Attachment 18 - SDVAMS MCM 11-24 Identification Assessment and Management of Veterans at Risk for Suicide.pdf

VA SAN DIEGO HEALTHCARE SYSTEM MEMORANDUM 11-24

SAN DIEGO, CA January 2, 2021

IDENTIFICATION, ASSESSMENT, AND MANAGEMENT OF

VETERANS AT RISK FOR SUICIDE

1. PURPOSE: To establish VA San Diego Healthcare System (VASDHS) policies and procedures for the identification, assessment, and management of Veterans at risk for suicide and for reporting suicide attempts or related behaviors.

2. POLICY: To assess, manage, and document in the medical record suicide risk and related interventions for Veterans presenting with an emotional/behavioral problem or self-directed violence.

3. DEFINITIONS:

a. Non-Suicidal Self-Directed Violence Ideation: Self-reported thoughts regarding a person’s desire to engage in self-inflicted potentially injurious behavior. There is no evidence of suicidal intent.

b. Suicidal Ideation: Thoughts of engaging in suicide-related behavior.

c. Self-Directed Violence: Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself.

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

e. Suicide: Death caused by self-inflicted injurious behavior with any intent to die as a result of the behavior.

f. Suicidal Intent: There is past or present evidence (explicit and/or implicit) that the individual intended to kill him/herself, wished to die, and understood the probable consequences of his or her actions.

g. High Risk (HR) Flag: A Category I Patient Record Flag (PRF) which indicates that the Veteran is at high risk for suicide and is monitored regularly by a Suicide Prevention Coordinator (SPC). Application and removal of a new Category I High Risk (HR) for Suicide PRF will be determined by a SPC. A Category II flag related to suicide is the Overdose Precautions Flag which restricts the quantity of medications dispensed to high risk suicide Veterans to 2 weeks in order to mitigate risk of overdose. The Overdose Precautions Coordinator is responsible for placing or removing OD Precautions PRF.

h. Columbia Suicide Severity Risk Scale (C-SSRS): a nationally-standardized tool that screens for severity of suicidal ideation and related behavior during the past month (see Attachment D).

i. Columbia Suicide Severity Risk Scale Plus (C-SSRS+): a local note template adapted from the C-SSRS. The C-SSRS+ is designed to meet The Joint

Commission Standards in situations when assessment is indicated but not clinical reminders are due.

j. Comprehensive Suicide Risk Evaluation (CSRE): A nationally standardized evaluation tool that identifies specific Veteran characteristics and environmental features that may increase or decrease the risk for suicide and that yields estimates for levels of acute and chronic suicide risk (See Attachment D).

k. Safety Plan: A nationally standardized, written list of coping strategies and sources of support developed in collaboration with the Veteran. The Safety Plan includes: a) how to recognize warning signs that include thoughts, feelings, and behaviors; b) how to use internal coping strategies; c) encourages socializing with family and others for support and distraction; d) identifies family and friends to help resolve crisis and remove lethal means from the home; e) how to contact professionals or agencies equipped to help Veterans in crisis; f) recommends reducing the potential for use of lethal means which includes reducing access to guns at home (See Attachment E).

l. Suicide Behavior Overdose Report (SBOR): This is a reporting tool for self-harm behaviors with suicidal or undetermined intent, and for intentional and accidental overdoses (See Attachment F).

m. Suicide Prevention Coordinators (SPCs): The SPCs facilitate access to care for Veterans at risk for suicide and advise facility leadership and medical center staff on suicide prevention strategies.

n. Suicide Prevention and Management (SPAM) Workgroup: Under the leadership of a Suicide Prevention Coordinator, the SPAM Workgroup function is directed toward improving the delivery of safe, quality care to Veterans at high risk for suicide.

o. Overdose Precautions Coordinator (OPC): The OPC responds to consults requesting for placement or removal of OD Precautions.

