Running head: SUICIDE PREVENTION IN THE ED

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Suicide Prevention in the Emergency Department: Implementation of a Safety Plan and FollowUp with Postcards
Ryan H. Boothe
Arizona State University

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Table of Contents

Acknowledgements…4
Abstract…5
Chapter 1…7
Background & Significance…6
Problem Statement…12
Search Strategy…14
Evidence Synthesis…15
Purpose Statement…17
Chapter 2…19
Evidence Based Practice Model and Conceptual/Theoretical Model…19
Project Methods…20
Project Results…23
Discussion…23
Conclusion…25
Reference Page…26
Appendix A…33
Appendix B…43
Appendix C…45
Appendix D…46
Appendix E…47
Appendix F…48
Appendix G…49

SUICIDE PREVENTION IN THE ED
Appendix H…50
Appendix I…51
Appendix J…52
Appendix K…53
Appendix L…54

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Acknowledgements
I would like to extend my sincere thanks to Ann Guthery, PhD, RN, PMHNP-BC, who
provided unwavering support and guidance throughout this process. Her insightful suggestions
were invaluable to completing this project. Thanks also to Kathy Kenny, DNP, RN, ANP-BC,
FAANP, FAAN, for her advice on this project. I would also like to thank my family and my wife
Rachel, for her moral support and encouragement during this process.

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Abstract
Suicide has become a national concern due to the increasing rates across the country. The
2012 National Strategy for Suicide Prevention aims to improve the area of clinical prevention.
Emergency departments (ED) play a key role in addressing this effort as they have multiple
opportunities to connect with patients who are at risk. There exists a high-risk period of time
immediately following a patient’s discharge from emergency care. To address this period of
concern, a review of the literature was conducted on the effectiveness of follow-up contacts as a
means to prevent suicide and suicide related attempts in this at-risk population. Based on this
review, a follow-up intervention was proposed to increase patients’ social support and
knowledge on suicide prevention through a safety plan and the use of caring postcards. The aim
was to evaluate the degree to which implementation of a safety plan and follow-up using
postcards reduces suicide risk in the ED. ED suicide prevention practices such as safety planning
and caring contacts with postcards have shown to be feasible and cost-effective methods to
reduce patients’ risk of suicide as they provide education and address the high-risk period of time
after discharge. Using a quasi-experimental pre and post-test design, English speaking adults 18
years of age and older, admitted to an ED in the Phoenix Metropolitan area with suicidal
ideation, were voluntarily recruited for two weeks. The self-rated Suicidal Behaviors
Questionnaire-Revised (SBQ-R) was used as a baseline assessment along with the introduction
of a safety plan. Participants were then followed with the receipt of postcards with caring
messages over a two-week period, and a final SBQ-R. The SBQ-R has shown beneficial
reliability and validity measuring suicidality in the adult population. Data from the pre-SBQ-R
was analyzed using descriptive statistics as no post-SBQ-Rs were received. Outcomes for this
project included a reduction in suicidal ideation and suicide risk. This project provides insight

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into the implementation of a safety plan and follow-up intervention in the ED and their attempts
to reduce acute suicide risk as well as highlight the value that post-ED support provides.
Keywords: suicide, prevention, safety plan, caring messages, postcards, emergency
department, follow-up, contacts, brief intervention

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Chapter1
Introduction

Suicide currently ranks as the 10th leading cause of death in the United States.
Approximately 45,000 Americans die by suicide each year and the costs are estimated to be 69
billion annually (CDC, 2016). In Arizona, suicides rates are also on the rise (AZDHS, 2016).
Unfortunately, the stigma surrounding suicide raises the possibility of underreporting, and the
number of suicides and suicide attempts are estimated to be higher (AFSP, 2018). These alarming
statistics present a need to find effective clinical preventive solutions as part of a comprehensive
approach to help save lives. From a clinical perspective, the use of safety planning and follow-up
are important ways to make inroads in reducing suicide.
Background and Significance
Can a safety plan intervention combined with follow-up using caring postcards translate
into less suicidal behavior in patients seen and treated in the emergency department? This is a
clinically significant question as it relates to patient care in an emergency setting. To better
understand this question, a look at the background of this issue, the population it affects, the
different types of interventions that have been tried in the past and their outcomes, as well as the
current state of practice should be evaluated.
Suicide is a complex issue due to the multitude of risk factors of suicide and the
demographic variability. There is no singular approach to preventing suicide; it is likely that a
comprehensive approach works best (Miller et al, 2017). Suicide is defined as the act or an
instance of taking one’s own life voluntarily and intentionally (Merriam-Webster’s dictionary,
2018). The various factors that put patients at risk of suicide include a history of mental or
emotional disorders, previous suicide attempt, history of trauma or loss, terminal illness, alcohol

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and drug abuse, social isolation, and being recently discharged from inpatient psychiatric care
(Joint Commission, 2016).
Population
Certain populations such as military veterans and men over the age of 45 are more at risk
than others (Joint Commission, 2016). A review from Reger et al. (2017) concluded the target
population would be one that has multiple risk factors such as prior attempts or recent psychiatric
hospitalization. Patients with a previous suicide attempt are likely to make another attempt,
eventually 5-10% will die by suicide (Larkin & Beautrais, 2010). The average number of ED
visits for attempted suicide and self-inflicted injuries in the U.S. from the 1990’s to the 2000’s
has doubled, and a high proportion of these patients have mood disorders (Kawashima,
Yonemoto, Inagaki, & Yamada, 2014). People with mood disorders may have experienced
stressful events in their life such as a death or divorce and may have a higher genetic risk of
becoming depressed. They may go through periods of depression where they feel guilt,
helplessness, hopelessness, and may have lost interest in things they used to enjoy. Some people
experience a lack energy making it difficult to get out of bed, let alone make it to an outpatient
psychiatric appointment. These symptoms can affect a person’s ability to function and lead to
thoughts of suicide. Depression is typically treated and managed by psychotherapy, medications,
and other health approaches (NAMI, 2017). However, these methods may not work immediately
and can take several weeks or months to take effect, putting depressed patients at a higher risk of
suicide and adding to the importance of follow-up with these patient’s post-discharge from the
ED.
Interventions

