Introduction: Individuals who die by suicide often make ED contact the year prior to death. In accordance with Joint Commission recommendations, universal suicide screening has been implemented across UMass Memorial Health Care EDs, in an effort to improve quality of care for patients with suicide risk. We developed clinician decision aids, clinical workflows, and electronic health record (EHR) items, and introduced them using an 'at-the-elbow' training model in the ED.

Methods: We programmed a data visualization application (Tableau), which pulls data directly from the EHR, to measure suicide-positive detection rates and physician secondary screener completion. Training logs were completed following every shift, and were used to identify barriers to training and lessons learned.

Results: Over an average of 3.4 weeks per site, 207 ED clinicians (79 physicians, 32 residents, and approximately 96 nurses) were trained across all five EDs; encounters usually took 5-10 minutes. Trainers successfully reached 79 of 104 attending physicians (76%) across all sites. Suicide-detection rates increased post-training for three units, and secondary screening rates increased for four units. Three common barriers included understanding the definition of a suicide-positive screen; importance of physician secondary screening and how to use the tool for decision-making; and issues with nurse-physician communication of suicide risk.

Discussion: The 'at-the-elbow' approach was an efficient way of reaching the majority of ED clinicians and facilitated rapid-cycle improvement in response to emerging barriers. However, this approach was resource-intensive for project staff and not sustainable long term. Integration into onboarding and a 'train-the-trainer' model could improve sustainability.