4. RESPONSIBILITIES:

a. All staff will complete Suicide Prevention Training during New Employee Orientation (which is coordinated through Human Resources) and during annual training.

b. Per the VHA Memorandum dated November 13, 2020 (“Eliminating Veteran Suicide: Suicide Risk Screening and Evaluation Requirements and Implementation (Risk ID Strategy”), facilities are required to screen all Veterans annually for suicide risk. Screening is embedded in the clinical reminders system, via a new clinical reminder titled “Suicide Screen”.

1) In all VASDHS clinical settings, staff will complete the “Suicide Screen” reminder when it is due. The screen can be completed by most clinical staff members, including non-licensed independent providers (LIPs), as shown in Attachment B. When the Suicide Screen reminder is completed by a non-LIP, it includes an option to document a warm handoff to a licensed provider in the event that the screen is positive.

2) If the Suicide Screen reminder is positive, a CSRE is required on the same calendar day. The CSRE is a separate note template that is outside of the reminder system. The CSRE can only be completed by LIPs. Clinics outside of Mental Health and Social Work that do not have embedded Mental Health staff will implement a process for identifying an appropriate LIP to receive warm handoffs in the event that a CSRE is required (e.g., if on an inpatient medical unit, an appropriate process may be to alert the Psychiatry Consult team)..

c. In addition to the requirements above, Licensed independent providers (LIPs) in the Mental Health Care Line and Social Work Service:

1) Will complete suicide risk management training within 90 days upon entry to this facility.

2) Will conduct a comprehensive suicide risk assessment including: (1) evaluation of suicidal ideation, warning signs, risk factors, and protective factors; (2) estimation of risk level; and (3) recommendations for mitigating risk. Suicide risk assessments should be conducted:

a) Upon intake into any Mental Health or Social Work program, using either the national CSRE or the local C-SSRS+ to evaluate individual risk/protective factors, risk level, and mitigation strategies. The title of the C-SSRS+ note template is “Columbia-Suicide Severity Rating Scale (C-SSRS)”. It can be found by entering either “Columbia” or “SSRS” in the note title location in CPRS.

b) At any time after the initial intake that a suicide risk assessment is clinically indicated. This is dependent on each LIP’s judgment but may include upon being transferred to a new provider, beginning a new course of treatment (especially after waiting for an opening), or following significant medical, occupational, or psychosocial changes. Either the national CSRE or C-SSRS+ may be used for such assessments.

c) Within 24 hours of Inpatient Mental Health admission and the 24 hours prior to discharge from Inpatient Mental Health, using the C-SSRS. If the C-SSRS is positive, a CSRE is required on the same day.

d) Within 24 hours of Mental Health Residential Rehabilitation Program (RRTP) admission and in the last 24 hours prior to discharge from an RRTP. If the C-SSRS is used, it is also required that the CSRE be administered in the first 7 days after admission, and/or during the final 7 days prior to discharge.

Alternatively, if the CSRE is administered during the first 24 hours after admission and the final 24 hours before discharge, this requirement is satisfied.

3) Will screen established patients for suicide risk annually utilizing the Suicide Screen in the clinical reminders system during visits to Mental Health or Social Work clinics. When screens are positive, will complete the CSRE on the same day.

4) Will address the immediate safety needs and most appropriate setting for treatment of the individual served for patients identified as intermediate to high acute or chronic risk for suicide on the CSRE or the C-SSRS+.

5) Will provide suicide prevention information (such as a crisis hotline – 1- 800-273-8255) to the individual identified as intermediate to high acute or chronic risk for suicide, and his or her family, when the Veteran leaves the care of the facility.

d. Emergency Department or Urgent Care clinic staff: will screen all patients for suicide risk using the C-SSRS. If the C-SSRS is positive, a same-day CSRE is required.

e. Sleep Clinic LIP: All Sleep Clinic patients should be screened for suicide risk using the C-SSRS at referral or intake. Screening is required at intake if not completed at the time of referral, or if the referral occurred > 30 days prior to the intake. Screens may be conducted using the Suicide Screen reminder, the C-SSRS+, or a separate template that incorporates the C-SSRS. A positive C-SSRS requires completion of a CSRE on the same calendar day.

