36C25019R0093-021.pdf

VA NORTHERN INDIANA HEALTH CARE SYSTEM

August 2011 POLICY NO. 116A-36-11

MENTAL HEALTH EMERGENCY/CODE PINK

1. PURPOSE: To state policy, assign responsibilities, and provide procedures for alerting the CODE PINK Team and the VA Police Department to a need for immediate assistance with individuals verbalizing/demonstrating intentions of suicide/homicide or other behavior that indicates the individual is gravely disabled and may be of harm to self or others.

2. POLICY: The policy of the VA Northern Indiana Health Care System (VANIHCS) is that individuals that verbalize/demonstrate intentions of suicidal/homicidal or other behavior that indicates the individual may be at risk of harm to self or others will be efficiently managed with minimum risk of injury to the individual, patients, visitors, or

VANIHCS personnel. Concern for human dignity, safety, and the least restrictive methods will be paramount.

3. DEFINITIONS:

a. Mental Illness: A substantial disorder of thought or mood which significantly impairs judgment, behavior, capacity to recognize reality, or ability to cope with the ordinary demands of life.

b. Emergency Detention Order (EDO):

(1) A legal means to assure that a mentally ill patient who lacks insight and refuses treatment is provided appropriate help in order to prevent harm to self or others.

The process requires determination by a judge.

(2) Involuntary hospitalization requires that the adult who has observed the inappropriate behavior of the individual petition the Court because the patient is a danger to him/herself and/or others.

c. Suicidal Ideation: Includes generalized feelings of self-destruction. Suicidal ideation may also include suicidal impulses.

d. Suicidal Plan: Includes time, location, intent, and availability of the means to complete the plan. A person with a suicidal plan is at high risk for suicide. If it is determined that the patient has a plan, the patient must not be left alone until he/she is hospitalized.

POLICY NO. 116A-36-11

e. Homicidal Ideation: Includes thoughts of great bodily harm directed towards one or more identifiable persons.

f. Homicidal Plan: Includes time, location, intent, and availability of the means to complete the plan. A person with a homicidal plan is at high risk for homicide. If it is determined that the patient has a plan, the patient must not be left alone until he/she is hospitalized.

g. One to One Observation: Constant supervision with eye contact and in the same room.

h. Suicide attempt: A non-fatal self-inflicted potentially injurious behavior with any intent to die as a result of the behavior.

i. Protective Search: A search performed by clinical staff, with VA Police present, for objects that may be harmful to patient or staff, including a check of belongings, pockets, and immediate area.

j. CODE PINK Team: A team of trained staff.

During administrative hours, the team consists of: A Mental Health Licensed

Independent Practitioner MH/LIP (Social Worker, Psychologist, Psychiatrist), an assigned nursing staff member for 1:1 observation, and VA Police.

During non-administrative hours, the team will consist of: the MOD, NOD (to conduct or delegate 1:1 observation assignment), and VA Police. The MH LIP or MOD will be the assigned designated Leader.

The CBOC will utilize local Police as necessary.

k. Provider: Term Provider refers to Primary Care (PC) Physician or MOD or Psychiatrist.

4. PROCEDURES:

a. Fort Wayne and Marion: Any employee who becomes aware of an individual who is verbalizing/demonstrating intentions of suicide/homicide or other behavior that indicates the individual is gravely disabled and may be of harm to self or others will:

(1) If the individual is actively attempting to harm self, property or others, call a

CODE ORANGE (See policy 116A-06-10). If the individual is in possession of a weapon or any other item that could potentially be used as a weapon, the VA Police are responsible to address this with the individual.

(2) If the individual is not actively attempting to harm self, property or others, call a CODE PINK (Refer to Attachment A, CODE PINK Algorithm).

(3) Initiate a CODE PINK by dialing extension 73911 or by using the Lynx

System and notifying the police dispatcher of CODE PINK, identifying campus location, building number and room number. (The Lynx System may be utilized by staff any time they feel threatened or intimidated by an individual.) The VA Police Department dispatcher will respond by paging for the CODE PINK Team.

(4) A staff member will remain in the presence of the individual until such time as the CODE PINK is resolved or the hand-off is completed with the admitting unit.

