2012). The ZS toolkit recommends having a standardized safety planning template and advocates for involvement of supportive others (e.g., family, friends) when possible (DeBeer et al., 2019). Safety plans may be completed by a variety of staff with adequate training. Initial research suggests provider-led safety planning in the ED is feasible and observed that collaborative, complete safety plans were often developed within 5 minutes (Wilson et al., 2022). Safety planning templates have also been adapted for self-administration among ED patients. If time and resources do not permit collaborative safety planning, primary nurses can introduce and review a self-guided template with their patients (Boudreaux et al., 2013).

Lethal means assessment and counseling is another opportunity to engage patients. Incorporating lethal means safety strategies (e.g., psychoeducation on risks of lethal means access) can further mitigate future suicide risk (Betz et al., 2016). However, past research suggests that missed opportunities for lethal means discussion are a gap in many EDs’ practice guidelines and protocols (Betz, Kautzman, et al., 2018; Betz, Miller, et al., 2013; Runyan et al., 2018). Extant research supports the feasibility and acceptability of non-physician-led lethal means assessment and counseling in the ED (Mueller et al., 2020). ED nurse leaders can explore incorporating similar practices into existing workflows (e.g., as part of initial screening and safety planning; Antai-Otong, 2016; Mueller et al., 2020). Documentation of these practices provides important clinical data for future providers, but suicide risk assessment, safety planning, and lethal means discussions (e.g., noting access to firearms) may be routinely under-documented (I. H. Stanley et al., 2019). ED nurse leaders may develop or refine existing procedures to support complete documentation of suicide-related visits (Suicide Prevention Resource Center, 2015).

ED nurse leaders should note that many states have laws that aim to prevent those at imminent risk for harming themselves or others from accessing firearms (Everytown for Gun Safety, n.d.). In some states, such laws allow or require health care professionals to initiate a petition for removal of someone’s firearms under certain criteria. ED nurse leaders should collaborate with their hospital’s administrative and executive leadership teams to understand implications of local and state laws on lethal means assessment and counseling procedures.

Treat

The Treat component promotes use of evidence-based, suicide-specific treatments (e.g., cognitive behavioral therapy for suicide prevention, dialectical behavioral therapy). Many of the recommended treatments from the ZS framework may not be feasible in ED settings. As such, ED nurse leaders may help develop strategies for executing institutional safety procedures as applicable (e.g., 1-to-1 observation), engaging patients in care (e.g., safety planning, lethal means counseling) and facilitating transitions to appropriate care (e.g., inpatient or outpatient follow-up). ZS recommends utilizing an evidence-informed, stepped-care model to facilitate appropriate referrals based on suicide risk and provide the least restrictive care (Jobes et al., 2018; Zero Suicide Institute, n.d.-c). For example, involuntary hospitalization for a patient at low risk can be unnecessarily restrictive and harmful for future care engagement. Current guidance encourages ED leadership to consider use of telepsychiatry services to provide medication management and therapeutic interventions for patients at risk for suicide (Suicide Prevention Resource Center, 2015).

Transition

The Transition step focuses on care coordination. ZS encourages the creation of written policies and procedures for facilitating care transitions. Engagement and collaboration with outpatient and inpatient staff are of vital importance for developing effective referral processes, including warm handoffs. Limited knowledge of finding outpatient resources for patients at risk for suicide has been identified as a barrier for ED providers (Betz, Sullivan, et al., 2013). ED nurse leaders can support including centralized, regularly updated documentation of local resources to address this gap. ED nurse leaders can also advocate for further developing relationships with outpatient mental health providers (e.g., agreements to provide follow-up services; Centerstone of Tennessee, n.d.) Smaller EDs can consider use of widely available services referral lines (e.g. 2–1-1; Helpline Center, 2022). Although challenging at times, involving supportive others, existing providers, and receiving providers can facilitate care transitions and decrease risk of patients being lost to follow-up (DeBeer et al., 2019). The ED-SAFE study and others have shown that a key intervention associated with decreased suicide attempts is structured follow-up to enhance safety and engagement in care (Boudreaux et al., 2013; Exbrayat et al., 2017; Miller et al., 2017). When planning post-discharge outreach, emergency nurses may consider documenting multiple contacts in case the patient cannot be reached. Limited mental health staffing and time pressure (e.g., during night shifts) pose additional barriers to conducting warm handoffs and post-discharge follow-up contacts. Revising professional roles, such as designating a staff member to be the primary care transitions support, could address these barriers (Allison et al., 2022). Research also supports the feasibility of adapting a post-discharge caring contacts (i.e., postcard follow-up) intervention in the ED and suggests it requires minimal dedicated time once implemented (Landes et al., 2021). Nurse leaders can serve as champions and implementation supports for these efforts.