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Over the last decade, brief contact interventions have been trialed in several settings with
positive results. The interventions have included follow-up phone calls, post cards, emails, text
messages that vary in design, the number of participants, methods, and follow-up period.
Although some have been more effective than others, these interventions have been found to be
easily implemented, low cost, and accepted by patients and staff (Falcone et al., 2017; Luxton,
June, & Comtois, 2013; Reger et al., 2017). Follow-up contacts are one part of a brief
intervention and contact (BIC) in which patients with suicidal ideation in the ED are provided
with information, educated about suicidal behavior, and offered effective coping strategies before
they are discharged. Supportive letters, phone calls or postcards are then sent over a period of
time and used as a means to maintain contact with the patient and offer re-contact services if
needed with the hope of reducing the suicide rate (Milner, Carter, Pirkis, Robinson, & Spittal,
2015).
A randomized clinical trial by Luxton et al. (2014) found follow-up contacts help patients
connect socially and adds to a sense of belongingness for them. This thought is similar to Motto
and Bostrom’s (2001) point which emphasized how important human social connection is with
preventing suicide. A study by Berrouiguet et al. (2014), stated the goal of their text message
intervention was to facilitate human to human interaction by connecting patients with health care
providers. They found that their therapeutic intervention allowed patients at-risk for suicide to
feel continuously cared for the by ED staff. A review of the mechanisms of brief contact
interventions suggested social support and increased suicide prevention literacy as the most
likely reasons why contact interventions work (Milner et al., 2016).
The evidence reviewed supports that reaching out to at-risk patients who have committed
self-harm or have had thoughts of doing so are receptive to a form of social support, whether

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they be phone calls, emails, postcards or text messages. These interventions are well suited to the
ED setting due to the time and staffing constraints many EDs face. Furthermore, focusing on a
population that is considered higher risk may be more cost-effective due to the likelihood this
population will make another attempt.
Current State of Practice/Comparison
Usual care for treating suicidal patients in the ED consists of assessing how serious the
risk is, and then referring the patient to either a higher level of care (psychiatric inpatient facility)
or outpatient mental health clinic depending on the level of risk. Other forms of clinical
preventive services utilized by EDs have included universal screening, lethal means counseling
and safety planning. Universal screening requires nurses to screen every patient that enters the
ED, which is thought to identify more patients at risk. However, one study did not find any
evidence that showed universal screening had improved outcomes (Miller et al, 2017).
Lethal means counseling is a part of the Joint Commission’s recommendations to health
care organizations advising them to address whether patients have access to firearms,
medications or other means, as they increase the risk of suicide (Runyan, 2018). Fewer than half
of EDs have discharge protocols which include lethal means counseling (Runyan, 2018). A safety
planning intervention in the ED entails helping the patient to identify warning signs of a suicidal
crisis, coping strategies, ways to make the environment safe, and people they can turn to for help
(Stanley & Brown, 2012). A BIC combines a similar education intervention with a follow-up
component. All of these interventions have potential and may add to a health care system’s
suicide prevention measures, but EDs must rely on the necessary staff and resources to provide
the interventions.
Outcomes of Follow-Up Interventions

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Overall, there are common themes in the data showing benefits of implementing followup contacts as a way to prevent suicide. Suicide rates after discharge are an area of particular
concern due to the elevated level of risk. Follow-up contacts are one way to address this period
of risk, as they have shown to be promising interventions in mitigating suicide risk after
discharge and reducing the risk of repeat suicide (Inagaki et al., 2014; Luxton et al., 2013; Reger
et al, 2017; Riblet et al., 2017). One study tested the efficacy of a postcard intervention over 12
months on the number of repeat episodes of deliberate self-poisoning and found the intervention
had cut in half the number of self-poisoning events over the time period (Carter, Clover, Whyte,
Dawson, & E’Este, 2005). The intervention comprised of a postcard sent to participants at 1, 2,
3, 4, 6, 8, 10, and 12 months after discharge, with messages expressing concern that someone
still cares and is thinking about the patient. After five years, this intervention was shown to also
have reduced the number of psychiatric admissions by a third, representing a cost savings to the
hospital (Carter, Clover, Whyte, Dawson, & D’Este, 2013). A study by Denchev et al. (2018)
also found adding postcards, compared with usual care, was shown to reduce costs and improve
outcomes. The fact that these interventions are cost-effective provides additional support for
implementation.
Internal Evidence
At an ED in the Phoenix metropolitan area, there were multiple opportunities to identify
clinical needs in the care of patients in a mental health crisis. The current practice of this ED is to
perform a suicide risk screening for patients that have a primary complaint of an emotional or
behavioral disorder. Patients that are identified as at-risk receive a consult with a social worker
who performs a risk assessment and helps determine the patient’s disposition and course of
treatment. Emergency medicine physicians are responsible for the medical clearance of these

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patients. Once medically cleared and in coordination with the social worker’s assessment,
patients will either be transferred to an inpatient psychiatric facility or discharged. Patients that
are discharged will receive resources such as a crisis line, lethal means counseling, and referrals
for outpatient treatment. Patients that are transferred from the ED to an inpatient psychiatric
facility may be discharged several days later in a similar fashion. Data on how many patients are
discharged home versus how many are transferred to an inpatient setting was difficult to discern
as there were limitations with the electronic health record.
There is no guarantee that patients will follow-up with the referrals they are given; it is
the patient’s responsibility. Thus, some may not connect with outpatient services due to the
nature of depression; depressed persons may have difficulty initiating follow-up because of lack
of motivation, which is a symptom of depression. This ED implements many of the suicide
prevention strategies that is currently recommended by the Joint Commission (Joint
Commission, 2016). However, the increase in the rate of suicide in the State of Arizona begs the
question of what more can be done to stop suicides from occurring?
Problem Statement
The 2012 National Strategy for Suicide Prevention (USDHHS, 2012) provides several
recommendations for suicide prevention actions in the United States over the next decade. One
part of this strategy focuses on increasing clinical and community preventive services. Several
national organizations have issued position statements and partnered together to address gaps in
suicide related care identified by the 2012 National Strategy for Suicide Prevention. The
American Psychiatric Nurses Association (APNA, 2018) developed suicide competencies that
educates nurses who provide care to persons with mental health needs that will improve
outcomes in suicide risk assessment, prevention, and intervention. The American Association for

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Suicidology (AAS, 2018) made recommendations to ensure mental health professionals are
properly trained and competent in managing suicidal patients. The Substance Abuse and Mental
Health Services Administration has partnered with the National Action Alliance for Suicide
Prevention to advance the national strategy for suicide prevention (SAMHSA, 2017; Schmitz et
al., 2012).
Healthcare organizations have been encouraged to develop and implement programs that
prevent suicide and related behaviors to meet these objectives and recommendations. In
implementing these programs, healthcare organizations are taking responsibility to address the
gaps in care that occur when a patient transitions from an inpatient setting to an outpatient one
without a follow-up plan or established appointment with a mental health provider. Filling this
gap in care is important because research has shown that patients with a history of suicide
attempts and comorbid psychiatric disorders are at a higher risk of suicide following discharge
from a psychiatric inpatient or emergency department (ED) setting (Bickley et al., 2013; Murphy,
Draper, & Mckeon, 2010).
Suicide risk is particularly high the first few days and weeks after discharge. One study
found a greater incidence of suicide occurred in the first week following discharge, half of the
suicides occurred before the first outpatient appointment, and patients were more likely to
commit suicide if they had a short hospital stay and experienced an adverse life event following
discharge (Bickley et al., 2013). Another study found that the suicide rate was highest within 3
months after discharge among patients admitted with suicidal ideas or behaviors (Chung et al.,
2017). Clinical preventive services that provide a follow-up plan can help address this high-risk
period of time after a patient is discharged.

