D11. SUICIDE PREVENTION.pdf

D.11 SUICIDE PREVENTION

36C25922R0102

DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE SYSTEM

Oklahoma City, Oklahoma

Center Memorandum 116-05 March 5, 2019

SUICIDE PREVENTION

1. Summary: Center Memorandum 116-05 dated October 10, 2014, has been revised with major changes to include revision of different suicide risk levels, new suicide risk screening process for the facility as well as adding a new program, REACH-VET.

2. Purpose: To define policies and procedures for the Suicide Prevention Program at the Oklahoma City VA Medical Center.

3. Policy: These policies apply to all direct patient care personnel. They follow VA national directives, memoranda and guidelines. Specific instructions for disposition of suicidal patients physically presenting to the medical center are included. Suicidal patients will be under direct observation; at no time is the patient left alone. The goal is to identify veterans at high risk for suicide as early as possible in order to provide access to enhanced care and services that may prevent ongoing issues of suicidality.

4. Procedures:

a. Suicide Precautions: Emergency Room

(1) When a veteran presents any complaint related to suicidal ideation to the reception area in the Emergency Department (ED), the Medical Administration staff will immediately walk the patient into the ED triage area and report to the registered nurse (RN) the immediate concerns.

(2) As soon as the RN accepts the care of this patient, the ED staff will assess the patient and enter the details into the Triage Note in the computer. Patient will be placed on 1:1 observation. Appropriate nursing staff will be informed of patient's arrival and need for 1:1 observation.

(3) The RN will complete a Third-Party Statement for patient protection if appropriate (third-party statements are in CPRS under Note Title).

(4) ED staff will have the patient change into pajamas, and an inventory of their personal belongings will be completed. In reviewing a patient’s personal belongings, staff will ensure that there’s no weapons, or any materials available that can be used by the patient to harm themselves.

(5) Patient's money will be sent to agent cashier, and the receipt will be sent with patient's belongings to 8 North upon admission.

(6) Patient's medications will be labeled in a special pharmacy bag and will be

Center Memorandum 116-5, March 5, 2019 mailed back to the patient. Any narcotics will be destroyed.

(7) After RN evaluation, ED physician will be notified, and a medical evaluation will be completed by the ED physician.

(8) ED staff will treat patient per orders.

(9) After assessing the patient, the ED physician will consult with appropriate mental health staff.

(10) The ED physician evaluates the patient regarding medical stability.

(11) If the patient requires admission and is appropriate for voluntary admission, he/she must sign a consent form stating he/she is agreeing to voluntary admission.

He/she is then escorted to the 8th floor.

(12) The above flow through the area ensures that the patient will be under direct observation throughout the process. At no time is the patient left alone in the waiting room or in the ED. The patient will be in direct supervision at all times while in the ED and while being transported to 8 North or other treatment areas. Even if the patient requests to go to the bathroom, he/she must be escorted and observed. Escorting the patient provides support to the patient, demonstrates a sincere approach, and ensures the patient does not leave the building prior to treatment.

b. Identification of Veterans at High Risk for Suicide:

(1) Levels of Risk: (Note: Because suicidal behavior is fluid and cannot be accurately predicted, the designations below are not absolute. Providers should use their clinical judgment in conjunction with these guidelines to determine risk level.)

(a) Low Acuity Risk: no current suicidal intent, no plan and no preparatory behaviors and collective high confidence in the ability of the patient to independently maintain safety.

(b) Intermediate Acute Risk: current suicidal ideation without intent and ability to maintain safety independent of external support/help.

