摘要：Reducing deaths from veteran suicide is a public health priority for veterans who receive their care from the Department of Veterans Affairs (VA) and those who receive services in community settings. Emergency departments frequently function as the primary or sole point of contact with the health care system for suicidal individuals; therefore, they represent an important venue in which to identify and treat veterans who are at risk for suicide. We describe the design, implementation and initial evaluation of a brief behavioral intervention for suicidal veterans seeking care at VA emergency departments. Initial findings of the feasibility and acceptability of the intervention suggest it may be transferable to diverse VA and non-VA settings, including community emergency departments and urgent care centers. KEY FINDINGS ▪An innovative project (SAFE VET) designed to help suicidal veterans in emergency departments in the Department of Veterans Affairs (VA) has been successfully implemented in 5 intervention sites. ▪Using quality assurance data acceptability of the SAFE VET intervention was determined as percent of veterans willing to receive the intervention; information on follow-up mental health and other psychiatric services was also obtained. ▪SAFE VET is a promising alternative and acceptable delivery of care system that augments the treatment of suicidal veterans in VA emergency departments and helps ensure that they have appropriate follow-up care. If future research finds that this brief behavioral intervention is effective on key outcomes such as suicide attempts and engagement in care, the approach may be transferable to a wide variety of VA and non-VA settings, including community emergency departments and urgent care centers. Reducing deaths from veteran suicide and decreasing the burden on individuals and families caused by suicidal behavior in veterans is an important priority for the Department of Veterans Affairs (VA). Emergency departments (EDs) frequently function as the primary or sole point of contact with the health care system for suicidal individuals. 1,2 This contact often occurs either immediately following a suicide attempt or when suicidal thoughts escalate and the individual feels in danger of acting on these thoughts. Moreover, the risk of suicide is very high following contact with acute psychiatric services, 3 and persistent challenges exist for providing continuity of care after discharge. 4,5 Therefore, EDs represent an important venue in which to identify and treat veterans who are at risk for suicide. In response to a priority recommendation from a Blue Ribbon Panel on Veteran Suicide in 2008 6 VA leadership called for development and implementation of an ED-based intervention for suicidal veterans. The rationale for such an approach was based on the recognition that ED providers may prefer to hospitalize moderate risk patients because of limited availability and feasibility of interventions that can be provided in the ED. The Blue Ribbon panel recommended that the VA address this gap in services. We describe the design and implementation of an innovative brief behavioral intervention for suicidal veterans who seek care in VA hospital EDs. The overall vision of this VA initiative was to augment emergency mental health service delivery to (1) enhance identification of veterans at risk for suicide in VA hospital EDs, (2) provide a brief intervention to reduce risk, and (3) ensure that veterans receive appropriate and timely follow-up care. This clinical demonstration project became the Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment (SAFE VET) Project. Designed to mitigate suicidal thoughts and behaviors in veterans through a veteran-focused, clinical safety plan intervention conducted in EDs or Mental Health Urgent Care settings, SAFE VET includes an outreach protocol following discharge. The protocol includes facilitating the veteran’s transition to outpatient mental health care, maintaining veteran safety during this transition through regular telephone contact and reviewing and revising the veteran’s safety plan. Prior to development of the SAFE VET project, Stanley and Brown 7 developed an innovative clinical approach to suicide risk reduction across clinical settings for the general population. Stanley and Brown’s 7 initial strategy consisted of a brief behavioral intervention they called Safety Planning. Following the Blue Ribbon Panel recommendation, and in collaboration with VA clinicians, Stanley and Brown 8 then developed a modification of Safety Planning specifically tailored for the veteran population. The SAFE VET intervention is grounded on the tenets of Safety Planning, incorporating elements of 4 evidence-based suicide risk reduction strategies: (1) means restriction, (2) teaching brief problem-solving and coping skills (including distraction), (3) enhancing social support and identifying emergency contacts, and (4) motivational enhancement for further treatment. As a novel addition to Safety Planning, SAFE VET integrates intensive follow-up of veterans after discharge from the ED. Key to the delivery of the SAFE VET intervention was the creation of a new position in the VA, the acute services coordinator (ASC) who administers the veteran version of Safety Planning in the ED and makes all the follow-up contacts. The follow-up protocol involves both veterans and their families in implementation of the veteran’s individualized safety plan, which is tailored to the veteran’s distinctive warning signs, internal coping strategies, contacts of family members or friends, and contacts of professionals or agencies who can offer crisis assistance, including VA’s Suicide Hotline (now known as the VA’s Crisis Line). SAFE VET primarily targets those veterans who are assessed as being at moderate risk for suicide and who often become hospitalized. SAFE VET allows for immediate reduction in distress and therefore can provide an alternative to hospitalization. However, identification of high risk veterans also is a critical component of the SAFE VET Project because veterans identified as high risk may be hospitalized, placed on a VA Suicide Prevention Coordinator’s high-risk list, or referred for comprehensive outpatient follow-up. Regardless of level of risk, all veterans in the SAFE VET intervention receive VA’s Crisis Line number. Figure 1 outlines the pathway of veterans seen in VA ED or Urgent Care who are determined to be at some level of risk for suicidal behaviors. Open in a separate window FIGURE 1— Pathways to care for veterans in Veterans Affairs (VA) emergency department (ED) or urgent care settings. Note . SAFE VET = Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment. Open in a separate window FIGURE 2— Logo used to promote SAFE VET program.
