Zero Suicide Framework Research Articles

Adapting the Zero Suicide framework to the adult emergency department setting: Strategies for nurse leaders

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.

The implementation of a zero-suicide framework in a child and youth mental health service in Australia: processes and learnings.

Suicide in children is a significant and growing problem. The "zero suicide" framework (ZSF) is one approach to suicide prevention used in health services for adults and children. This paper reports on the introduction of the first suicide prevention pathway (SPP) based on ZSF at a Child and Youth Mental Health Service (CYMHS) in Australia. It begins by describing the adaptations made to elements of the SPP originally designed for adults to meet the needs of children. Lessons learned in applying the SPP in the service are then discussed. The aim is to inform and improve practice in the use of zero suicide approaches in child and youth mental health settings in Australia and worldwide.

Descriptive analysis of 1,048 presentations in the first five years of a zero-suicide framework in a child and youth mental health service in Australia.

Suicide in children is a significant and unacceptable global phenomenon. This paper provides a descriptive overview of the children presenting in the first five years (2016-2021) of the implementation of the Zero Suicide Framework (ZSF) and Suicide Prevention Pathway (SPP) at a Child and Youth Mental Health Service in Queensland, Australia. Basic demographic variables (sex, age, socioeconomic status), and changes in presentations over time, are presented for 1,048 children. Completeness of selected SPP components relating to care planning and universal interventions are examined as an indicator of fidelity to the SPP model of care. The paper then focuses on the cohort of children who received care through the SPP in 2020, describing their demographic characteristics and baseline clinical scores. There was an increase in admissions each year and children presented with a diverse range of clinical needs. The SPP greatly increased the provision of first line interventions for patients. A standardized approach to suicide prevention improves consistency in management. These findings may inform the use of the ZSF/SPP in child mental health settings globally.

Employee attitudes toward suicide prevention and Counseling on Access to Lethal Means: initial findings from an academic medical center implementing the Zero Suicide framework.

Zero Suicide is a strategic framework designed to transform a healthcare system's suicide prevention activities. In 2020, University of Utah Health launched a Zero Suicide program and Counseling on Access to Lethal Means (CALM) training for its employees. In 2022, the healthcare system surveyed its workforce's attitudes toward suicide prevention and CALM. We sought to evaluate employees' attitudes and behaviors toward suicide prevention and CALM training following the launch of the Zero Suicide program. A Zero Suicide Workforce Survey was administered online through REDCap to all University of Utah Health employees. The analytic sample included 3,345 respondents. We used two-portion z-tests to compare the proportions of respondents who (1) completed CALM training and (2) did not yet complete the CALM training because they felt it was irrelevant to their position by different employee characteristics. More than half of the respondents in the analytic sample were directly interacting with patients who may be at risk for suicide (57.6%). About 8.4% of the respondents had completed CALM training. Among those who had not yet completed CALM training, 9.5% indicated they did not think CALM was relevant to their job. Respondents knowledgeable about warning signs for suicide and respondents who were confident in their ability to respond when suspecting elevated suicide risk were significantly more likely to complete CALM training. This evaluation provides important insights from the workforce of a large academic medical center implementing a Zero Suicide program, including insights on opportunities for improving program implementation and evaluation.

The Paradox of Suicide Prevention.

The recognition that we cannot use risk stratification (high, medium, low) to predict suicide or to allocate resources has led to a paradigm shift in suicide prevention efforts. There are challenges in adapting to these new paradigms, including reluctance of clinicians and services to move away from traditional risk categorisations; and conversely, the risk of a pendulum swing in which the focus of care swings from one approach to determining service priority and focus (e.g., diagnosis, formulation, risk and clinical care) to a new focus (e.g., suicide specific and non-clinical care), potentially supplanting the previous approach. This paper argues that the Prevention Paradox provides a useful mental model to support a shift in paradigm, whilst maintaining a balanced approach that incorporates new paradigms within the effective aspects of existing ones. The Prevention Paradox highlights the seemingly paradoxical situation where the greatest burden of disease or death is caused by those at low to moderate risk due their larger numbers. Current planning frameworks and resources do not support successful or sustainable adoption of these new approaches, leading to missed opportunities to prevent suicidal behaviours in healthcare. Adopting systems approaches to suicide prevention, such as the Zero Suicide Framework, implemented in a large mental health service in Australia and presented in this paper as a case study, can support a balanced approach of population- and individual-based suicide prevention efforts. Results demonstrate significant reductions in re-presentations with suicide attempts for consumers receiving this model of care; however, the increasing numbers of placements compromise the capacity of clinical teams to complete all components of standardised pathway of care. This highlights the need for review of resource planning frameworks and ongoing evaluations of the critical aspects of the interventions.

