36C24419R0074-015.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

Erie, Pennsylvania

Medical Center Memorandum No. 116-05 June 7, 2018

SUICIDE IDENTIFICATION AND PREVENTION

I. PURPOSE: To delineate policies, responsibilities, procedures, and guidelines for mitigating the risk of suicide through screening and action.

II. POLICY:

A. Any patient who presents to or calls the Medical Center or a Community Based Outpatient Clinic (CBOC) with a primary complaint of an emotional or behavioral disorder will be assessed for suicide risk.

B. Any patient who screens positive for suicide risk will be further assessed by a Behavioral Health (BH) clinician on the same day.

C. Patients who are identified at high risk for suicide will be identified with a Category I Suicide Risk Flag.

D. The Medical Center will provide support for patients who are deemed to be at high risk for suicide and will advise and educate staff concerning suicide prevention strategies for individual patients.

E. Inpatients and residents will be assessed by Suicide Prevention Coordinators (SPCs) and individualized recommendations will be provided to unit staff regarding their care and environment.

III. RESPONSIBILITY:

A. The Chief of Staff and the Medical Center Director are jointly responsible for initiating, implementing, and assuring compliance with this policy.

B. The Medical Director, Primary Care; the Chief, Behavioral Health; the Medical Director, Community Living Center; the Medical Director, Hospitalist Services;

and the Supervisor, Urgent Care Center are responsible for ensuring that patients are screened for suicide.

C. BH clinicians are responsible for completing suicide assessments, screening patients for lethality at every behavioral health appointment, determining level of severity, and developing a safety plan if deemed at high risk.

Attachment M

MCM 116-05, Suicide Identification and Prevention

D. The Suicide Prevention Coordinators (SPCs) are responsible for implementation of suicide prevention strategies within the VA Medical Center to help ensure that all appropriate measures are being taken to prevent suicide in the patient population.

E. The SPCs, in coordination with treating providers, are responsible for determining appropriateness of placing the Patient Record Flag (PRF), reviewing patients who have been flagged, and removing the PRF when patients are no longer considered at high risk for suicide.

F. The Assistant Chief, Behavioral Health, completes a clinical review of all consults to ensure that patients have received an initial screening evaluation.

G. Community Living Center (CLC) Nurse Managers are responsible for ensuring that Safety procedures and staff education for high risk Veterans are followed.

IV. PROCEDURES:

A. Patients who present to the Medical Center with a primary complaint of an emotional or behavioral problem will be screened for suicidality and immediate care needs by a Licensed Independent Provider (which includes primary care – providers, Urged Care Center physicians, behavioral health social workers, licensed professional counselors, psychologists, psychiatrists, nurse practitioners, and physician assistants). The Licensed Independent provider must ensure safety and identify urgent care needs, identify the appropriate setting and specialty for evaluation and treatment, arrange for treatment, respond to the patient’s questions or concerns, and facilitate engagement into mental health care. Unless the need is urgent, this can be facilitated through the completion of behavioral health clinical reminders and a routine behavioral health consult (see Attachment B). Each consult is reviewed by the Assistant Chief, Behavioral Health to ensure that the initial screening has been completed. If it was not completed, Primary Care/Mental Health Integration staff is directed to call the patient to complete a screening assessment.

B. All patients who screen positive for depression and/or Posttraumatic Stress

Disorder will be screened for suicide by a Licensed Independent Provider.

1. Patients will be asked a standardized set of questions (Attachment A).

2. If the Veteran is seen in Erie and initial screen is positive, the Primary

Care/Mental Health Integration clinicians should be paged to complete a further assessment. Veterans who are seen in the CBOC who need further assessment should have a same day access consult placed and the Veteran will be further screened by a mental health Licensed Independent Provider. If a behavioral health clinician is not available at the CBOC, a provider will assess the Veteran using clinical video technology (CVT).

3. If the screen is positive, the BH clinician and/or the SPCs will develop a safety plan for the patient ensuring that he/she has considered the patient’s safety, mitigating factors, history, and risk factors.