Improve

The Improve component focuses on continuous quality monitoring and improvement. ZS recommends ongoing data collection (e.g., via electronic health record integration) to assess fidelity to the ZS model, areas for improvement, and progress toward patient-, staff-, and systems-level goals As ED evaluation resources can be limited, attaching specific questions of interest to ongoing patient satisfaction questionnaires may provide informative data while limiting staff burden. ED nurse leaders can continue to leverage strategies (e.g., messaging, workgroups) from the Lead component to support implementation of any changes.

The Improve component also informs incident reviews as part of continuous quality improvement. Several incident review guidelines can be adapted for use in the ED (e.g., The Joint Commission, n.d.; Turner et al., 2020). ED nurse leaders can participate in incident reviews and provide guidance on the feasibility and implementation of process change outcomes. When applied to incident reviews and ZS more broadly, a restorative just culture lens is intended to facilitate support, healing, and learning among staff. To address the psychological health and support needs of staff, ED nurse leaders can advocate for and participate in the implementation of staff support programs (e.g., peer support; Turner et al., 2020).

Challenges and Future Directions

Although ZS provides a framework for enhancing suicide prevention across all levels of care, much remains unknown regarding the best strategies for implementation in the ED. The ED-SAFE study validated several interventions for use in the ED as part of implementation of the ZS framework, but it is unclear which components are the active ingredients that led to decreased suicide risk. For example, only 61% of participants completed at least one structured follow-up call, suggesting the need for additional exploration into intervention mechanisms (Miller et al., 2017). How to best manage suicide risk in the presence of intoxication also remains unclear. Past research shows that approximately 20% of adult ED patients reporting suicide risk have recently used alcohol (Urban et al., 2020). These patients are less likely to receive a mental health evaluation despite similar levels of suicidality compared with those without recent alcohol use (Urban et al., 2020). Further research is needed to better understand mechanisms impacting care decisions (e.g., other patient characteristics, implicit biases; Petrik et al., 2015). Though many ZS practices (e.g., safety planning, lethal means counseling), appear to be feasible within ED settings, they have often been researched in isolation from other quality improvement changes (e.g., DeBeer et al., 2019; Runyan et al., 2018). Research on costs of comprehensive ZS implementation is needed to better inform ED resource allocation and manage burden on ED staff. Additionally, many of the aforementioned barriers to ZS implementation and suicide prevention quality improvement (e.g., staffing shortages; see Cullen et al., 2019) would be best addressed at the organizational level.

Conclusion

Emergency nurse leaders play a vital role in ensuring quality care and safety for suicidal patients and are therefore ideal ZS implementation advocates and coordinators. However, ED staff face numerous barriers to effective suicide prevention, and continuous quality improvement in support of ZS implementation can be demanding. Considering that ZS implementation is an iterative process with several implications for ED workflows and nursing practices, ED nurse leaders can provide ongoing leadership and support for several ZS components. While this paper provides strategies for adapting the ZS framework to the ED, much remains unknown about how best to facilitate each ZS component within the ED and support ZS implementation at the organizational level, particularly in light of limited ED resources.

Highlights.

• Research highlights the importance of emergency department-based suicide prevention

• Zero Suicide is a framework for continuous quality improvement in suicide prevention

• ED nursing staff can adapt evidence-based practices to support Zero Suicide efforts