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ED visits provide healthcare organizations with opportunities to intervene and help save
lives (SPRC, 2018). The number of mental health related visits to EDs has increased which
provides healthcare organizations with more patient contacts (Simon & Schoendorf, 2014).
People that have attempted suicide will likely seek medical treatment in the ED. They will
initially receive a psychiatric evaluation in the ED, and after the patient is evaluated, they are
likely to be discharged with referrals or transferred to an inpatient psychiatric facility. There
needs to be a system in place to follow-up and connect with patients to make sure they are safe
after they have been discharged, and to confirm they have followed up with their referrals.
Sending a follow-up email, telephone call, postcard, or text message to the patient are several
ideas. Research has shown promising findings that follow-up contacts reduces the number of
episodes of self-harm and/or suicide attempts after patients have been discharged from the ED
(Falcone et al., 2017).
PICO
This leads us to the clinically relevant PICOT question, “In adult patients that present to
the ED for suicidal ideation and behavior, how does follow-up contacts compared to no followup contacts, affect readmission rates to the ED for suicidal behavior over a period of 4 weeks?”
Search Strategy
The goal of the initial search strategy was to determine if follow-up contacts affect
readmission rates for suicidal ideation, attempts, and behavior in the ED. An extensive search for
literature related to this PICOT question was conducted. The databases searched included the
Cumulative Index of Nursing and Allied Health Literature (CINAHL), the Psychological
Information database (Psych INFO), and Public/Publisher Medline (PubMed). Keywords used in
the searches were suicide, ideation, prevention, emergency department, follow-up, post-

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discharge, outpatient, aftercare, intervention, email, text, service, theory, and recidivism. Criteria
was narrowed to peer-reviewed studies with a focus on randomized controlled trials, systematic
reviews, and meta-analyses.
The initial CINAHL search with the terms suicide, prevention, and emergency
department yielded 147 results. Adding the Boolean phrase outpatient to the prior search
combination yielded 33 results and adding intervention yielded 56 results. Combining suicide,
prevention, emergency department, and post-discharge yielded just 3 results. Search terms
suicide, prevention, emergency department, and follow-up then yielded 22 results. Searching
PsychINFO initially had a higher number of results than the CINAHL search. The search began
with the terms suicide and prevention which yielded 15,463 results. By adding in the terms
emergency and attempts, the yield resulted in 267 results. Further adding the term follow-up
yielded 62 results, and finally adding the search term contacts yielded 17 results. PubMed had
the largest initial yield of results at 76,227 for the term suicide; 16,478 for suicide and
prevention; 801 for suicide, prevention, and emergency department; 144 for suicide, prevention,
emergency department, and follow-up; and 7 for suicide, prevention, emergency department,
follow-up, and contacts. Other studies were identified through the ancestry method by reviewing
the reference lists within the retrieved articles. Studies were identified through review of
abstracts and whether the intervention employed the use of follow-up methods such as telephone
contacts, emails, or postcards/letters with patients discharged after an ED visit. After combining
these search methods, 10 studies were chosen to be evaluated (appendix A).
Evidence Synthesis
Of the ten studies evaluated for this review, two studies were systematic reviews, six
studies were randomized controlled trials (RCTs) and two were case-controlled studies

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(Appendix A). Overall, the strength of the evidence is high as the level of evidence ranges from I
to III (Appendix B). The studies generally exhibited moderate homogeneity in the demographics
as the targeted population in these studies were of individuals with risk factors for suicide that
had presented to an ED or inpatient psychiatric unit for treatment. There was some heterogeneity
in the age of participants as three of the studies included participants younger than age 18
(Appendix B). There were only two settings in which the all of the studies took place, that of
EDs and inpatient psychiatric units.
There is moderate heterogeneity among the dependent variables related to suicidal
behaviors. Five studies focused on the number of suicide deaths; five studies looked at repeat
suicide attempts; two of the studies looked at repeat episodes of non-fatal suicidal behavior; one
study looked at time between first suicide attempt and subsequent one; and one study looked at
repeat episodes of deliberate self-poisoning (Appendix B). Moderate heterogeneity is also
evident by the different types of follow-up interventions studied. Three of the studies evaluated
sending postcards. Four studies assessed follow-up telephone calls and one study used letters as a
method of follow-up. Four studies included a brief intervention with the follow-up contacts. All
of the studies used a treatment as usual (TAU) as the comparison group which may have
minimized some of the studies’ results as every suicidal patient typically receives an intense level
of care and support.
Validity and reliability of the evidence is confirmed through the systematic approach of
randomized controlled trials and systematic reviews. Validity was found to be good in two of the
studies and reliability was noted to be good in two of the studies. Two studies noted consistency
in their findings in comparison with other studies. Potential bias was debated regarding three
studies. Methodological concerns found in the studies included small sample size, difficulty

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contacting patients resulting in large dropout rates, and inadequate of time of follow-up. The
follow up period of the studies ranged from 6 months to 5 years. The studies’ differences in their
sample sizes among the control and intervention groups may have impacted the statistical
significance of the results. The studies generally relied on data gleaned from electronic medical
record databases and questionnaires to measure the effects of their interventions. Data was
analyzed in a similar fashion across the studies as mainly Chi-square and t-tests were performed,
and both systematic reviews used the Cochrane’s Q and the I squared test.
Overall, the evidence suggested that follow-up contacts for patients seen and treated in
the ED for suicidal behavior has a beneficial effect on reducing suicides, suicide attempts, and
suicide ideation. Sending letters, postcards, and placing telephone calls varied in their level of
effectiveness. However, it was difficult to determine if one method of follow-up was more
effective than the other as none of the RCTs or systematic reviews compared the effectiveness of
one follow-up intervention to another. All three methods showed a reduction in suicidal behavior,
and it would be reasonable to implement any one of them depending on the resources available.
The three follow-up interventions were feasible in an ED setting and cost-effective. If staffing
and financial limitations exist, a postcard follow-up program may be the best option as it was
associated with lower costs than the other methods (Denchev et al., 2018).
Purpose and Rationale
Patients experiencing mental health emergencies are visiting EDs at increasing rates. It is
important to stay in touch with these patients once they leave the ED due to the period of high
risk immediately after discharge. The purpose of this evidenced-based project was to reduce
suicidal behavior through increasing patients’ social support and knowledge on suicide
prevention by using a safety plan and follow-up with caring postcards. The question this project

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aimed to answer was “Can a safety plan intervention combined with follow-up using postcards
reduce suicidal behavior in patients in the emergency department?”

