36C25819R0003-005.pdf

Phoenix VA Health Care System Policy Memoranda No. 116A-08 Phoenix, AZ October 3, 2016

MENTAL HEALTH CRISIS EVALUATION (SUICIDE) POLICY

1. PURPOSE: To establish a policy that outlines the process for referral of Veterans and non-Veteran visitors or employees to designated safe areas for immediate triage/assessment/intervention after exhibiting/expressing potentially dangerous behaviors or thoughts such as feeling unsafe with hopeless, suicidal, or homicidal thoughts. This policy is intended for the Phoenix VA Health Care System (PVAHCS) and the Community-Based Outpatient Clinics (CBOC).

2. POLICY: It is the policy of the Phoenix VA Health Care System (PVAHCS) that any individual presenting with unsafe behaviors or thoughts be evaluated without delay, in an environment that assures their safety and the safety of others.

3. PROCEDURES:

At the PVAHCS main campus:

a. If an individual presents on VA property reporting that s/he “feels unsafe” or “feels hopeless” or reports having suicidal or homicidal thoughts, or demonstrates behaviors indicating that s/he may be having suicidal or homicidal thoughts, plan, or intent, staff will immediately intervene to ensure safety is maintained for the individual and their surroundings. Staff will provide a trained 1:1 Safety Observer (may be obtained by calling the Nursing Supervisor) or clinic personnel may be assigned to stay with the individual until the patient is escorted to the Mental Health (MH) Clinic during regular business hours (7:30am – 4:00pm) except if the patient is agitated or combative. They will be escorted by the VA Police Department directly to the ED. Outside of these hours (nights, weekends, holidays), all patients are to be escorted to the Emergency Department (ED).

b. The staff member discovering this risk will stay with the individual while notifying the appropriate designated staff member assigned to their area of the need for assistance. The VA Police Department may be notified as well for their immediate assistance. One-to-one observation of the individual, by the Safety Observer, will be maintained without interruption. Initiating 1:1 observation will not be delayed until a medical hold order is obtained or is visible in the chart. Changes in statements or behaviors by the individual are not sufficient reason to stop the crisis response; any change to the crisis response will require the evaluation of a licensed independent provider (LIP) in all cases. An LIP will evaluate the individual and may place them on a medical hold.

The LIP may continue 1:1 observation if it assures additional safety for the individual while waiting for the next step in care, whether or not the medical hold is continued.

Any patient choosing to leave 1:1 observation after the medical hold has been removed cannot be forced to stay for treatment unless new suicidal or homicidal

Phoenix, AZ October 3, 2016 behaviors are observed or statements are made, in which case a new medical hold order must be obtained.

Note: Any patient fleeing the 1:1 situation must be assumed to be at the highest risk for harm. The VA Police will be notified at once in the event of an elopement. If they are unable to recover the patient that has eloped, the VA Police will be responsible for communicating this with the appropriate local Police Department. A protocol should be used to assure that all staff clearly understand and are capable of carrying out these actions consistently (refer to Policy Memorandum No. 132-13 Management of Wandering and Missing Patients).

c. For patients presenting to the Mental Health Clinic with Suicidal/Homicidal Ideation: The Medical Support Assistant (MSA) will use the form that is completed by the Veteran when checking in without an appointment to determine whether the Veteran has checked the suicidal/homicidal box. The MSA will immediately place the Veteran on a 1:1 observation status notifying a MH LIP/Registered Nurse (RN)/Social Worker (SW) at once of their presence.

The Mental Health Clinic LIP is tasked with seeing the suicidal/homicidal patient urgently. If the LIP deems that the individual requires admission either here (Veteran) or to an outside facility (employee, visitor) then the individual will be escorted to the ED by designated Clinic personnel.

The Mental Health Clinic provider will contact the ED provider to inform them the individual is coming with a 1:1 observation staff member and VA Police escort (if involuntary admission or deemed necessary by staff). Upon arrival to the ED a warm handoff will occur to the ED nurse to include the reason for the 1:1 observation status, and descriptions of any behaviors or statements made by the individual or others that relate to their safety in the ED environment.

d. For patients presenting to the ED: The ED nurse/Triage nurse will notify the charge nurse of the immediate need for 1:1 observation for a suicidal/homicidal patient. The RN will alert the ED provider, Nursing Supervisor and VA police, and will request a medical hold order. Suicidal/homicidal patients will not be left alone.

The nurse/designee will remain with the Veteran until a Patient Safety observer is obtained. Patients are asked to wear a hospital gown (strings removed) or pajamas and their belongings are placed in a bag and separated from the patient per Directive 2010-008. If weapons or contraband are discovered the VA Police must be notified.

e. The ED Social Worker, MH RN and/or designated Mental Health LIP will consult with the ED provider in assessing the risk of harm to self or others and will provide recommendations for next steps in care. This includes recommendations to the assigned ED provider regarding continuation of a medical hold, 1:1 staff observation continuation, or admission for inpatient services. Off-tours, weekends, and holidays, the treating ED physician may consult the Psychiatrist on Duty (POD) via telephone.

Phoenix, AZ October 3, 2016

f. The ED Provider will provide further assessment of any medical issues identified by the individual through physical exam, review of recent vital signs, and review of recent lab results to ensure the safety of the individual for discharge home or admission to the hospital.

g. Individuals being admitted to the hospital may be transported to the inpatient unit by hospital staff and VA Police due to higher risk of elopement during that transfer.

Belongings will be carried by a staff member to the appropriate collection location as detailed in Phoenix Policy Memorandum No. 120-07.

h. Individuals being discharged home will have their belongings returned to them at the time of discharge.