Studying the implementation of Zero Suicide in a large health system: Challenges, adaptations, and lessons learned

BackgroundSuicide remains the 10th leading cause of death in the United States. Many patients presenting to healthcare settings with suicide risk are not identified and their risk mitigated during routine care. Our aim is to describe the planned methodology for studying the implementation of the Zero Suicide framework, a systems-based model designed to improve suicide risk detection and treatment, within a large healthcare system. MethodsWe planned to use a stepped wedge design to roll-out the Zero Suicide framework over 4 years with a total of 39 clinical units, spanning emergency department, inpatient, and outpatient settings, involving ∼310,000 patients. We used Lean, a widely adopted a continuous quality improvement (CQI) model, to implement improvements using a centralize “hub” working with smaller “spoke” teams comprising CQI personnel, unit managers, and frontline staff. ResultsOver the course of the study, five major disruptions impacted our research methods, including a change in The Joint Commission's safety standards for suicide risk mitigation yielding massive system-wide changes and the COVID-19 pandemic. What had been an ambitious program at onset became increasingly challenging because of the disruptions, requiring significant adaptations to our implementation approach and our study methods. ConclusionsReal-life obstacles interfered markedly with our plans. While we were ultimately successful in implementing Zero Suicide, these obstacles led to adaptations to our approach and timeline and required substantial changes in our study methodology. Future studies of quality improvement efforts that cut across multiple units and settings within a given health system should avoid using a stepped-wedge design with randomization at the unit level if there is the potential for sentinel, system-wide events.

Exploring mental health clinicians' perceptions of the Zero Suicide Prevention Initiative

Suicide continues to impact rural and regional families and communities across Australia and has become a key focus of healthcare, research, and government policy in recent years. The challenge for healthcare organizations is to translate policy visions and research for clinicians to effectively embed in day to day practice when supporting people who experience suicidal crisis. This study explored the introduction of an evidence-based Zero Suicide framework that includes a suicide prevention pathway and training package to a rural and regional community mental health team in Victoria, Australia. A qualitative semi-structured interview technique was used to explore the perceptions of mental health clinicians of the Zero Suicide approach, the training package and the barriers to inform its implementation across a specialist mental health service. Clinicians were complimentary of the intent of Zero Suicide and the training package and felt they had increased confidence in delivering suicide safe care. Four major themes were identified through thematic analysis: (i) Minimizing risk with realistic expectations; (ii) A good approach to making a difference; (iii) Lessons learnt; and (iv) Barriers to implementation needing to change culture. Overall participants identified the importance of continued regular suicide prevention training for all staff but also in tailoring it to different consumer and clinician needs. In addition, organizational structure and adequate staff resourcing were important to participants as was working within a safety culture.

Towards Zero Suicide: need and opportunities to improve implementation of clinical elements for older adults.

The Zero Suicide (ZS) framework is increasingly used in Australia, but without published adaptations for older people, and limited access by older people when implemented. The aim of this paper is to inform Towards Zero Suicide (TZS) implementations to benefit older adults by considering the key differences in older adults at risk of suicide according to each clinical component of the ZS framework. TZS aspires to reduce deaths by suicide for people within healthcare by refocusing interventions on suicidality rather than diagnosis alone, emphasising evidence-based practices and cultural change. For TZS to be effective for older people, it is essential to ensure practices are based upon evidence relevant to older people and to ensure ageism is effectively counteracted. Older adults have distinct patterns of help seeking and service use, accompanied by differences in risk factors, presentations, and outcomes of suicidal behaviours. Ageism affects assessment, decision-making and actions to address self-harm and suicide for older people. Immediate and longer-term actions are essential to effectively implement TZS in this population.

Consumer and Carer Perspectives of a Zero Suicide Prevention Program: A Qualitative Study.