Additional screening should be conducted if clinically indicated.

f. Community Living Center, inpatient Medical/Surgical and inpatient rehabilitation unit staff: will screen all patients within 24 hours of admission and in the 24 hours prior to discharge using the C-SSRS, and a positive C- SSRS must be followed by a CSRE on the same calendar day.

g. The Suicide Prevention Coordinators (SPCs):

1) Will educate employees across the continuum of care on recognizing the signs and risk factors of suicidal behavior and thinking, and effective clinical interventions to reduce suicidal behavior.

2) Will assist Veterans in receiving timely care when faced with a crisis, particularly when the Veteran has made a call to the Crisis Line (800 273- 8255) and will provide feedback to the Crisis Line staff.

3) Will identify Veterans who may be at risk for self-directed violence by using the C-SSRS+, CSRE, and other mental health screening tools and will monitor them through the course of medical or psychiatric treatment as described in Mental Health Care Line Standard Operating Procedure 1, Suicide Prevention Program (Attachment K).

4) Will coordinate efforts to address suicide and/or self-directed violence events related to where Veterans' safety may have been compromised.

5) Will liaise with the VA Office of Mental Health and Suicide Prevention.

6) Will implement the Behavioral Health Autopsy Program (BHAP). This includes:

a) completing a standardized medical record review utilizing the BHAP Post-Mortem Chart Analysis Template for all suicides known to the facility and reported on or after October 1, 2012.

b) submitting these reviews to the Mental Health Service (MHS) Suicide Prevention Program within 30 days of the facility becoming aware of the death by suicide via the approved SPC SharePoint portal.

h. Suicide Prevention and Management (SPAM) Workgroup will complete individual case analysis of all suicide attempts and completed suicides and make recommendations for action (e.g., education, Peer Review, Issues Briefs, Root Cause Analysis).

I. Research and Development (R&D) Committee or its designated Institution Review Board of record will ensure compliance of Research Investigators with this MCM (see Attachment G – Procedures for Research).

5. PROCEDURES:

a. Certain clinical settings have requirements for suicide risk screening and/or evaluation beyond the universal requirement for annual screening.

Attachment B summarizes the requirements by setting and guidance about which tools can be used by specific staff.

b. A suicide risk evaluation is required for Veterans evaluated by or receiving services from VASDHS Mental Health and Social Work programs as listed below. In these settings, unless otherwise indicated, the requirement can be satisfied by either the C-SSRS, the C-SSRS+ or the CSRE. However, if at any time the C-SSRS or C-SSRS+ is utilized and is positive, a CSRE is required the same calendar day. The C-SSRS clinical reminder can be completed by most clinical staff as outlined in Attachment B. The C-SSRS+ can be completed by LIPs and by RNs; the CSRE can only be completed by LIPs.

1) Upon presentation to the Psychiatric Emergency Clinic by a LIP or RN

2) In the 24 hours immediately before or after admission to Inpatient Mental Health, SARRTP, or the ASPIRE Center. At SARRTP and the ASPIRE Center, if the C-SSRS or C-SSRS+ is employed at the time of admission, a CSRE is required within 7 days of admission.

3) In the 24 hours prior to discharge from Inpatient Mental Health, SARRTP, or the ASPIRE Center. At SARRTP and the ASPIRE Center, if the C-SSRS or C-SSRS+ is utilized, then an updated CSRE is also required in the 7 days prior to discharge.

4) Upon admission to any new mental health program (MHICM, CORE, BHIP, PTSD, or other team) by a LIP or RN.