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Chapter 2
Evidence Based Practice Model and Conceptual/Theoretical Model
Joyce Travelbee’s Human-to-Human Relationship Model acted as a conceptual
framework for understanding the proposed practice change (Appendix D). This model focuses on
the phases of the nurse-patient relationship. The phases of original encounter, emerging
identities, developing feelings of empathy, developing feelings of sympathy, and building rapport
help to highlight the importance of the communication process between the nurse and patient
(Nelson, 2015). This model was chosen for this evidenced based practice (EBP) project as its
ultimate goal is to instill hope. Using sympathy and empathy, patients will be offered suggestions
for safety planning. These suggestions would include developing a personal set of warning signs,
a list of specific behaviors that will help the patient calm down, and ways for them to reconnect
with themselves and others.
The Iowa Model of Evidence-Based Practice to Promote Quality Care is the model
chosen to help guide the application and decision-making process of the proposed EBP project
(Appendix C). The Iowa model has been used to guide nurses in addressing a wide range of
clinically important topics that affect patient outcomes. For example, the Iowa model can be
applied to this project by identifying the practice question of “whether a brief intervention and
follow-up contacts change outcomes with patients with suicidal ideation that are discharged from
the ED?” This question was derived from research that questions current practice standards in the
ED (Dang et al., 2015). Nurses must then consider the organizational context of this topic, if it is
a priority for the organization, and whether there is enough quality evidence to move forward
with implementation. If the findings are sufficient in quality, clinically relevant, feasible and

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generalizable to the population, a change can then be instituted (Dang et al., 2015). There are
feedback loops throughout the model that support the evidence-based practice process and guide
the practitioner to make informed decisions with the aim of continual improvement of the
process.
Project Methods
Ethics
Permission to use the safety plan was obtained (appendix E). The institution’s internal
IRB approved the EBP project on March 25th and signed an IRB authorization agreement with
Arizona State University (appendix F) (appendix G). This process safeguards the participant’s
rights, welfare, and well-being. The IRB evaluated the project to confirm it had sound design and
determined the project was worth exposing patients to risk. The IRB also examined the
recruitment methods, consent procedure, and privacy and confidentiality procedures to ensure
they were sufficient. Steps were taken to protect the participant’s privacy. A unique ID code was
developed by each participant to de-identify their data. The data gathered was kept confidential
and secured in a locked office in the ED.
Participants and Setting
The inclusion criteria consisted of English-speaking adults 18 years of age and older who
presented to the emergency department with suicidal ideation. They had to be residents of the
Phoenix metropolitan area, have a mailing address where they receive mail, be able to consent,
and be waiting for voluntary transfer to an inpatient setting. Individuals who were under the age
of 18 and adults who were unable to consent were excluded from participating. The setting was a
60-bed ED and level I trauma center in the Phoenix metropolitan area.
Recruitment

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The co-primary investigator (Co-PI) conducted the recruitment of the participants
(patients) in the ED. The Co-PI worked closely with the ED social worker to identify potential
participants that had been medically cleared by the ED physician, had received a psychiatric
evaluation by the social worker, and determined they would be voluntarily transferred to an
inpatient psychiatric facility. The Co-PI was verbally notified in person by the ED social worker
of a patient that was pending transfer. The co-primary investigator then met with the potential
participant and used a consent form to explain the study, answer questions, ask if they were
willing to participate, and then obtained verbal consent (appendix I). The recruitment period was
two weeks.
Intervention
If the participant was interested and gave verbal consent, the Co-PI in coordination with
the participant, developed a unique ID code that was used to label and identify the pre-post
questionnaires and safety plan. Envelopes were then labeled with the participant’s mailing
address. The participant was then asked to complete a baseline Suicide Behaviors QuestionnaireRevised (SBQ-R) (appendix H) to assess for suicidal ideation, or thoughts about suicide. After
completing the baseline SBQ-R, the patient then completed a written safety plan with the help of
the Co-PI. The safety plan consisted of the patient identifying warning signs, internal coping
strategies, settings that can provide distraction, and people to reach out to in times of crisis
(appendix L). A note was then placed in the patient’s chart stating the patient agreed to
participate in the project and that they completed the first questionnaire.
After the safety plan was completed, the participant was sent a total of 4 postcards. The
postcards included positive messages that expressed concern for their well-being, provided
personalized ideas for health promotion and served as a reminder of sources of help the

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participant identified during the safety plan (appendix J & K). The postcards were sent in sealed
envelopes, to protect the participants confidentiality, and were sent over a period of 14 days; on
days 3, 7, 10, and 14 following discharge from the ED. The envelopes had no revealing
information from the sending institution and only included a stamp and the participant’s mailing
address. The last postcard mailed included a self-addressed stamped envelope and a post-SBQ-R
questionnaire with their unique ID code. The Co-PI then relied on the participant to complete the
post-intervention questionnaire and mail it back to the ED. The return envelope was addressed to
the emergency department with ATTN: (SPFU-ED). A crisis number was also included in each
postcard and the postcards were signed by members of the care team.
Outcome Measures
The outcome measured for this project was suicidal behavior. Suicidal behavior was
measured using the Suicidal Behaviors Questionnaire-Revised (SBQ-R) which looks into
lifetime suicide ideation and/or suicide attempts, assesses the frequency of suicidal ideation over
the past twelve months, assesses the threat of suicide attempt, and evaluates the likelihood of
suicidal behavior in the future. It is used to measure the risk of suicide and has high sensitivity
(93%) and specificity (95%) in the adult general population. The total score ranges from 3-18. A
cutoff score equal to or greater than 7 will correctly classify those with risk. The measure is selfreported.
Data Collection and Analysis Plan
All data was collected using the Suicidal Behaviors Questionnaire-Revised at the initial
meetings with the participants. No post-intervention SBQ-Rs were received. All data was kept
secured in an office in the ED. A total of 4 participants were recruited during the recruitment
period. A Wilcoxon Matched-Paired Signed Rank Test had been planned to analyze the pre- and