(5) The CODE PINK Team will arrive and will assume responsibility for one to one observation. The VA Police will stand by until the CODE PINK Team member (s) and/or the physician can assess for admission or release. Assessment by Code PINK team and/or the physician is to be completed in a timely manner. If the individual is deemed necessary to see a physician for assessment and decides to leave prior to the assessment taking place, the VA Police will detain the individual until the physician has an opportunity to evaluate them for admission or release. The decision to issue an emergency detention order will not exceed 30 minutes. Once the decision is made not to issue an emergency detention order, the VA Police may be released from the Code

Pink.

(6) The police remain on standby. If the decision is made to issue an emergency detention order and to admit the Veteran, the Nursing Staff member will then conduct a protective search, removing all personal effects (such as cell phones, belts, jewelry, shoestrings, etc.; See Attachment C, Contraband Listing), and documents in the medical record. The designated observer, Nursing Staff member, assumes responsibility for the 1:1 constant supervision, remaining within eye contact and in the same room, ensuring a safe environment for both staff and the Veteran.

(7) The first clinical staff aware of the suicidal/homicidal ideation or plan will document the patient’s verbalized suicidal/homicidal ideation or suicidal/homicidal plan in the Computerized Patient Record System (CPRS) and add the Suicide Prevention

Coordinator and Suicide Prevention Specialists as co-signers for suicidal patients. Staff may contact the Suicide Prevention Program at extension 75781 for the names of the staff to add on as co-signers.

(8) The MH LIP/MOD or RN will complete the note titled Suicide Self Harm

Assessment and the Suicide Behavior Report Template (if SBR appropriate) in CPRS.

(9) The Primary Care (PC) Physician/Emergency Room (ER) Physician/MOD or

Psychiatrist:

(a) Orders 1:1 monitoring, specifying the type of monitoring that is to be provided: suicidal or homicidal behavior, medications, & alcohol/drug tests as indicated.

(b) Determines if hospitalization is indicated; voluntary or involuntary (may be done with input from CODE PINK Team).

1 If hospitalization is not indicated, completes the Safety Plan template in

CPRS prior to release. The Veteran is given a copy of the Safety Plan prior to his/her release.

2 If hospitalization is indicated, facilitates clinical acceptance.

(10) Voluntary Hospitalization:

(a) The AOD or Admission Clerk will have the patient sign the Registration

Form and complete the consent for transfer, if necessary.

(b) The Physician will :

1 Make phone contact with the receiving facility and determine clinical acceptance and provide hand off communication.

2 Determine the appropriate form of transport, write an order, initiate the inter-facility transfer, and document a note in CPRS.

(c) The Legal Clerk (during duty hours FW 71008, M 73248 or the AOD (after duty hours, FW 71561, M 73850) will contact the AOD at the receiving facility for

Administrative details, such as travel details.

(d) The VA Police will:

1 Remain in the immediate area until released by the designated leader

(MH LIP or MOD).

2 Detain the patient should the patient decide to leave until the Physician can reassess for admission or release.

3 The decision to issue an emergency detention order will not exceed 30 minutes. If the decision is made not to issue an emergency detention order, the VA

Police may be released from the Code Pink.

(e) The Nursing Staff/designated observer will:

1 Continue monitoring and notify physician (Primary Care, MOD, and

Psychiatrist) of behavior changes.

2 If patient decides to leave prior to transport re-initiate CODE PINK.

Complete the intra-facility transfer note and make phone contact with receiving facility providing hand off communication.

(11) Involuntary Hospitalization:

(a) The Physician will:

1 Complete or delegate (to any staff member who witnessed or has firsthand knowledge of the patient’s behavior) Page 1, Application for EDO.

2 Complete Page 2, the physician’s statement, and notify the Legal Clerk

(during duty hours FW 71008, M 73248) or the AOD after duty hours FW 71561, M

73850).

3 Notify the Suicide Prevention Coordinator (by adding as an additional signer/View alert) and make phone contact with the receiving facility for clinical acceptance and provide hand off communication.

(b) The Legal Clerk/AOD will:

1 Coordinate the EDO process and contact the Judge/Mental Health

Association (MHA) for a verbal EDO approval.