4. If the patient in Erie is determined to be at imminent risk to self or others, arrangements will be made for admission to an inpatient facility. If not already in the Urgent Care Center (UCC), the patient will be escorted to the UCC by a BH clinician and will be placed in a safe room as directed in MCM 118-20, One to One Observation. If a safe room is already occupied, another room will be utilized and arms-length 1:1 will be initiated until a safe room is available. Police will conduct a safety check to ensure that the patient does not have any weapons or contraband. This will be conducted in the UCC if the patient presents directly to the UCC.

If in the BHC or another clinical area, the search will be conducted before being escorted to the UCC. Staff who identifies patients at imminent risk in a CBOC will follow guidelines established in MCM 116-18: Behavioral Health Emergency Guidelines for CBOCs.

C. Patients who call the Medical Center or CBOC with a primary complaint of an emotional or behavioral problem will also be screened for suicidality. Patients who are new to the Behavioral Health Clinic who are self-referring will be warm transferred to the Primary Care/Mental Health Integration line (x6995) and will be screened for immediate needs and suicide. Veterans who call in crisis to any area of the Medical Center or a CBOC should be warm transferred to the Suicide Prevention Coordinators at extension 6996 or 6999. Any Veteran established with Behavioral Health who calls the Medical Center or CBOC requesting a mental health appointment with their provider will be asked if they need to speak with someone immediately and transferred to Behavioral Health (x2038) or the Suicide Prevention Coordinators (x6996 or x6999) at their request.

D. Patients who are determined to be at high-risk for suicide will be indicated as such, utilizing the Patient Record Flag system.

1. High-risk suicidal patient: A patient with a current reported or witnessed suicide attempt or current serious identified ideation that requires an immediate treatment plan change such as hospitalization. Presence of any of the following warning signs: threatening to hurt or kill themselves with a plan; looking for specific ways to kill themselves and seeking access to means such as pills, weapons, or other means; talking or writing about death, dying, or suicide; or a patient who is deemed to be at high-risk determined by the judgment of a clinician.

2. Suicide Risk Flag: A flag that appears as a pop-up warning notifying all clinical staff of patients who are deemed as high risk for suicide.

E. The Suicide Prevention Coordinators will coordinate suicide prevention strategies and provide education to all facility leadership, managers, and staff and will:

1. Maintain a list of patients at high-risk for suicide, including but not limited to, those who have suicidal ideation and those who survived suicide attempts, as well as others with high-risk behaviors.

2. Call all patients who have had suicide attempts and advise clinicians of these attempts throughout the Medical Center by including them as additional signers on a templated note.

3. Track any no-show appointments by these patients and follow up with the patient as soon as possible to reschedule the appointment.

4. Patients who are admitted for hospitalization as a result of a high-risk for suicide behaviors must be placed on the high-risk list and kept on the list for a period of at least 3 months after discharge. Patients identified as surviving a suicide attempt and those who are placed on the high-risk list for other reasons should also be clinically evaluated at least weekly for a minimum of 30 days.

5. Disseminate, organize, and conduct evidence-based practices for emerging suicide prevention.

6. Ensure that all patients are aware of how to access assistance if in crisis to include the Veterans Crisis Line at 1-800-273-8255, county crisis lines, and the availability of 24/7 on-call through the Behavioral Health Clinic.

7. Work with community resources such as Veteran Service Organizations and other community groups to ensure that they are aware of how to recognize Veterans at risk for suicide and their options for getting these Veterans assistance.

8. Develop and implement an ongoing education plan for providers, Veterans, families, and members of the community on risk factors and warning signs for suicide and treatment options.

9. Track and follow up with patients who call the Veterans Crisis Line.

F. Veterans who are admitted to the medical center for inpatient, residential, or rehabilitative care are screened for suicide. In the event a Veteran is admitted who has a high risk suicide flag, the following measures will also be taken to continually ensure their safety during the admission:

1. A Behavioral Health inpatient consult will be placed for the purpose of initiating coordination of care and suicide prevention recommendations with the SPCs.

2. The SPCs, in conjunction with the CLC Psychologist, will develop personalized suicide prevention recommendations which may include, but is not limited to:

a. Initiation of an arms-length 1:1

b. Completion of the Suicide Prevention Environmental Checklist

(Attachment B) in order to reduce environmental hazards

c. Transfer of care to another facility

d. Consultation with Behavioral Health medication prescribers for medication recommendations

e. Completion of a safety plan

3. The SPCs, in conjunction with the CLC Psychologist, will provide personalized, just-in-time education to unit staff on suicide prevention strategies for Veterans who are admitted with high risk flags. Attempts will be made to provide the training in-person. However, read-and-sign copies of the recommendations will also be provided for staff that is unable to attend face-to- face trainings. The CLC managers will ensure that staff completes the read-and-sign or face-to-face education.