At the CBOCs:

If an individual presents expressing suicidal ideation in a community setting staff should follow these guidelines:

(i) Immediate assessment of the individual for acuity and severity utilizing the Suicide Risk Assessment by the RN or LIP. If the individual is at risk, in crisis per SRA and agrees to receive mental health care, immediately contact a LIP within the CBOC to further evaluate the individual. (For those CBOCs with telehealth capabilities, they may want to consider accessing a MH provider via telehealth in those situations involving Veterans). If the individual is in crisis and refuses further assessment and assistance, call 911. At no time is the individual left unattended; 1:1 must be maintained at all times.

(ii) Veterans determined to be at risk for suicide who are willing to come to the Phoenix ED voluntarily may be transported by family members, if assessed to be safe by the CBOC LIP. If no family is available, the Veteran may come by ambulance. It is the Veterans preference as to whether or not he/she is transported to the Phoenix VA or another facility of their choosing. If there are no beds available at the Phoenix VA, the Veteran is transported the closest emergency department or a facility of their choosing. Non-Veterans are safely transported to the nearest emergency department for further evaluation.

(iii) If a Veteran is at risk for self-harm or a suicide attempt was made, a Suicide Safety Plan will be completed by both the patient and an appropriate provider (an MD, PA, NP, RN, SW or Psychologist). A copy to be given to patient and a completed Safety Plan documented in CPRS. All patients reporting thoughts of self-directed violence will receive the phone number of the National VA Crisis Hotline (800) 273-8255 (TALK), choosing Option #1.

In the community:

Phoenix, AZ October 3, 2016

When facility personnel are visiting with Veterans in their homes or the community, an expression of suicidal ideation must be addressed by dialing 911 and alerting the local community emergency medical services (EMS). Personnel should stay with the Veteran until the local EMS has arrived. Facility personnel may also consider transporting the Veteran to the Phoenix VA.

4. RESPONSIBILITIES:

a. The Medical Center Director is responsible for implementation of policy facility wide.

b. Service chiefs are responsible for training of staff and ensuring compliance.

c. VA Police are responsible for assisting hospital personnel in ensuring safety for individuals and staff.

5. REFERENCES:

a. VHA Directive 2010-008, Standards for Mental Health Coverage in Emergency Departments and Urgent Care clinics in VHA Facilities.

b. Phoenix VA Health Care System, Policy Memorandum No. 120-07, Disposition of Patient Funds, Clothing, Effects, Luggage, medication, Valuables and Lost and Found.

6. RESCISSION: PVAHCS Policy Memorandum 116A-08 dated December 14, 2015

7. ATTACHMENTS:

Appendix A: Encountering Someone in the Building or on the Hospital Grounds Who is in Crisis or Expressing Suicidal Thoughts/Plans Appendix B: For Someone in Crisis: Algorithm for the Emergency Department Appendix C: For Someone in Crisis: Algorithm for the Mental Health Clinic Appendix D: CBOC MH Crisis Evaluation Algorithm

8. EXPIRATION DATE: October 2019

RIMAANN O. NELSON

Medical Center Director

Phoenix, AZ October 3, 2016

APPENDIX A

1:1 observation status is initiated immediately

Stay calm and let the person know you are concerned. Tell them you are going to get them help.

A Warm Handoff is Given to Receiving Staff.

The Person is Left in Their Care

Encountering Someone in the Building or on the Hospital Grounds

Who is in Crisis or Expressing Suicidal Thoughts/Plans

During Regular Business Hours

(7:30am – 4:00pm)

After Regular Business Hours or During the

Weekend/Holidays or if the Person is Combative/

Agitated

The Person is Escorted by Staff or the VA PD to the Emergency

Department

Escort the Person to the MentalHealth

Clinic

Phoenix, AZ October 3, 2016

APPENDIX B

The ED Charge Nurse is notified immediately and observation staff is obtained

The ED Triage RN identifies that Veteran is at risk, i.e., SI/HI, psychotic, etc.

If the Veteran is to be admitted, a medical clearance is done. The Veteran is then escorted to the MH Unit with the assistance of the VA PD if requested with NO

INTERRUPTION IN THE 1:1 STATUS!

For Someone in Crisis Algorithm for the Emergency Department

A MEDICAL HOLD is requested from the LIP.

The VA PD and the House Supervisor are alerted.

The ED Social Worker, MH RN or designated MH LIP will consult with the ED provider assessing risk of harm to self or others.

Admit

Yes

Discharge with f/u appt in MH

Clinic No

Phoenix, AZ October 3, 2016

APPENDIX C

1:1 observation status is initiated immediately and requests a MEDICAL HOLD from the LIP

At risk individual is identified

The patient is escorted to the ED by VA personnel and the assistance of the VA PD, if needed. A warm hand-off is given to the ED triage RN or LIP with NO INTERRUPTION IN

THE 1:1 STATUS!

For Someone in Crisis Algorithm for the Mental Health Clinic

If the patient has already been assessed by an LIP, then the ED is called and a Doc to Doc warm handoff occurs

Phoenix, AZ October 3, 2016

Appendix D

CBOC MH CRISIS MANAGEMENT

Arrange transport by calling the local emergency transport service in your community. If transporting to

Phoenix VA, call and alert personnel to patient arrival

LIP determines admission is required

Suicide Safety Plan

DO, MD, NP, PA,

PhD, PsyD, SW, RN

Clinician (MD, DO, NP, PA, PhD, PsyD or SW) does direct communication with VA ED 602-277-5551 ext 1-7158

NO

YES

Voluntary

YES

Involuntary: Local emergency services are contacted for those that are to be involuntarily admitted. The CBOCs within the Maricopa County may begin the paperwork for assistance from the

UPC.

Patient determined to be in crisis and is placed on 1:1

NO