(c) High Acute Risk: Suicidal ideation with intent to die by suicide and inability to maintain safety independent of external support/help.

c. Suicide Risk Assessment: A formal suicide assessment is to be completed on each veteran upon intake into any outpatient mental health program--i.e., STAR Clinic;

Trauma, Deployment and Recovery Services; Ambulatory Mental Health Clinic, Homeless Program, etc., prior to discharge from the program and when clinically indicated by the provider. All staff will use the VA standardized Suicide Risk Evaluation-Comprehensive template. If veteran has been previously evaluated, staff can complete an updated version of the suicide risk evaluation.

d. Suicide Behavior Report: The Suicide Behavior Report (SBR) is the primary means for reporting veterans who have had a suicide attempt or exhibited suicidal behavior within the last year. The first staff member (i.e., primary mental health provider, primary care provider, evaluating mental health provider, Emergency Department physician or nurse) who learns of a veteran’s suicidal behavior will complete the Suicide Behavior Report template in CPRS and add the Suicide Prevention Coordinator as an additional signer.

e. High Risk For Suicide Behavior Tracking List: Suicide Prevention Coordinator will maintain a list of veterans who meet criteria for high risk for suicide (see above definitions). Veterans on this list will have a patient record flag and a 6-step suicide safety plan and will be regularly monitored by the Suicide Prevention Clinicians (SPC) (see below).

f. Patient Record Flag (Category I: High Risk for Suicide): For every patient deemed at high risk for suicide and added to the HR Tracking List, a Category I Patient Record Flag will be activated. The initial flag will typically remain in place for a minimum of 90 days. After the 90-day period, the case will be reviewed and, with input from the veteran’s primary mental health provider(s), will be inactivated or continued depending on veteran’s current suicide risk level. In certain cases, veterans may be removed prior to the 90 days (i.e., if he/she is deceased). When a veteran is placed on the High-Risk List, they should receive services throughout the medical center based on their needs. The Patient Record Flag should not be used to deter a veteran from receiving residential treatment or other outpatient services. When referred to a residential treatment program, the veteran must be assessed by a mental health provider or suicide prevention coordinator and noted to be psychiatrically stable for transfer to the program. The High-Risk List was developed to be used as a tool in taking a veteran’s concerns seriously, making medical personnel aware of no-show appointments and so that enhanced care could begin.

g. Safety Planning: Every veteran on the High Risk for Suicide Behavior Tracking List should have a 6-step safety plan in place shortly after being placed on the list. Any staff member (mental health provider, physician, nursing, etc.) trained on safety planning can conduct safety planning with a veteran. However, veterans’ primary mental health providers are responsible for completing the safety plan with their patients who are on the HR List and have a level I patient record flag. Providers will develop safety plans with veterans who have suicidal ideation even if they do not meet criteria for a high-risk designation, if indicated based on the provider’s clinical judgment.

h. Monitoring and Case Management: Veterans who are added to the high-risk list, while inpatient or outpatient will have their cases monitored (either by record review, face-to-face encounter or telephone contact) by the SPC weekly for the first 30 days.

They will be monitored at a minimum of once monthly for the remaining 60 days of the

90- day review period. If the flag is extended, monthly monitoring will continue. This monitoring and case management is in addition to the required weekly follow-up mental health visits.

i. Telephone calls: Telephone calls from at-risk suicidal patients during normal duty hours will be promptly referred to the Suicide Prevention Team, and staff will do a warm phone transfer to that team. If the Suicide Prevention Team is not available, staff will do a warm transfer to the National Veterans Crisis line. If a veteran is at imminent risk, staff will stay on the phone with the veteran while another staff member coordinates with VA police for a welfare check. Information on how to handle suicidal calls during duty and after duty hours can be found by clicking on the desktop icon, Suicidal Caller or by going to the Gold Star-OKL Shortcuts- Suicidal Caller.

j. Inpatient Mental Health Services: The admitting physician will screen each patient for suicide risk at the time of admission and will place patient on High Suicide Risk, 1-1 if patient continues to pose an imminent threat to his/her safety.

(1) High Suicide Risk:

(a) This designation is assigned to those individuals for whom serious suicidal behavior appears imminent in which a patient is actively suicidal with intent and a feasible plan. This is a psychiatric emergency.

(b) The high suicide risk designation requires placing inpatients on suicide precautions as follows:

1 The staff person(s) making the determination will immediately implement precautions listed for high suicide risk patients.