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post-questionnaires, however with a n of 4 and no post-questionnaires, it was not feasible.
Therefore, descriptive statistics were used to describe the sample and outcome variables.
Proposed Budget
Minimal expense was needed to fund the project. Ink, envelopes, card stock, office paper,
and postage stamps were the only expenses. The total cost was under $30.00.
Project Results
The total number of participants recruited was 4 and no post-intervention questionnaires
were received in the mail. Of the participants, 75% were females and 25% were male. The
average age of the sample was 61.5 (sd=14.48). And the age ranged from 41 to 71 years of age.
The average score on the SBQ-R was 11.5 (sd=1.73) and the scores ranged from 9 to 13 points.
The question being asked was “does the intervention of a safety plan and follow-up using
postcards decrease suicidal behavior?” With a total number of only 4 participants and no post
questionnaires, statistical significance was not reached, and therefore the question remained
unanswered.
Discussion
The clinical significance and what the reported scores from the pre-intervention
questionnaire show is that all of the patients were at-risk. Regardless of age or gender, they were
all at-risk. All of them had some suicidal ideation during the past year. And that the social
worker, ED physician, and patient made the correct decision for the patient to be transferred to
an inpatient setting for more care and support. It is difficult to determine the impact of this EBP
project because there were not enough participants recruited and post-intervention questionnaires
received. However, with that being said, the safety plan and the idea of postcards was well
received by the patients and by the staff. The emergency department management was very

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supportive. The nursing staff and social workers all thought it was a great idea and a nice thing to
do for the patients. To sustain this project in the practice setting, the post card messages could be
automated. If there is time, social workers or trained nurses could do the safety plan with
patients.
One of the strengths of this project was just sitting down and talking with the patients. It
was beneficial for them and they enjoyed talking with someone. Personalizing the messages was
a nice addition, but there were some studies that, interestingly, found no impact on whether the
messages were personalized or not; automated messages had the same positive impact (Luxton et
al., 2014). For the limitations and barriers, getting through the IRB process was the biggest
hurdle by far. Several changes were made to the project because approval was not received till
the end of March. Initially, the plan was to do a longer recruitment period and a longer period of
mailing the postcards but, that timeframe had to be cut in half in order to complete the project on
time. Also, there was a plan to do a chart review to see if any patients returned to the ED and that
had to be cut as well. The inclusion criteria were narrow and prohibitive in recruiting patients.
There were multiple adolescent patients, several patients were admitted to the ICU, some
patients were discharged home, and others were intoxicated and unable to consent. This project
relied on participants to mail back questionnaires and it is an important limitation to mention. To
increase the potential for results, any future projects may need to consider other options to
receive post-intervention data, altering the inclusion criteria, and adding a chart review.
A study by Stanley and Brown (2018) which had a total of 1640 patients found that “a
safety plan intervention with follow-up was associated with a reduction in suicidal behavior and
increased treatment engagement among suicidal patients following ED discharge.” Even though
this project did not show statistical significance, based on this study, an intervention with a safety

SUICIDE PREVENTION IN THE ED

25

plan and follow-up is something emergency departments should consider. Recommendations for
further study would also include using a qualitative approach to see how patients perceived the
intervention.
Conclusion
Although this project did not show statistical significance that a combined safety plan and
follow-up intervention using postcards reduces suicidal behavior, an emergency department may
still benefit from their implementation. In several studies, these clinical tools have been shown to
positively impact patients in addressing their suicidal behavior. Every attempt should be made to
add these tools to the care provided to patients with suicidal ideation in the emergency
department. Projects that involve patients with suicidal behavior take a significant amount of
time to get through the IRB process and may not be a suitable population to incorporate into
Doctor of Nursing Practice projects due to their short implementation time.

SUICIDE PREVENTION IN THE ED

26
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SUICIDE PREVENTION IN THE ED

33
Appendix A

Table 1
Evaluation Table
Citation
Amadeo et al.,
(2015)
Testing brief
intervention
and phone
contact among
subjects with
suicidal
behavior: A
randomized
controlled trial
in French
Polynesia in
the frames of
the
WHO/Suicide
Trends in AtRisk
Territories
study
Funded by the
French
Polynesia
Ministry of
Health
No COI.
French
Polynesia

Theory/
Conceptual
Framework
Joyce
Travelbee’s
Human-toHuman
Relationship
Model

Design/
Method

Sample/ Setting

Design: RCT

N=200
IG (TAU + BIC)
(n=100)
CG (TAU)
(n=100)

Purpose:
Establish a
monitoring
system for
suicidal
behavior and
conduct a
RCT
intervention
for non-fatal
suicidal
behaviors.
Follow-up
period 18
months

Inclusion
Criteria: Patients
admitted to the ED
over 2008-2010 for
suicidal behavior
with short
psychiatric
hospitalization (24
hours)
Exclusion
Criteria: Maximm
entry to the study
was locked at 200
due to funding
limitations.

Major
Variables &
Definitions
IV- IG received
TAU + BIC,
BIC consisted of
one-hour
information
session and 9
follow-up
contacts (phone
calls) at 1, 2, 4,
7, 11 weeks and
4, 6, 12, 18
months after
intake
CG received no
contact
DV1-Number of
suicides
DV2-repeated
NFSB

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Survey questionnaire:
EPSIS

Chi-square
Fisher’s exact
test

There was a
reduction in the
number of
suicides and
episodes of
NFSB in the IG
Episodes of
NFSB:
IG: 26.7%
CG: 21%
Suicide:
IG: 0%
CG: 2%

Level/Quality of Evidence;
Decision for practice/
application to practice
LOE: II
WOS: A brief intervention and
phone contact reduced suicides
and NFSB
STR: RCT design; Patients were
happy to be involved in the
study.
WE: Size of sample and
timeframe may have impacted
the statistical significance.

No significant
difference in
the frequency
of SB between
the two groups.

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

Citation
Carter et al.,
(2005)
Postcards from
the EDge
project:
randomised
controlled trial
of an
intervention
using
postcards to
reduce
repetition of
hospital
treated
deliberate selfpoisoning
Funded by
NSW Health
No COI.
Risk of bias.
Australia

Theory/
Conceptual
Framework
Joyce
Travelbee’s
Human-toHuman
Relationship
Model

34

Design/
Method

Sample/ Setting

Design: RCT

N=772
IG (n=378)
CG (n=394)

Purpose: To
determine
whether an
intervention
using PCs
reduces
repetitions of
hospital
treated DSP
Follow-up
period 1 year

Inclusion criteria:
Participants (> 16
yr) presented to
toxicology service
from the ED with
DSP from April
1998 to December
2001)
Exclusion
criteria: Patients
not capable of
informed consent,
considered to pose
a threat to
interviewer, those
of ‘no fixed
address’

Major
Variables &
Definitions
IV- IG
received a PC
expressing care
and concern at
1, 2, 3, 4, 6, 8,
10, and 12 mo
after discharge.
CG received no
contact after
discharge
DV1- The
proportion of
patients with at
least one repeat
episode of DSP
in 12 mo
DV2- The
number of
repeat episodes
of DSP per
individual over
12 mo

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Toxicology service
database EMR to
measure outcomes

SPSS

-Significant
reduction in
repeat DSP
IG vs CG
-Proportion of
patients who
repeated
episode of
DSP:
IG: 15.1%
CG: 17.3%
-Number of
repeat episodes
of DSP:
IG: 101
CG: 192
-IRR of
repetition:
IG:0.55
CG:1.00
[ES=0.13 (CI:
0.35 to 0.87);
p>.01]
-Nonsignificant
reduction in
proportion of
individual
repeaters

Chi-square
Negative
binomial
regression

Level/Quality of Evidence;
Decision for practice/
application to practice
LOE: II
WOS: A PC intervention
reduced repeat DSP
STR: RCT design; good
randomization
WE: Questionable
generalizability to other settings.