This study explored the experiences of healthcare consumers who had recently attempted suicide, and their carers, following placement on a Suicide Prevention Pathway based on the Zero Suicide framework. Qualitative interviews were conducted with 10 consumers and 5 carers using a semi-structured interview schedule. Interviews were transcribed and thematic analysis was applied to identify prominent themes and sub-themes. Three interrelated themes were identified. The first theme was ‘Feeling safe and valued’ with the associated sub-theme pertaining to perceived stigmatizing treatment and self-stigma. The second was ‘Intersection of consumer and staff/organizational needs’ with a related sub-theme of time pressure and reduced self-disclosure. The final theme was ‘Importance of the ‘whole picture’, highlighting the relevance of assessing and addressing psychosocial factors when planning for consumer recovery. Overall, consumers and their carers reported a favorable experience of the Suicide Prevention Pathway; however, there were several areas identified for improvement. These included reconciling the time-pressures of a busy health service system, ensuring consumers and carers feel their psychosocial concerns are addressed, and ensuring that adequate rapport is developed. Key to this is ensuring consumers feel cared for and reducing perceptions of stigma.

AN ASPIRATIONAL GOAL OF ZERO SUICIDE: PREVENTING SUICIDE DEATHS WITHIN THE HEALTHCARE SYSTEM THROUGH INDIVIDUAL AND ORGANIZATIONAL CHANGE

This Clinical Perspectives is designed to draw attention to the increasing rates of suicide among children and adolescents and discuss the importance of addressing this national health problem. We will discuss how different pediatric healthcare institutions have included elements from the Zero Suicide framework within their work in screening, treatment, and prevention of youth suicide. This talk includes 4 presentations. The first is a discussion about the Zero Suicide framework as a model to reduce suicide within a healthcare system. The second presentation will highlight the development of a clinical care pathway that can be used when caring for youth at risk for suicide. The third presentation will focus on a curriculum for training pediatric residents on suicide prevention that combines a didactic with standardized patients. The final presentation will showcase one successful pediatric hospital system’s implementation and expansion of the Zero Suicide framework. Youth suicide is the second leading cause of death for children and adolescents aged 10-21 years in the United States and worldwide, and it is the fifth leading cause of death for children aged 5-15 years. Within the month prior, 40% of youth who died by suicide visited a medical setting. This emphasizes the importance of having comprehensive suicide care within a healthcare system, including training providers to screen, assess, and treat for suicidal ideation. The Zero Suicide framework is one example of a transformational model that reduces suicide in healthcare systems by using evidence-based interventions. Pediatric healthcare systems that have incorporated elements of Zero Suicide have demonstrated that it is feasible, reduces variability, and changes providers’ attitudes. There is a worldwide mental health crisis with increasing rates of suicide deaths, which has worsened in the setting of the COVID-19 pandemic. In order to reduce suicides, it is critical to focus on both the training of individual providers and on comprehensive, organizational change. The Zero Suicide framework is an evidence-based interventional model that can be applied to everything from clinical decision making and training providers to quality improvement and data monitoring.

20.1 ZERO SUICIDE: COMPREHENSIVE, EFFECTIVE SUICIDE CARE IN HEALTH CARE

People who die by suicide are touching the healthcare system. Eighty-three percent of those who die by suicide have seen a healthcare provider (emergency room, primary care, specialty care) in the year before their death, but many patients do not disclose their thoughts of suicide and almost half of those who die by suicide do not have a mental health diagnosis at the time of their death. Evidence-based practices that target reductions in suicide thoughts and behaviors do exist but are underutilized, and most providers, including licensed mental health providers, are not trained in or familiar with these practices. This presentation will describe the Zero Suicide framework, a comprehensive, system-wide, transformational model that reduces suicide in healthcare systems. Zero Suicide is both an aspirational goal as well as a detailed roadmap for how healthcare leaders can reduce suicide and suicide behaviors among their patients. Fundamental to Zero Suicide is a multilevel-system view on suicide prevention that includes: evidence-based clinical interventions that directly address suicidal behaviors; continual improvement of the quality and safety of care processes using meaningful data collection efforts; and an organizational commitment to the aspirational goal of zero suicides. This presentation will describe the core clinical components of Zero Suicide that providers can start using immediately, how to support the adoption of a robust Zero Suicide initiative in a healthcare system, and the outcomes seen in healthcare systems that have already adopted this framework. Central to this discussion will be the powerful role of leadership and culture change to transform suicide care and save lives. Healthcare systems that have adopted a Zero Suicide framework have seen suicide reductions by their patients by as much as 65% to 75%. Evidence-based practices now exist to better identify and effectively care for people at risk for suicide. In order to reduce suicide, as well as improve the wellness, hope, and resiliency for those at risk, suicide prevention must be seen as a core responsibility of health care, and every person in the system must be trained to use best practices. This presentation will provide an overview of Zero Suicide, a comprehensive, effective, transformative model for reducing suicides in health care.