2 The patient will be confined to the ward at all times. If he/she needs to leave the ward for any reason (i.e., only in a medical emergency), he/she will be escorted by an employee who knows he/she is a high-risk suicidal patient.

3 The patient will be constantly monitored with a 1:1 staff-to-patient ratio while on high suicide precautions including sleeping, bathing, etc., and this will be documented in patient’s record per policy.

4 A room search will be done immediately upon implementation of these precautions. Document that the search was done and document the finding and removal of any potentially harmful items.

5 Patient is to be watched carefully while swallowing medications--if liquid is available, consider converting to this form of medication administration.

6 Document each shift the patient's potential for suicide, behavior and verbalization.

(2) Removal from High Suicide Risk:

(a) Removal of a patient from high suicide risk is accomplished only by written orders of a physician; however, documentation in progress notes will show multidisciplinary consideration.

(b) The physician will consider the following criteria before removing a patient from high suicide risk:

1 The patient has a close and dependable therapeutic relationship with his/her treatment team.

2 Emergency treatment is available.

3 Patient's relationship with family (or suitable substitutes) has been stabilized as much as possible. The physician will use his/her own judgment and state it in the record.

4 There is objective evidence, in terms of patient's statements or other behavior, that the suicidal crisis has been diminished or resolved.

5 If a patient harms or threatens to harm him/herself, and an interdisciplinary team believes there is no real intent to die, they will document this in the treatment record.

Suicidal precautions do not apply when suicidal behavior or threats are clinically viewed as manipulative behavior, without intent to die. This clinical judgment must be clearly documented in the record.

6. All hospital staff are responsible at all times for observing and reporting patient suicidal indications. It is highly desirable that all actions reflect the input of more than one professional.

7. Observations shall be documented in the progress notes in the patient's medical treatment record by the person making the observations. That person also will notify the treatment team and the suicide prevention team. When any professional staff member determines that a suicidal person is at imminent risk for harming him/herself and cannot be safe on the inpatient psychiatric unit, that person will place the patient on 1-1 and notify patient’s treatment team.

8. Providers will also complete a formal suicide risk assessment prior to inpatient psychiatric discharge.

k. Outpatient Mental Health Services:

(1) Each patient being evaluated and/or treated in an outpatient area will be evaluated for suicide risk by one of the professional staff members of the clinic. The primary health professional will evaluate the patient representing a suicidal risk, according to criteria outlined above, determine the need for hospitalization and proceed through the admission steps. All patients are examined for suicidality at time of admission to an outpatient program and when clinically indicated thereafter.

(2) If the patient is considered at imminent suicidal risk, a professional staff member of the clinic will coordinate with 8N admitting staff. A Third-Party Statement or Affidavit for Emergency Detention will be done prior to admission. See Center Memorandum 116-6 for details.

(3) When an at-risk suicidal patient presents to the Ambulatory Mental Health Clinic (AMHC) check-in area or is brought to that area by others with concerns about the patient's safety, the following procedures will be implemented:

(a) The patient will be immediately checked in.

(b) A member of the Outpatient Consultation Team will be immediately contacted for evaluation of the patient.

(c) If the patient is accompanied by VA staff, that staff member will stay with the patient until the provider can see the patient.

(d) If the patient is too agitated, he/she will be escorted to a private office, and the VA police will be contacted to help keep the patient safe until the patient can be evaluated.

(e) Should the patient leave the area prior to the evaluation or during the evaluation, follow procedures listed in CM 11-46.

(4) If an at-risk suicidal patient has a mental health provider, it is expected that the patient will be evaluated by that respective clinic, Ambulatory Mental Health Clinic, Substance Treatment and Recovery (STAR), REACH Program, Trauma and Deployment Recovery Services (TDRS), Neuropsychology, Health Psychology, Mental Health Intensive Case Management (MHICM) and Veterans Recovery Center (VRC) etc.

(5) If the patient does not have a mental health provider, they will be evaluated by Ambulatory Mental Health Clinic or in the ED.

