36C24419R0052-016.pdf

Department of Veterans Affairs POLICY 116-16-436 Medical Center August 6, 2016 Wilkes-Barre, Pennsylvania 18711

SUICIDE SCREENING AND INTERVENTION

I. SCOPE/EFFECT: This Medical Center Policy (MCP) affects all clinical personnel under the purview of the Wilkes-Barre VA Medical Center.

II. PUPOSE: The purpose of this policy is to establish procedures and policies for the Wilkes-Barre VA Medical Center and all outpatient clinics that will provide screening, assessment and intervention of all patients for suicide.

III. POLICY: All patients with a primary diagnosis or primary complaint of emotional or behavioral disorder will have a Suicide Risk Assessment completed.

IV. PROCEDURE:

A. All patients admitted to the Wilkes-Barre VA Medical Center including the Community Living Center will be screened for suicide risk using the Initial Inpatient Nursing Assessment (IINA) contained as a nursing note template in the Computerized Patient Record System (CPRS). An example is provided as Attachment A.

B. All patients screening positive on the initial assessment are referred to the Suicide Prevention Coordinator and further evaluated for their suicide risk level by a Mental Health provider, who will complete the Suicide Risk Assessment (SRA) note template in CPRS. An example is provided as Attachment B. The SRA will include documentation of a narrative assessment and treatment plan. Additionally, SRA will be completed on prior to discharge on all inpatients that screened positive at the time of admission. A Suicide Safety Plan note template will also be completed in CPRS on all patients considered to be at risk for suicide and on patients identified with a High Risk Flag for suicide. A copy of the completed Suicide Safety Plan note will be handed to the patient.

C. Outpatients who screen positive for depression via Patient Health Questionnaire (PHQ-9) screening but are negative on the subsequent suicide risk screen will be referred to Mental Health Service for additional follow-up and will arrange for further evaluation and treatment as appropriate to patient needs. PHQ-9 positive outpatients who are positive for suicide will be immediately evaluated by a mental health/crisis worker for assessment/treatment action as appropriate.

http://vaww.archive.oqp.med.va.gov/oqp_services/performance_measurement/uploads/ mentalhealth/phq9.pdf http://vaww.archive.oqp.med.va.gov/oqp_services/performance_measurement/uploads/mentalhealth/phq9.pdf http://vaww.archive.oqp.med.va.gov/oqp_services/performance_measurement/uploads/mentalhealth/phq9.pdf

D. Suicide Behavioral Alerts for SRA positive patients are entered as postings into CPRS through collaboration with both Risk Management (via use of VA Form 10- 2633, Report of Special Incident Involving a Beneficiary http://vaww.va.gov/vaforms/medical/pdf/102633.PDF) and individual providers (via e-mail or consult to the Disturbed Behavior Committee).

E. A Mental Health provider will complete the suicide risk assessment, document any follow-up plan, and will arrange/provide for treatment according to plan, when appropriate. Additionally, on the inpatient psychiatry unit, a pre-discharge suicide risk re-assessment will be completed. A Suicide Safety Plan note will also be completed, as appropriate, and a copy of the completed Suicide Safety Plan note will be handed to the patient.

F. In the Community Living Center, the suicide screen is completed by nursing personnel through completion of the initial nursing assessment. A positive screen requires referral to the unit social worker for completion of suicide risk assessment.

When appropriate, the unit social worker will refer to a Mental Health provider for additional evaluation and/or treatment.

G. Within the Wilkes-Barre VA Medical Center Primary Care outpatient clinics and the Mental Health Clinic, suicide screening is initiated through application of PHQ-9, Depression Screen. Positive depression screens are referred to Mental Health/Behavioral Service. Positive suicide screens are escorted to the Mental Health Crisis Worker for further evaluation by SRA and by direct intervention of MHC provider to treat/admit/refer.

H. At Allentown and Williamsport Outpatient Clinics, patients will be screened by nursing personnel through application of PHQ-9, Depression Screen. Positive depression screens are referred to Allentown/Williamsport Outpatient Clinic Mental Health staff for follow-up. Positive suicide screens are escorted to mental health treatment team for evaluation and treatment/plan as crisis walk-in.

I. At other community based outpatient clinics (CBOCs) with mental health staff, screening is completed by nursing personnel through application of PHQ-9, Depression Screen. Positive depression screens and positive suicide screens are referred to Mental Health/Behavioral Service at Wilkes-Barre VA Medical Center for evaluation and appropriate treatment intervention. The Suicide Prevention Coordinators are also notified, whenever appropriate.

J. Patients and family members can call their primary care provider or the Suicide Prevention Coordinator if they have a crisis situation. After 4:30 PM, patients are advised to call the National Suicide Prevention number at 1-800-273-8255 (1-800-

273-TALK).

http://vaww.va.gov/vaforms/medical/pdf/102633.PDF

V. RESPONSIBILITIES:

A. Primary Care: Primary Care and Nursing are responsible for completion of the initial assessment on all patients at the Wilkes-Barre VA Medical Center and CBOC’s. Primary Care Service is responsible for notifying Mental Health/Behavioral Service of patients who require completion of Suicide Risk Assessment. Nursing Service is responsible for notifying the attending physician or psychiatrist of patients who are actively suicidal at the time of screening, arranging for escort of the patient to the location of the mental health provider/crisis worker who will be assessing the patient and for remaining with that patient until seen by the mental health provider/crisis worker.

