Formative evaluation of Zero Suicide in the emergency department: Identifying strategies to overcome implementation barriers

Background: Zero Suicide has been widely promoted as a comprehensive suicide prevention approach in healthcare systems, yet less is known about the barriers to implementing this approach in the emergency department.Objectives: This developmental evaluation aimed to assess emergency department providers' perceived knowledge and self-efficacy regarding suicide prevention practices, as well as apply the Consolidated Framework for Implementation Research to explore potential facilitators and barriers to implementing Zero Suicide and identify strategies to overcome barriers.Methods: A sequential mixed methods approach was used, including a survey assessing emergency department providers' perceived knowledge and attitudes and semi-structured interviews exploring potential determinants of implementation.Results: Survey respondents (n = 43) perceived that they have the knowledge and self-efficacy to implement clinical elements of Zero Suicide; however, interview participants (n = 18) revealed that some clinical elements are not implemented consistently and perceive implementation barriers across multiple levels, including limited training on suicide risk assessment and limited resources needed to engage and re-engage at-risk patients in their suicide care management plan and provide follow-up supportive contacts during patients' transitions in care.Conclusion: To overcome identified barriers in this setting, targeted implementation strategies are needed, including integration in electronic health record systems, leadership advocacy, and ongoing staff training.