36C25718R0247-036.pdf

DEPARTMENT OF VETERANS AFFAIRS Policy Memorandum 116A-17-01 South Texas Veterans Health Care System San Antonio, Texas 78229-4404 May 15, 2017

SUICIDE RISK ASSESSMENT AND PRECAUTIONS

FOR OUTPATIENTS

1. PURPOSE: To establish procedures and guidance for implementing strategies to improve patient safety and mitigate the risk of suicide through appropriate assessment and treatment planning to ensure the safety of patients receiving care in the South Texas Veterans Health Care System (STVHCS).

2. POLICY: To evaluate and appropriately intervene when any employee identifies depression or the potential for suicide in any patient from Primary Care and the Specialty Clinics.

3. ACTION:

a. Clinicians (i.e., nurse, nurse practitioner, physician, physician assistant, psychologist, or social worker.) will perform a suicide risk screen on any patient with signs or symptoms of depression or suicidal ideation, or with any patient who has a positive depression or Post Traumatic Stress Disorder (PTSD) screen done by a clinician (i.e., nurse, nurse practitioner, physician, physician assistant, psychologist, or social worker, etc.) before leaving the clinical setting.

b. Providers should also be alert to situations and events that may increase a patient’s risk for suicide and warrant suicide risk screen, even in the absence of a primary or secondary diagnosis or complaint of an emotional or behavioral disorder. These situations and events include, but are not limited to, significant psychosocial stressors (e.g., job loss, marital difficulties, and financial problems); a diagnosis of a serious medical illness, or a significant change in psychiatric or medical condition. All suicidal statements made by a patient will be reported to a staff physician/Mental Health provider/Primary Care Physician/Attending able to act on the information in a quick and timely manner.

c. Suicide Risk Screen: (As included in Primary Care and Specialty Clinic computerized patient record system [CPRS] templates)

(1) “Have you been feeling that life is not worth living?”

(2) “Do you have thoughts of death or suicide?”

d. Any patient who responds affirmatively to either of these two Suicide Risk Screen questions will be considered at-risk for suicide, will be immediately placed on 1:1 observation and referred immediately to a qualified provider.

e. At-risk patients will receive an immediate (same day) assessment for suicide potential utilizing one or more of the following options as available and needed:

(1) An emergency appointment will take place immediately (same day) with the patient’s Primary Care Provider.

(2) An emergency appointment will take place immediately (same day) with a Mental Health Professional (i.e., psychiatrist, psychologist, psychiatric social worker, or psychiatric nurse) who will complete a thorough suicide risk assessment.

POLICY MEMORANDUM 116A-17-01

(3) An emergency visit will take place immediately (same day) with an Emergency Room mental health provider.

f. All at-risk patients will be escorted to one of the above appointments and not left unaccompanied until communication with the receiving provider ensues and appropriate hand-off occurs.

g. All at-risk patients will continue to receive immediate care and intervention until it has been determined by a physician or other mental health provider that suicide risk is no longer an imminent threat to the patient’s safety. (Security will stay with the patient if hospitalization is being considered in order to prevent elopement.) If the patient is not voluntary for psychiatric admission and admission is indicated, emergency detention procedures will be performed. If the patient is voluntary for admission, 1:1 observation should be maintained until the patient is transported and admitted to the inpatient psychiatry unit.

h. This policy will be re-evaluated for effectiveness every three years by the Chief of Psychiatry and appropriate appointees, or in the event of serious para-suicidal occurrences involving the processes described in this policy.

4. REFERENCES: Substance Abuse and Mental Health Services Administration:

https://www.samhsa.gov/suicide-prevention

5. RESPONSIBILITY: Chief, Mental Health (116A)

6. RECISSION: STVHCS Policy Memorandum 116A-12-01, dated June 13, 2012

7. RECERTIFICATION: May 2022

(Signed original on file)

ROBERT M. WALTON

Director

DISTRIBUTION: B & C

https://www.samhsa.gov/suicide-prevention