2 Notify the Physician and the CODE PINK team once the verbal EDO is obtained.

3 Contact the AOD at the receiving facility for Administrative details.

(c) The VA Police will:

1 Remain at the door of the Patient’s Room.

2 Detain the patient should the patient attempt to leave.

(d) The Nursing staff member will:

1 Continue 1:1 monitoring.

2 Complete the required documentation, notifying the provider of behavior changes.

3 Complete the intra-facility transfer note.

4 Make phone contact with receiving facility providing hand-off communication.

(e) When there is injury of significance to staff or patients, the Nurse

Managers in charge of the area or NOD arriving on the scene will notify the Associate

Director for Patient Care Services who will then notify senior management (Chief of

Staff, Associate Director and Director).

b. Completing the CODE PINK Critique, Attachment B: The LIP will complete the

CODE PINK Critique which will be completed electronically on the designated

Sharepoint site. Tracking and trending of CODE PINK information will be completed by the PMDB Coordinator and reported to the Prevention and Management of Disruptive

(PMDB) Committee.

c. Mock CODE PINK Training:

1 Mock CODE PINK training is performed and coordinated under the direction of the Education Department. A record of the training is maintained in the Education Department.

2 The PMDB Coordinator will critique and evaluate the Mock CODE PINK and will determine any educational needs or actions necessary. Findings and recommendations will be reported to the appropriate Nurse Managers/Team Leaders/Coordinators and to the PMDB Committee.

3 Mock CODE PINK’s will occur at least on a quarterly basis for training purposes.

d. Community Based Outpatient Clinics:

1) Any employee who becomes aware of an individual who is verbalizing/demonstrating intentions of suicide/homicide or other behavior that indicates the individual is gravely disabled or may be of harm to self or others will:

a) If the individual is actively attempting to harm self, property or others, call

911.

b) The patient is to be seen immediately. The first clinical staff available will access and document in Computerized Patient Record System (CPRS) the patient’s verbalized suicidal/homicidal ideation or plan, complete the

Suicide Self Harm Assessment and include both the Suicide Prevention

Coordinator and Suicide Prevention Specialist as additional signers and complete the CPRS note titled Suicide Behavior Report, if appropriate. A staff member must assume responsibility for one to one observation at all times.

c) The Mental Health Provider or Primary Care LIP determines if hospitalization is indicated.

1 If hospitalization is NOT indicated, a Safety Plan template in

CPRS is completed with the patient, and a follow-up appointment is made before the patient leaves the clinic. The patient is given a copy of the Safety Plan.

2 If hospitalization is indicated and patient is voluntary, the provider will facilitate clinical acceptance with the parent facility (provider to provider), provide hand off communication, and initiate transport request. If the voluntary patient should decide to leave before transport has arrived, call 911 and initiate an Emergency Detention

Order (EDO). One on one observation must be ensured during transport.

3 If hospitalization is indicated and patient is involuntary, any staff member can initiate page 1 of the application for an Emergency

Detention Order (EDO). Page 2 must be completed by a physician.

Each CBOC will follow county specific EDO instructions with contact names and numbers provided at each clinic. Local law enforcement is responsible to transport patient.

5. RESPONSIBILITIES:

a. The Chief Mental Health Service (MHS) is responsible for this policy in coordination with the VA Police Department, Primary Care Services, and Patient Care

Services.

b. Nurse Managers/Team Leaders/Coordinators are responsible for responding to all identified CODE PINK and Mock CODE PINK deficiencies or problems.

c. The PMDB Committee is responsible for addressing ongoing issues related to

CODE PINK management, such as staff education and changes in practice. These findings will be reported through the PMDB Committee minutes to the Patient Care

Safety Board.

6. REFERENCES:

a. Joint Commission Comprehensive Accreditation Manual for Hospitals and

Behavioral Health

b. VANIHCS Policy Memorandum No. 116A-06, Behavioral Emergency Code

Orange, dated February 23, 2011

c. VANIHCS Policy Memorandum No. 116A-35, Management of Psychiatric

Emergencies, dated October 27, 2010

7. RESCISSIONS: None.

8. RESCISSION DATE: August 2014

9. FOLLOW-UP RESPONSIBILITY: Chief, Mental Health Service

ISAKI AFOLABI, MD

Chief, Mental Health Services

HELEN RHODES, MPA, RN

Associate Director for Operations, Marion Campus

STEVEN L. CLARKE

Acting, Associate Director for Operations, Fort Wayne Campus

AUDREY L. FRISON, MHA, BSN, RN

Associate Director Patient Care Services

RICHARD A. LOLKUS, DDS

Acting, Chief of Staff

DANIEL D. HENDEE, FACHE

Director

Attachments: A: CODE PINK Algorithm

B: CODE PINK Critique

C: Contraband Listing

Attachment A

Code Pink Algorithm

YES

Veteran verbalizes/demonstrates intention of suicidal or homicidal behavior or behavior that indicates gravely disabled

Staff member calls a

Code Orange

YES

NO

Notify VA Police of CODE PINK by calling STAT 73911 or Lynx System and identify location. Staff member remains with Veteran.