Surveillance for Violent Deaths - National Violent Death Reporting System, 34 States, Four California Counties, the District of Columbia, and Puerto Rico, 2017.

Surveillance for Violent Deaths - National Violent Death Reporting System, 34 States, Four California Counties, the District of Columbia, and Puerto Rico, 2017.

Implementing a systems approach to suicide prevention in a mental health service using the Zero Suicide Framework.

The Zero Suicide Framework, a systems approach to suicide prevention within a health service, is being implemented across a number of states in Australia, and internationally, although there is limited published evidence for its effectiveness. This paper aims to provide a description of the implementation process within a large health service in Australia and describes some of the outcomes to date and learnings from this process. Gold Coast Mental Health and Specialist Services has undertaken an implementation of the Zero Suicide Framework commencing in late 2015, aiming for high fidelity to the seven key elements. This paper describes the practical steps undertaken by the service, the new practices embedded, emphasis on supporting staff following the principles of restorative just culture and the development of an evaluation framework to support a continuous quality improvement approach. Improvements have been demonstrated in terms of processes implementation, enhanced staff skills and confidence, positive cultural change and innovations in areas such as the use of machine learning for identification of suicide presentations. A change to 'business as usual' has benefited thousands of consumers since the implementation of a Suicide Prevention Pathway in late 2016 and achieved reductions in rates of repeated suicide attempts and deaths by suicide in Gold Coast Mental Health and Specialist Services consumers. An all-of-service, systems approach to suicide prevention with a strong focus on cultural shifts and aspirational goals can be successfully implemented within a mental health service with only modest additional resources when supported by engaged leadership across the organisation. A continuous quality improvement approach is vital in the relentless pursuit of zero suicides in healthcare.

Efficacy of the Zero Suicide framework in reducing recurrent suicide attempts: cross-sectional and time-to-recurrent-event analyses.

The Zero Suicide framework is a system-wide approach to prevent suicides in health services. It has been implemented worldwide but has a poor evidence-base of effectiveness. To evaluate the effectiveness of the Zero Suicide framework, implemented in a clinical suicide prevention pathway (SPP) by a large public mental health service in Australia, in reducing repeated suicide attempts after an index attempt. A total of 604 persons with 737 suicide attempt presentations were identified between 1 July and 31 December 2017. Relative risk for a subsequent suicide attempt within various time periods was calculated using cross-sectional analysis. Subsequently, a 10-year suicide attempt history (2009-2018) for the cohort was used in time-to-recurrent-event analyses. Placement on the SPP reduced risk for a repeated suicide attempt within 7 days (RR = 0.29; 95% CI 0.11-0.75), 14 days (RR = 0.38; 95% CI 0.18-0.78), 30 days (RR = 0.55; 95% CI 0.33-0.94) and 90 days (RR = 0.62; 95% CI 0.41-0.95). Time-to-recurrent event analysis showed that SPP placement extended time to re-presentation (HR = 0.65; 95% CI 0.57-0.67). A diagnosis of personality disorder (HR = 2.70; 95% CI 2.03-3.58), previous suicide attempt (HR = 1.78; 95% CI 1.46-2.17) and Indigenous status (HR = 1.46; 95% CI 0.98-2.25) increased the hazard for re-presentation, whereas older age decreased it (HR = 0.92; 95% CI 0.86-0.98). The effect of the SPP was similar across all groups, reducing the risk of re-presentation to about 65% of that seen in those not placed on the SPP. This paper demonstrates a reduction in repeated suicide attempts after an index attempt and a longer time to a subsequent attempt for those receiving multilevel care based on the Zero Suicide framework.

Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework.

The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians' experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent 'inconvenient truths' that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture-based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.