(6) All specialty mental health programs will follow the same procedures as mentioned above when an at-risk patient is brought to their check-in areas.

l. Inpatient General Medical/Surgical, Community Living Center:

(1) All veterans will be given an initial suicide risk screener within 24-hours of their admission and prior to their discharge. If the initial screener is positive then a Licensed Independent Provider will do the secondary screener and if that’s positive, will complete the third screener which involves the Suicide Risk Evaluation-Comprehensive note template. All screeners need to be completed same calendar day.

(2) If nursing staff has reason to believe a patient is suicidal then the physician will be alerted who may initiate a psychiatric consultation. Measures to protect the patient must be taken until a psychiatric consultation is done.

(3) Non-psychiatric patients who are felt to present a suicidal risk will be provided psychiatric consultation. A patient at high suicide risk may need a Third-Party Statement or Emergency Detention (ED). The patient may be transferred to 8 North; or if the patient is too ill to move, will be placed under 1:1 observation.

(4) High risk categories of suicidal precautions will be valid for inpatient General Medical & Surgical units (GM&S) with similar criteria and procedures as on the Psychiatry Inpatient Units. Responsibility for termination of suicidal precautions shall rest with the patient's primary physician in consultation with Psychiatry Consultation and Liaison Team.

(a) GM&S patients on high suicide risk status but requiring minimal medical/surgical intervention and nursing care, should be transferred to the Psychiatry Inpatient Unit with the concurrence of the Psychiatry staff. Patients on high suicide risk status who require significant medical/surgical intervention with moderate to heavy nursing care that cannot be carried out on the inpatient psychiatric unit will remain on Medicine.

m. Sleep/Pain Clinics: All veterans will be given an initial suicide risk screener as part of the evaluation process. These clinics will follow same protocols as inpatient if screeners are positive.

n. Veterans in the Community: If a veteran is being seen by a staff member of MHICM, the Homeless Program, or Home-Based Primary Care (HBPC), the staff member will evaluate the patient and, if considered at imminent risk for suicide, will arrange appropriate transportation to the VA or nearest ER. Depending on acuity level of patient, transportation may be by VA staff member, family member, by ambulance, or involve police if needed.

o. Employees who present at-risk for suicide:

(1) If an employee has a mental health provider at the VA, they can be escorted to that specific mental health clinic.

(2) If the employee is not seen by a VA mental health provider, they can be escorted either to Occupational Health, Ambulatory Mental Health Clinic or ED for an evaluation.

(3) If an employee is at one of the outlying clinics, supervisors need to contact Psychology Services for an evaluation.

p. REACH-VET (Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment):

(1) REACH-VET is a national strategy to identify veterans that could be at-risk not only for suicidal behavior but other negative outcomes to include psychiatric/medical hospitalizations, external-cause mortality (accidents, overdoses, violence, injuries) and non-suicide all-cause mortality.

(2) The REACH-VET Coordinator will receive a list of veterans from national that have been determined to be at statistical risk. The coordinator and/or designee will review charts and determine the appropriate mental health or primary care providers for the case.

(3) Providers will review the veteran’s chart and will re-contact veteran if that’s clinically indicated based on last contact. Their review of the chart may include:

treatment plan, current medication regime, evidence-based treatment and any recommendations for further care.

(4) Providers will document their findings using the REACH VET Provider Note Template within appropriate time frames.

5. References:

a. Psychiatric Annals 28:9, September 1998

b. Joint Commission Hospital Accreditation Standards

c. Center Memorandum OQSV-2, Patient Safety Improvement

d. Center Memorandum 116-3, Mental Health Emergency Policy and Procedures for CBOCs and Telemental Health

e. Center Memorandum 116-6, Civil Involuntary Detention and Commitment of Veterans

f. American Journal of Public Health, Sep 2015; Vol 105, No. 9

g. Center Memorandum 11-46, Missing Patient Policy

6. Follow-up Responsibility: Chief, Psychiatry (116).

7. Concurrence Responsibility: Clinical Service Chiefs; Nursing

8. Renewal Date: March 5, 2023

Wade Vlosich Health Care System Director