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

Citation
Cebria et al.,
(2013)
Effectiveness
of a telephone
management
programme for
patients
discharged
from an
emergency
department
after a suicide
attempt:
Controlled
study in a
Spanish
population
Funded by
European
Commission,
Health
Department of
de Generalitat
de Catalunya

Theory/
Conceptual
Framework
Joyce
Travelbee’s
Human-toHuman
Relationship
Model

35

Design/
Method

Sample/ Setting

Design: CaseControlled
study

N=991
IG (n=604)
CG (n=387)

Purpose: To
determine the
effectiveness
of a specific
telephone
management
program on
patients
discharged
from an ED
after a SA
over one year.
Follow-up
period 1 year

Inclusion criteria:
Patients in the ED
with a SA and
treated in the years
2007 and 2008. No
age limit was set.
Exclusion
criteria: Patients
not willing to give
informed consent

Major
Variables &
Definitions
IV- IG received
telephone
follow-up after
1 week and then
1, 3, 6, 9, and
12-month
intervals to
assess SR
CG received no
contact
DV1- Time
elapsed between
the first SA and
subsequent one
DV2- Changes
in the annual
rate of patients
who reattempted
suicide in the
year of the
intervention

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Obtained data from
EMR

SPSS

Delayed time
between
suicide
reattempt, year
2008= 346.47,
sd= 4.65
Year 2007=
316.46, sd=
7.18; p <
0.0005

Kaplan-Meier
method
Chi-square
with Yates’
correction

Reduced the
rate of patients
who
reattempted
suicide
IG: 6%
CG: 14%,
difference 8%,
95% CI 2%12%

Level/Quality of Evidence;
Decision for practice/
application to practice
LOE: III
WOS: A telephone management
program is effective in delaying
SA and in reducing suicide
reattempts for patient admitted
to an ED with SI.
STR: Telephone follow-up was
started earlier, within a week,
and more frequent
WE: Difficulty in contacting
patients. Coincided with another
intervention that aimed at early
diagnosis of depression which
may have influenced results.

No COI.
Spain

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

Citation
Exbrayat et al.,
(2017)
Effect of
telephone
follow-up on
repeated
suicide
attempt in
patients
discharged
from an
emergency
psychiatry
department: a
controlled
study
Funded by
Regional
Public Health
Group of the
Rhone-Alpes

Theory/
Conceptual
Framework
Joyce
Travelbee’s
Human-toHuman
Relationship
Model

36

Design/
Method

Sample/ Setting

Design: CaseControlled
study

N=823
IG (n=436)
CG (n=387)

Purpose: To
evaluate the
efficacy of a
protocol of
telephone
follow-up on
any further
attempts

Inclusion criteria:
IG Patients seen
for SA in a psych
ED from Jan. 1Dec. 31 2010
CG Patients seen
in ED for SA in
prior year Jan. 1Nov. 30 2009 that
met same inclusion
criteria

Follow-up
period 1 year

Exclusion
criteria: Patients
younger than 18,
potentially harmful
or would interfere
with care

Major
Variables &
Definitions
IV- IG received
telephone
follow-up at 1
week, 1 month,
and 2 months
CG received no
contact
DV- Rate of
recidivism, a
repeated
suicidal gesture,
one year after
the initial
episode

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Systematic review of
EMR

Statistical
analysis
software

The rate of
repeated
suicide
attempts was
significantly
fewer among
IG than CG (p
= 0.037)

Chi-squared
test
t-test

The odds ratio
of recidivism
was lower:
0.50 (95% CI
0.62 to 0.80)

Level/Quality of Evidence;
Decision for practice/
application to practice
LOE: III
WOS: Telephone follow-up is a
protective factor against repeat
SA. Agreed with other studies
on risk factors of previous SA,
previous psychiatric
hospitalization, and personality
disorders
STR: Single center prospective
study using univariate and
multivariate analyses
WE: Potential sample selection
bias among control than study
patients.

No COI.
Risk of
selection bias.
France

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

Citation
Fleischmann
et al., (2008)
Effectiveness
of brief
intervention
and contact for
suicide
attempters: a
randomized
controlled trial
in five
countries
Funded by the
Department of
Mental Health
and Substance
Abuse, WHO
No COI.
Brazil, India,
Sri Lanka,
Iran, and
China

Theory/
Conceptual
Framework
Joyce
Travelbee’s
Human-toHuman
Relationship
Model

37

Design/
Method

Sample/ Setting

Design: RCT

N=1867
IG(BIC) (n=922)
CG(TAU)(n=945)

Purpose: To
determine
whether brief
intervention
and contact is
effective in
reducing
subsequent
suicide
mortality
among SA in
low and
middleincome
countries.
Follow-up
period 18
months

Inclusion criteria:
Patients in ED
setting for SA
Exclusion
criteria: Refusal
of enrollment,
death in the ward,
clinical conditions
not allowing an
interview, leaving
AMA

Major
Variables &
Definitions
IV- IG received
1-hour info
session about
suicidal
behavior at
discharge and 9
follow-up phone
calls and/or
visits at 1, 2, 4,
7, and 11 weeks,
and 4, 6, 12, and
18 months
CG received no
contact
DV- Death from
suicide at 18month followup

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Survey questionnaire:
EPSIS

Chi-squared
test

Significantly
fewer suicide
deaths occurred
in the IG than
in the CG.
Suicide deaths:
IG: 0.2%
CG: 2.2% (p <
0.001)

Level/Quality of Evidence;
Decision for practice/
application to practice
LOE: II
WOS: BIC provided a form of
psychosocial counseling and
supportive ongoing contact to
suicide attempters. BIC required
little training
STR: Good validity. Cost
effective.
WE: Difficult to keep track of
enrolled participants. Difference
in sample sizes across each of
the five sites.

