Validation of a Secondary Screener for Suicide Risk: Results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE)

Abstract

Background: Validated secondary screeners are needed to stratify suicide risk among those with nonnegligible risk. This study tested the predictive utility of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Secondary Screener (ESS), one of the screeners listed by The Joint Commission's Patient Safety Goal 15 resources as a potential secondary screener for acute care settings.

Methods: The researchers performed secondary analyses of data collected for the ED-SAFE study. Data were collected during an emergency department (ED) visit for 1,376 patients who endorsed active suicide ideation or a suicide attempt in the past week. Participants were followed for 12 months using telephone-based assessments, review of health care records, and National Death Index query. The study examined the predictive validity of the individual items, total score, and a scoring algorithm using the total score and critical items. Bivariable analyses, multivariable logistic regression, and test operating characteristics were calculated.

Results: Of the 1,376 patients enrolled, most were positive for at least one indicator. Four of the indicators were significantly associated with several outcomes. Based on score and critical items, the patients were trichotomized: The three strata were associated with significantly different rates of prospective suicidal behavior, with 52% of the high-risk group engaging in suicidal behavior within 12 months.

Conclusion: The ESS possesses adequate operating characteristics for triage purposes. The researchers recommend validation in new samples to confirm its operating characteristics and potentially reduce its length by removing the substance and agitation items, which offered little predictive utility in this study.

Appendix 3:. Association between final strata and prospective outcomes at (a) 6 weeks and (b) 12 months

This figure shows the step change in prospective suicidal behavior associated with strata based on the secondary screener

Figure 1:

Shown are the six indicators of the Emergency Department Safety Assessment and Follow-up Evaluation Secondary Screener (ESS).

Figure 2:

ROC curve of associations between secondary screener score and outcomes: (a) association between score and suicide attempt at 6 weeks; (b) association between score and suicide attempt at 12 months; (c) association between score and any suicidal behavior at 6 weeks; and (d) association between score and any suicidal behavior at 12 months.