The Suicide Assessment Five-step Evaluation and Triage, widely known as SAFE-T, is a structured, evidence-based method utilized by healthcare professionals to evaluate and manage a patient’s risk for self-harm. This standardized tool provides a consistent approach for clinicians across various settings to gauge the severity of suicidal intent and determine the appropriate immediate course of action. Its structured nature promotes a comprehensive and systematic evaluation process, ensuring no factors are overlooked during a high-stakes conversation. Using this formal protocol standardizes an otherwise complex and subjective clinical decision, ultimately supporting patient safety.
Defining the Suicide Assessment Five-step Evaluation and Triage
The full name of the protocol, Suicide Assessment Five-step Evaluation and Triage, defines its function as a tool for assessing risk and organizing intervention. Developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) in collaboration with other agencies, this framework provides a unified approach for clinicians. The goal is to reduce the variability in how suicide risk is assessed across different practitioners and clinical environments.
The SAFE-T protocol guides the clinician through a series of mandated inquiries, moving beyond simple checklists. It is designed as a triage and management tool, focusing on determining the immediate level of risk. This determination is then linked to specific, time-sensitive actions, helping clinicians make rapid, informed decisions about patient safety and necessary care escalation.
The Five Core Steps of the SAFE-T Protocol
The first step is to systematically Identify Risk Factors, exploring historical and current elements that increase the likelihood of a suicide attempt. These factors include a history of prior suicide attempts, which is a strong predictor of future risk. Other factors frequently noted are current substance use, recent significant losses, specific mental health diagnoses (such as major depression), and access to lethal means. The clinician notes which factors can potentially be modified through intervention to reduce the overall level of risk.
The second step is to Identify Protective Factors, which are elements of a person’s life that actively reduce suicide risk. These strengths may include a strong religious or cultural belief system, effective coping skills, or a strong sense of responsibility to family or pets. Identifying these factors helps shift the focus from pathology to resilience, which can be leveraged during the safety planning process. Protective factors are carefully evaluated, as they may not be sufficient to counteract a high level of acute risk.
The third step is to Conduct a Suicide Inquiry, involving specific and direct questioning about suicidal thoughts, plans, behaviors, and intent. This inquiry explores the ideation itself, including the frequency, intensity, and duration of the thoughts over the past 48 hours, the past month, and the worst time ever. The clinician must ask about any specific plan, including the timing, location, availability of the means, and any preparatory acts the person has taken.
A thorough inquiry also involves assessing the patient’s intent, which is the extent to which they believe the plan is lethal and the likelihood they will act on it. Direct questions about access to means are mandatory, such as whether a person has access to a gun or has stockpiled pills. Clinicians also explore the patient’s ambivalence, weighing the “reasons to live” against the “reasons to die” to understand the internal conflict.
The fourth step is to Determine the Risk Level and Intervention, requiring the clinician to synthesize the gathered information and categorize the risk. The risk is triaged into three levels: low, moderate, or high, with each level corresponding to specific clinical actions. A high-risk determination warrants immediate intervention, such as continuous observation or hospitalization, especially if there is a recent attempt or a highly lethal plan with intent.
The final step is to Document the assessment, rationale, intervention, and follow-up plan thoroughly. This documentation ensures continuity of care and provides a clear record of the clinical decision-making process. The record must include the specific findings from the risk and protective factor identification, the clinical rationale for the determined risk level, and the treatment plan implemented to address the current risk.
Integration into Clinical Practice and Safety Planning
The SAFE-T protocol is often referenced using a standardized “pocket card” that serves as a quick reference guide for clinicians. The systematic nature of the five steps facilitates a comprehensive evaluation even during high-stress situations in emergency departments or crisis centers. Following the determination of a risk level, the protocol directly informs the development of a personalized safety plan.
A safety plan is a collaborative, prioritized, written list of coping strategies and resources the patient can use during a suicidal crisis. This plan includes identifying personal warning signs, internal coping strategies, and external resources like friends, family, and crisis lines. The plan then outlines the specific professionals and agencies that should be contacted in an escalating crisis.
The protocol emphasizes the importance of follow-up care and appropriate referral based on the determined risk level. For patients discharged from a higher level of care, the tool facilitates a warm handoff, ensuring the outpatient provider is aware of the risk assessment and safety plan. This continuity of care is paramount, as the period immediately following discharge from an inpatient setting carries an elevated risk of suicide. The SAFE-T documentation acts as a shared communication tool across the entire care team.