4. Hospitalists/CLC Providers will conduct suicide risk screens as part of the medical evaluation on all Veterans with high-risk flags who return to the unit following elopement.

V. REFERENCES:

A. Gitto, Michael F., MD and Rai, Anil K., MD. Evaluation and Treatment of Patients with Suicidal Ideation, Veterans Affairs Medical Center and University of Pennsylvania, Philadelphia, PA, 1999

B. 2015 National Patient Safety Goals – Joint Commission (Behavioral Health Care, effective January 1, 2015: NPSG.15.01.01, Identify individuals at risk for suicide)

C. MCM 118-20, One to One Observation, current edition

D. Mental Health Informational Bulletin: Guidance to Reduce Elopements by Mental Health Patients, dated October 31, 2014

E. MCM 116-18, Behavioral Health Emergency Guidelines for CBOCs, current edition

F. My VA Access: Mental Health Breakthrough Initiative Memo, dated April 22, G. A Guide to Promoting Emotional Health and Preventing Suicide in Senior Living

Communities (2011), U.S. Department of Health and Human Services H. Podgorski, C.A., Langford, L., Pearson, J.L., & Conwell, Y. (May, 2010). Suicide

Prevention for Older Adults in Residential Communities: Implications for Policy and Practice. PLoC Med, v.7 (5).

VI. FOLLOW UP RESPONSIBILITY: Chief, Behavioral Health

VII. REPORTING REQUIREMENTS: Quarterly Report to the Medical Executive

Committee

VIII. RESCISSION: MCM 116-05, Suicide Identification and Prevention, dated December 2, 2016.

(Original signed 6/7/2018) John A. Gennaro Medical Center Director

Attachments: A. Suicide Risk Screening Questions B. Suicide Prevention Environmental Checklist: Inpatient and Residents

ATTACHMENT A

SUICIDE RISK SCREENING QUESTIONS

Are you feeling hopeless about the present or future?

If yes: Have you had thoughts of taking your own life?

If yes: When did you have these thoughts?

Do you have a plan to take your own life?

Have you ever had a suicide attempt?

Do you have any thoughts of harming others?

If yes: Description/dates:

ATTACHMENT B

SUICIDE PREVENTION ENVIRONMENTAL CHECKLIST:

INPATIENT AND RESIDENTS

Last 4/initial: ___________________ Date: _________________

Initial when completed

Safety Measure

Remove all unnecessary medical supplies from room, particularly those that can pose as a hanging hazard (e.g., slings, tubes, lifts, cords)

Remove all plastic bags, to include those in garbage cans Store duffel bags/back packs out of patient room (handles can be removed and used for hanging) Remove any sharp or potentially dangerous objects from the room to include, but not limited to, razors, knives, safety pins, paper clips, glass vases, hand-held mirrors, glass in picture frames, and scissors

Remove necklaces, ties, or other neckwear from patient and patient’s room that could pose as a hanging hazard

Meals should be served on paper plates and tray with paper containers – no utensils are preferred. If this is not possible, utensils should be plastic. No cans/glass.

Ensure there are no personal or VA cleaning supplies left in the room. Other potential poisonous substances, to include colognes and other personal care liquids, should be removed.

Remove hangers Remove laundry bags from room and restroom If available, replace all call bell, electrical, telephone, and medical cords with shortened versions of the cord.

Ensure that sharp materials are not located in the hallways, at nurse station, in common areas if the individual is mobile.

Remove as many items as possible from room that could be used to barricade or throw. This includes personal items, furniture, etc.

If blinds are not self-contained in window, blinds/cords should be removed.

Because all risks cannot be eliminated, Veterans who are on a 1:1 status should be at an arms-length observation.

Whenever possible, Veteran should be engaged in CLC activities that will serve to distract him/her and provide him/her with social networking opportunities and social support. It is not recommended that suicidal Veterans leave the CLC for recreational purposes unless they are being transferred to another level of care.