B. Behavioral Medicine Service: Behavioral Medicine Service assumes responsibility for completion of the Suicide Risk Assessment and the appropriate treatment intervention for patients who screen positive for suicide risk and for re-assessment of inpatients, including the completion of the Suicide Safety Plan once the patient is determined not to be suicidal and is removed from 1:1 observation. A copy of the completed Suicide Safety Plan note will be handed to the patient. The Suicide Prevention Coordinator is responsible for the collection of performance data and submission of same to the Medical Center Director and the Performance Improvement Committee.

VI. CUSTOMER SATISFACTION: Patient and family satisfaction issues were considered in the development of this policy.

VII. REFERENCES: Uniform Mental Health Services Handbook 1160.01

VIII. RESCISSION: Medical Center Policy 116-12-436, Suicide Screening and Intervention, dated May 22, 2012.

IX. DISTRIBUTION: Electronic Access to All Employees

X. ATTACHMENTS: A, B

X Russell E. Lloyd

Medical Center Director

POLICY 116-16-436 ATTACHMENT A

TITLE: NURSING INITIAL ASSESSMENT / INITIAL TREATMENT PLAN

(PARENT)

LOCATION: ADMISSION DATE:

DATE OF NOTE: ENTRY DATE:

AUTHOR: EXP COSIGNER:

URGENCY: STATUS:

Problems:

Interventions:

Initial Goals:

Signed:

Cosigned:

TITLE: NUTRITION INITIAL ASSESSMENT / INITIAL TREATMENT

PLAN (CHILD)

DATE OF NOTE: STATUS:

Problem(s):

Interventions:

Initial Goals:

Signed:

TITLE: PSYCHIATRIST INITIAL ASSESSMENT ADM NOTE (CHILD)

DATE OF NOTE: STATUS:

Boilerplate Text Date:

COMMITMENT STATUS:

MENTAL STATUS EXAM: (Describe

APPEARANCE/ATTITUDE:

SPEECH PATTERN/THOUGHT PROCESSES:

AFFECT/MOOD:

THOUGHT CONTENT:

RISK FACTORS (suicidality / homicidal / unsafe behavior):

RISK FACTORS RELATED TO RESTRAINT USAGE (Drop Down)

None Pregnancy Obesity Seizures Ambulation Difficulty Other (Please elaborate)

COGNITIVE FUNCTION:

CONSCIOUSNESS (Sensorium):

ORIENTATION:

MEMORY (Immediate / short-term / remote):

INTELLIGENCE:

INSIGHT:

JUDGEMENT:

PHYSIOLOGICAL FUNCTIONING (sleep / appetite / weight / sexual functioning):

ABUSE HISTORY (Verbal / emotional / physical / sexual):

IDENTIFIED PATIENT WEAKNESSES / STRENGTHS:

DIAGNOSIS:

AXIS I:

AXIS II:

AXIS III:

AXIS IV:

AXIS V (GAF-Global Assessment of Functioning):

RECOMMENDATIONS:

Psychiatric:

Substance Abuse:

Medical:

ANTICIPATED DISCHARGE PLAN:

Anticipated aftercare plan:

MRC

Approved: 4/2/03 Job #03-12

Signed:

Receipt Acknowledged By:

TITLE: SOCIAL WORK INITIAL ASSESSMENT / INITIAL TREATMENT

PLAN (CHILD)

DATE OF NOTE: STATUS:

Problem(s):

Interventions:

Initial Goals:

Signed:

TITLE: ACUTE CARE INTERD TREATMENT PLAN (CHILD)

DATE OF NOTE: STATUS:

Multidisciplinary Treatment Team Meeting held on:

Present for meeting:

Discharge Plan:

Inpatient Treatment Plan:

1. Problem description:

Goal:

Interventions/by whom:

Frequency:

Evaluation Date:

2. Problem description:

Goal:

Interventions/by whom:

Frequency:

Evaluation Date:

3. Problem description:

Goal:

Interventions/by whom:

Frequency:

Evaluation Date:

Signed:

TITLE: OT ACUTE CARE INTERD PLAN (CHILD)

DATE OF NOTE: STATUS: COMPLETED

Identified needs for therapy:

Plan:

Goals to be met by discharge:

Signed:

TITLE: ACUTE CARE INTERD MEETING UPDATE (CHILD)

DATE OF NOTE: STATUS:

Multidisciplinary Treatment Team Meeting held on:

New Problem(s):

POLICY 116-16-436

ATTACHMENT A

1. Problem:

Goal:

Intervention with disciplines:

Signed:

POLICY 116-16-436 ATTACHMENT B

Wilkes-Barre VAMC

SUICIDE RISK ASSESSMENT

1. ASSESSMENT OVERVIEW

a. Current Suicidal Ideation / Intent / Plan: ( ) Yes ( ) No

If Yes:

Passive: ( ) Yes ( ) No Active: ( ) Yes ( ) No Intent: ( ) Yes ( ) No Plan: ( ) Yes ( ) No

Plan (if present): __________________________________________________

b. Previous Attempts: ( ) Yes ( ) No

Number of Attempts: ___________ Date of Most Recent Attempt: ______________ Methods: _______________________________________________________

c. Impulsivity/Aggression:

[ ] VIOLENCE: ( ) Yes ( ) No [ ] Verbal Aggression: ( ) Yes ( ) No [ ] Self Harm: ( ) Yes ( ) No

Examples: _______________________________________________________

d. Family History of Suicide: ( ) Yes ( ) No

Describe (Who and When):____________________________________________

2. OVERVIEW ACUTE RISKS

[ ] Recent Psychosocial Stressors (circle applicable and describe)

(a) Family ____________________________________________________

(b) Work_____________________________________________________

(c) Financial __________________________________________________

(d) Medical___________________________________________________

(e) Other_____________________________________________________

[ ] Weapons { } Currently Not Available { } Available

If available, is access restricted/removed? { } Yes { } No

How is access restricted? _______________________________________ If access is not restricted, reasons why_____________________________

Actions Recommended:_________________________________________

3. OVERVIEW OF PSYCHO-SOCIAL RISKS (check all that apply)

[ ] Social Support [ ] Environmental Change

[ ] Recent Discharge [ ] Recent Loss

[ ] Acute Life Stressors (example: Financial, Work, Homelessness etc)

SPECIFY:________________________________________________________

[ ] Family History of Suicide [ ] None

Social Risk Examples: _____________________________________________

4. PSYCHO-SOCIAL MITIGATING FACTORS

(Score each answer 0-3)

(3 – Strong; 2 – Some; 1 – Distant / Poor; 0 – None)

[ ] Family Support ______ [ ] Social Support ______ [ ] Therapeutic Support ______ TOTAL SCORE: ____________ [ ] Motivations ______ | [ ] Religiosity ______

5. OVERVIEW OF MENTAL ILLNESS

(a) Psychiatric Illness:

[ ] Depression [ ] Psychosis [ ] Bipolar Disorder

[ ] Impulse Control Disorders

[ ] PTSD

[ ] Substance Abuse (Active/Current)

(a) Drugs – Type: _____________________________________________

(b) Alcohol – Frequency: _______________ [ ] Serious Medical Illness:

(a) Type:

(b) Duration: _________________________________________________

[ ] Pain:

(a) Duration: _________________________________________________

(b) Severity: _________________________________________________

(b) Overview of Psychiatric Symptoms:

[ ] Depression ( ) No ( ) Yes [ ] Anxiety ( ) No ( ) Yes [ ] Hopelessness/Demoralization ( ) None ( ) Yes, occasional ( ) Yes, persistent [ ] Hallucinations

( ) None ( ) Yes, occasional ( ) Yes, severe

□ Auditory □ Visual □ Tactile □ Olfactory □ Command

If command hallucinations present, describe_____________________________

[ ] Delusions { } No { } Yes

Type:____________________________________________________________

(c) Treatment History:

[ ] No prior psychiatric treatment [ ] Active treatment compliance

[ ] Poor Adherence to Treatment [ ] Recent Medication Change (ex: Antidepressants, Pain Meds, etc) [ ] Pain treatment Compliance

Treatment History Comments: _______________________________________

6. RISK FACTOR INTERVENTIONS (Mark All) RECOMMENDATIONS TO

TREATMENT TEAM:

a. INPATIENT

[ ] Place/maintain on 1:1 observation

[ ] Medication Evaluation / Treatment [ ] Psychotherapy Intervention [ ] Refer for substance abuse treatment

[ ] Address Psychosocial factors (e.g., homelessness etc.)

SPECIFY ___________________________________________________

[ ] Arrange continuing care. SPECIFY ______________________________ [ ] Family involvement/schedule family meeting [ ] Removal of means prior to discharge [ ] Other______________________________________________________

b. OUTPATIENT

[ ] Psychotherapeutic intervention SPECIFY__________________________ [ ] Medication evaluation [ ] Admission/hospitalization [ ] Family agrees to observe patient [ ] Other social support (e.g. residence staff) agrees to observe patient [ ] Removal of means [ ] Arrange outpatient follow-up SPECIFY____________________________ [ ] Patient to be seen within 24 hours. BY WHOM _____________________ [ ] New Referrals sent SPECIFY ___________________________________

PATIENT RESPONSE TO INTERVENTION / RECOMMENDATION:

[ ] Positive [ ] Neutral [ ] Negative [ ] Unable to evaluate

DESCRIBE: _________________________________________________________

MRC Approved: 6-29-07 Job# 07-17 Rev (02-44)