Inpatient hospitalizatio n needed?

CODE PINK Team responds (Duty Hours – Mental Health LIP, an assigned 1:1 nursing staff, and VA Police;

After Hours – MOD, NOD, VA Police. (MH LIP or MOD is Team Leader). VA Police will detain the individual should the person attempt to leave before the Physician can assess for commitment or release.

VA Police remain on standby . If the decision is made to issue an EDO and admit the Veteran, Nursing Staff will conduct a protective search, removing all personal effects. LIP, with assistance from the CODE PINK Team initiates assessment of the Veteran. First clinical staff aware of suicidal/homicidal ideation or plan documents in CPRS.

LIP/MOD /RN complete Suicide Self Harm Assessment and Suicide Behavior Report (if appropriate). Provider orders 1:1 monitoring, medications & tests as indicated

Voluntary

Patient transferred to appropriate care facility; 1:1 during transport. Designated Team Leader calls off Code Pink and releases Team.

The CODE PINK Responder (LIP or MOD) completes the CODE PINK Critique form on sharepoint site.

NO

Involuntary

Provider develops Safety and Follow Up Plan and documents in Medical Record prior to discharge of Veteran.

Police remain until Designated Team Leader calls off CODE PINK.

Veteran actively attempting to harm self, others, or property?

Attachment B Attachment C

Last Name & Last 4 ________________________________ DATE: ________________

(June 2011 Form Revised)

CODE PINK Critique

Time Code Called: _____________ Location of Code: ___________________

Time of Admission/Transfer: _____________

Team Member Responding Service Arrival Time

1.

2.

3.

4.

5.

6.

7.

Algorithm Step: Yes No Comments

1. Staff who hears or witnesses Veteran expressing or demonstrating Suicidal or Homicidal Intention, or behaviors that indicate danger to self or others initiates code pink and completes code pink critique

2. Weapon Involved

3. Code Pink Team (MH, Nursing, Provider/MOD , VA Police) Responds within set time limits (<5 min)

4. Commitment status

a. Voluntary commitment

b. Involuntary Commitment

Attachment B

5. Admission Status

a. Admitted to Facility

b. Discharged with mental health appt within 7 days

c. Discharged with no Follow-up Appt.

d. Transferred to another facility due to Facility at full census.

6. CODE PINK Cancelled

7. CODE ORANGE CALLED

What worked well / suggestion for improvement

AttAttAttachment B [Type text]

CONTRABAND LIST

“Contraband” is defined as any item/substance that is inherently or potentially dangerous. The below list identifies contraband but is not limited to the below items:

1. Medication of any kind

2. Any glass items with the exception of eye glasses that have glass lenses

3. Belts and/or suspenders

4. Tobacco products

5. Lighters and matches

6. Mouthwash that is alcohol base

7. Open food or snacks of any kind Pornographic material

8. Sharps of any kind: knives, scissors, razors, nail clippers

9. Plastic bags of any size

10. Silverware

11. All jewelry with the exception of wedding bands and watches

12. Pens and pencils

13. Steel toe shoes

14. Drug paraphernalia

15. Cell phones, pagers, cameras, tape recorders

16. Permanent markers

17. Wire hangers

18. Shoe strings, leather cords, ties

19. Metal nail files

20. Metal hair picks

21. Purses with long straps

22. Toxic liquids

23. Brushes/combs with pointed ends

24. Electrical items with cords

25. Nail polish

26. Mirrors

27. Hairsprays

28. Ties, scarves

29. Paper clips

30. Bib overalls

31. Any item that can access the internet

32. Any item that could be used to harm self

33. Any electrical item with a cord (blow dryer, curling iron, etc.)

34. Aerosol cans

35. Lighter Fluid

36. Body jewelry

37. Spiral Notebooks