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

Citation
HossanianMoghaddam et
al., (2011)
Postcards in
Persia:
randomised
controlled trial
to reduce
suicidal
behaviours 12
months after
hospitaltreated selfpoisoning
Funded by the
Legal
Medicine
Organization
of Iran and the
LoghamHakim
Research
Development
Unit

Theory/
Conceptual
Framework
Joyce
Travelbee’s
Human-toHuman
Relationship
Model

38

Design/
Method

Sample/ Setting

Design: RCT

N=2300
IG(BIC + TAU)
(n=1150)
CG(TAU)(n=1150)

Purpose: To
test the
efficacy of a
postcard
intervention to
reduce
suicidal
behavior.
Follow-up
period 1 year

Inclusion criteria:
Patients above 12
years of age seen in
ED for DSP
Exclusion criteria:
Treatment only in
the ED, incapable
of informed
consent, psychosis,
having no fixed
address, unable to
read, and potential
threat to
interviewer

Major
Variables &
Definitions
IV- IG received
8 postcards that
were mailed at
1, 2, 3, 4, 6, 8,
10, and 12
months after
discharge
followed by a
questionnaire
CG received no
contact
DV1- SA
DV2- SI
DV3- NFSB
(cutting)

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Toxicology service
database EMR to
measure outcomes

SPSS

A PC
intervention
reduced SI and
SA in patients
that DSP.

Chi-squared
Poisson
regression
t-test
ANOVA

SI:
IG: 29%
CG: 41.7%
RRR=0.31,
95% CI=0.22,
0.38
SA:
IG: 3%
CG: 5.1%
RRR=0.42,
95% CI=0.11,
0.63

Level/Quality of Evidence;
Decision for practice/
application to practice
LOE: II
WOS: A PC intervention was
effective in reducing SI and SA.
It expressed concern for the
patient and offered contact if
needed.
STR: Design of study was
strong, good validity.
WE: Randomization not carried
out by a third party. No effect of
SB (self-cutting)

SB:
IG: 4%
CG: 4.7%

No COI.
Risk of bias.
Iran

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

Citation
Inagaki et al.,
(2014)
Interventions
to prevent
repeat suicidal
behavior in
patients
admitted to an
emergency
department for
a suicide
attempt: A
meta-analysis
Funding by a
grant from the
Ministry of
Health, Labor,
and Welfare
No COI.
Japan

Theory/
Conceptual
Framework
Joyce
Travelbee’s
Human-toHuman
Relationship
Model

39

Design/
Method

Sample/ Setting

Design:
Systematic
review and
meta-analysis

NS=24
n=5319

Purpose: To
assess the
effects on
repeat SB of
interventions
initiated in
suicidal
patients
admitted to
EDs.

Inclusion criteria:
Studies that had
patients who had
SB or a SA within
1 month and were
admitted to an ED
for their SB,
intervention
performed while
patient was
admitted to ED and
effect of
intervention was
examined in a RCT
Exclusion
criteria: Studies
not written in
English language
and studies
examining
experimental
interventions

Major
Variables &
Definitions
IV1- active
contact and
follow-up
Subgroups were
a.intensive care
plus outreach
b.BIC
c.letter or PC
d.telephone
e.composite of
letter/postcard
and telephone
IV2psychotherapy
IV3pharmacotherapy
IV4miscellaneous
groups
DV1- repeat SA
DV2- deaths by
suicide
DV3- any-cause
death

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Classified the trials by
type of intervention

StatsDirect
software

Assessed for risk of
bias

I squared and
Cochrane Q
statistics

Interventions
of active
contact and
follow-up were
effective in
reducing the
risk of repeat
SA (n=5319;
pooled
RR=0.83; 95%
CI: 0.71 to
0.97)

Used a fixed
effects model
for trials that
had similar
interventions
Used a random
effects model
for trials to
examine
heterogeneity
Examined
effects of each
IG on repeat
SA, death by
suicide, and
any cause
death by using
a meta-

Level/Quality of Evidence;
Decision for practice/
application to practice
LOE: I
WOS: Findings have
implications for clinical policy
makers to prevent repeat SB in
patients admitted to the ED for
SA.
STR: Findings consistent with
another systematic review
confirming the beneficial effect
of interventions for patients
admitted to the ED with SA
WE: Several of the trials
combined multiple
interventions. Number of deaths
by suicide was low, therefore
limited statistical power made it
difficult to conclude whether
there was a beneficial effect of
the intervention on number of
deaths by suicide.

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

Citation
Motto et al.,
(2001)
A Randomized
Controlled
Trial of
Postcrisis
Suicide
Prevention
Funded by
grants from
the National
Institute of
Mental Health,
Center for
Studies of
Suicide
Prevention,
and Mental
Health
Services
Development
Branch

Theory/
Conceptual
Framework
Joyce
Travelbee’s
Human-toHuman
Relationship
Model

40

Design/
Method

Sample/ Setting

Design: RCT

N=843
IG(BIC + TAU)
(n=389)
CG(TAU)(n=454)

Purpose: To
test whether
long-term
contact with
patients with
SR can exert a
suicideprevention
influence
Follow-up
period 5 years

Inclusion criteria:
Patients seen in
psychiatric
inpatient facility
for SA or SI that
provided informed
consent
Exclusion
criteria: Unwilling
to provide
informed consent

Major
Variables &
Definitions
IV- IG were
contacted by a
short letter four
times a year for
5 years (total of
24 letters)
CG received no
contact
DV- Suicide
rate

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Data was obtained
from California State
Department of Health,
coroner’s records,
death certificates,
clinical sources and
family members.

Kaplan-Meier
survival
probability

Patients in the
IG had a lower
suicide rate.

Breslow
generalized
Kruskal-Wallis
test

IG: 0.77%
CG: 1.32%
(P value =
0.043)

Level/Quality of Evidence;
Decision for practice/
application to practice
LOE: II
WOS: A contact program was
associated with a significant
reduction in suicides rates
among high-risk persons.
STR: Effect of intervention
lasted for two years after
discharge from inpatient
psychiatric facility.
WE: No significant reduction in
suicide rate at 5 years but
showed a preventive trend.
Feasibility: Carried out with
modest resources.

No COI.
United States

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

Citation
Mousavi, et
al., (2014)
The efficacy
of telephonic
follow up in
prevention of
suicidal
reattempt in
patients with
suicide
attempt history
Sources of
support: Nil
No COI.
Iran

Theory/
Conceptual
Framework
Joyce
Travelbee’s
Human-toHuman
Relationship
Model

41

Design/
Method

Sample/ Setting

Design: RCT

N=139
IG(BIC + TAU)
(n=69)
CG(TAU)(n=70)

Purpose:
Evaluation of
telephone
follow-up on
suicide
reattempt
Follow-up
period 6
months

Inclusion criteria:
Patients admitted
to intoxication
emergency service,
15 years or older,
conscious state,
history of 2 prior
SA, possibility of
telephone contact
after discharge,
and acceptance for
participation

Major
Variables &
Definitions
IV- IG received
7 telephone
contacts after
discharge at 2nd
and 4th week
and months 2, 3,
4, 5, and 6
CG received no
contact
DV1- suicide
reattempt
DV2- SI

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Data gathered by an
initial and follow-up
questionnaire

SPSS

Telephone
contacts
significantly
reduced the
frequency of
suicidal
thought (P =
0.007) and
increased hope
in life (P =
0.001) in
patients with
repeat SA in
the IG
compared to
the CG

Chi-square test

Level/Quality of Evidence;
Decision for practice/
application to practice
LOE: II
WOS: Telephone follow-up
decreased suicidal thoughts and
increased hope in life
STR: Consistent findings with
other studies, more women than
men.
WE: Short time of follow up,
follow up only through
telephone contacts, focused on
patients with DSP

Exclusion
criteria: Patients
needing emergency
intervention,
declining consent,
and death before
discharge

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

Citation
Riblet et al.,
(2017)
Strategies to
prevent death
by suicide:
meta-analysis
of randomised
controlled
trials
Funding by
VA National
Center for
Patient Safety
Center of
Inquiry
Program
No COI.
United States

Theory/
Conceptual
Framework
Joyce
Travelbee’s
Human-toHuman
Relationship
Model

42

Design/
Method

Sample/ Setting

Design:
Systematic
review and
meta-analysis

NS=78
n=2028

Purpose: To
compare the
efficacy of
various
interventions
versus control
to prevent
death by
suicide in
adults

Inclusion criteria:
Limited to RCTs in
English language;
studies needed to
randomly assign
patients to
intervention aimed
at suicide
prevention or a
control such as
usual care; studies
with patients 18
years or older;
primary or
secondary aim of
studies to include
death by suicide
and/or SI or SB
Exclusion
criteria: RCTs
that compared two
or more active
treatments

Major
Variables &
Definitions
IV1- complex
psychosocial
interventions:
a.WHO BIC
b.CBT
c.other programs
IV2pharmacological
interventions:
a.antidepressants
b.lithium
c.antipsychotics
d.mood
stabilizers
IV3- higherlevel care
interventions
a.ECT
b.TMS

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Pooled results of
RCTs

Peto method

The World
Health
Organization
(WHO) brief
intervention
and contact
(BIC) was
associated with
significantly
lower odds of
suicide (OR =
0.20, 95% CI
0.09-0.42)

RevMan 5.3
Cochrane’s Q
I squared

Level/Quality of Evidence;
Decision for practice/
application to practice
LOE: I
WOS: WHO BIC intervention is
associated with significantly
lower odds of suicide.
STR: Used peto method for data
analysis. Peto method is good
for combining data when event
rates are below 1%. Did not
exclude studies based on quality
or relevance. Little
heterogeneity in the analysis.
WE: Several of the interventions
had small sample sizes which
made it difficult to estimate the
effect size.

DV- death by
suicide in adults

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

43
Appendix B

Table 2
Synthesis Table
Author
Year
Design/LOE
Number of subjects
Independent Variables
BIC + Phone calls
Telephone calls
Postcards
Letters
Dependent Variables
# of suicides
Repeat episodes of NFSB
Repeat episodes of DSP
Repeat episodes of SA
Repeat episodes of SI
Time between 1st SA and
subsequent one

Amadeo Carter Cebria Exbrayat Fleischmann HossanianMoghaddam
2015
2005 2013
2017
2008
2011
RCT, II RCT, CCS, CCS, III RCT, II
RCT, II
II
III
200
772
991
823
1867
2300

Inagaki Motto Mousavi Riblet

X

X
X
X
X

X

X

X

X

X

X
X
X

X

X

X
X
X

X

X
X

X

X
X
X

2014
SRMA,
I
24
studies

X

2001
RCT,
II
843

2014
RCT, II
139

X

2017
SRMA,
I
78
studies
X

X
X

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED
Any cause death
Measurement
Instrument
Questionnaire
Data from EMR
Data Analysis
Chi-square
SPSS
t-test
Kaplan-Meier
Cochrane’s Q
I squared
Findings
Reduction in # of suicides
Reduction in NFSB
Reduction in DSP
Reduction in SA
Reduction in SI
Reduction in time
between SA
Setting
Emergency Department
Inpatient Psychiatric
Facility
Follow-up Period

44
X

X
X

X

X

X

X
X

X
X

X

X

X
X

X
X

X

X

X

X
X
X

X

X
X

X

X
X

X

X

18
months

1 year 1 year

X

X
X

X
X

X

X

X

X
X

X
X
X
X

X

X

X

X

X

1 year

18 months

1 year

N/A

X

X

X
5
years

X

X
X

6
months

N/A

Key: AMA- against medical advice; BIC- brief intervention and contact; CCS- case controlled study; CG- control group; CIconfidence interval; COI-conflict of interest; DSP- deliberate self-poisoning; DV-dependent variable; ED- emergency department;
EMR- electronic medical record; EPSIS- European Parasuicide Study Interview Schedule; IRR- incidence risk ratio; IG- intervention
group; IV-independent variable; LOE- level of evidence; N-number of participants; NS-number of studies; n- subset of participants;
NFSB- non-fatal suicidal behavior; OR- odds ratio; PC- postcard; RCT- randomized controlled trial; RRR- relative risk reduction;
SA- suicide attempt; SB- suicidal behavior; SI- suicidal ideation; SPSS- statistical package for the social sciences; SR- suicide risk;
SRMA- systematic review and meta-analysis; STR- strengths; TAU- treatment as usual; WE- weaknesses; WOS- worth of study to
practice;

SUICIDE PREVENTION IN THE ED

45
Appendix C

The 1998 Iowa Model of evidence-based practice to promote quality care.

SUICIDE PREVENTION IN THE ED

46
Appendix D

Joyce Travelbee’s Human-to-Human Relationship Model.

SUICIDE PREVENTION IN THE ED

47

Appendix E

SUICIDE PREVENTION IN THE ED

48
Appendix F

SUICIDE PREVENTION IN THE ED

49
Appendix G

SUICIDE PREVENTION IN THE ED

50
Appendix H

SUICIDE PREVENTION IN THE ED

51
Appendix I

SUICIDE PREVENTION IN THE ED

52
Appendix J

SUICIDE PREVENTION IN THE ED

53
Appendix K

SUICIDE PREVENTION IN THE ED

54
Appendix L