5) Suicide risk assessment is not otherwise required but should be completed as dictated by clinical judgment. Suicide risk assessment is recommended when events suggest potential for increased risk (e.g., job or relationship loss) or in conjunction with changes in treatment plan (e.g., transfer of care to new provider).

c. Annual screening for suicidal risk via the C-SSRS is required for all Veterans receiving ongoing care in any VASDHS setting. In all cases, a positive screen must be followed on the same day by a CSRE.

d. The C-SSRS is required upon intake for Veterans who are managed by the pain clinic pharmacist upon initiation of pain management therapy. If the C- SSRS is positive, a same-day CSRE is required.

e. All patients presenting to the Emergency Department or Urgent Care clinics must be screened for suicidal risk using the C-SSRS. If the C-SSRS is positive, a same-day CSRE is required.

f. Veterans treated in Sleep Clinics are required to be screened for suicide risk at referral or at intake, and also when screening is clinically indicated.

Screening is required at intake if (a) it was not completed at the time of referral, or (b) referral occurred more than 30 days prior to intake. Screens may be completed using the Suicide Screen reminder, the C-SSRS+ note template, or a separate template that incorporates the C-SSRS. For any format, a positive C-SSRS requires completion of a CSRE on the same calendar day.

g. For Veterans admitted to the Community Living Center or to inpatient medical units, screening must be completed within 24 hours of admission and in the 24 hours prior to discharge using the C-SSRS. A positive C-SSRS must be followed by a CSRE on the same calendar day.

h. For Veterans who are undergoing a procedure (3 South, IR, Hemodialysis), the Suicide Screen reminder should be completed if due. A positive screen must be followed by a CSRE, which is required on the same calendar day as the original screen.

i. Suicide Behavior Overdose Report (SBOR) procedure:

1) Staff from the Mental Health and Social Work services (e.g., psychiatrist, psychologist, psychiatric pharmacist, social worker or registered nurse) must complete the SBOR Progress Note Title if the patient presents with or after a suicide attempt or behavior. This note title automatically defaults to a consult which needs to be completed and signed. The SBOR should be completed by the first staff member who becomes aware of the behavior to be reported.

2) Staff from other clinical services who become aware of a suicide attempt or behavior not previously documented must either complete the SBOR or alert a Suicide Prevention Coordinator or other mental health provider to complete the SBOR.

3) A SBOR must be completed when a staff member becomes aware of a Veteran who has engaged in a completed suicide, a suicide attempt, undetermined self-directed violence, or preparatory behaviors for suicide, which has not been previously reported and occurred within the past year.

4) When the SBOR is completed, it will automatically populate the Suicide Attempts section in the CSRE. It is recommended that the SBOR is completed prior to the CSRE.

j. Safety Plan procedure:

1) For patients who are at intermediate or high acute or chronic risk for suicide, have a positive C-SSRS, or have an active High Risk Flag for Suicide, or when clinically indicated, a clinician and the Veteran will collaborate on the creation of a Safety Plan using the template attached to the progress note titled: SUICIDE PREVENTION SAFETY PLAN. Safety plans can be completed by non-LIP clinicians as well as by LIPs.

2) The clinician will give a copy of the Safety Plan to the Veteran.

3) If the Veteran is hospitalized, the Safety Plan can be completed during his/her hospitalization but prior to discharge.

4) If a Safety Plan already exists, it should be reviewed with the Veteran and updated if needed.

(a) If the Safety Plan is updated a new note should be entered CPRS using the SUICIDE PREVENTION SAFETY PLAN template.

(b) If the previous Safety Plan is reviewed but no update is deemed necessary, the clinician should complete the SUICIDE PREVENTION SAFETY PLAN REVIEW/DECLINE note template.

(c) If the Veteran declines to review an existing Safety Plan or to collaborate on a new Safety Plan, the clinician should document this using the SUICIDE PREVENTION SAFETY PLAN REVIEW/DECLINE template.

(d) Finally, the SUICIDE PREVENTION SAFETY PLAN – HISTORICAL should be used to document an existing safety plan that has not yet been reviewed with the Veteran (e.g., a Safety Plan developed at another facility accessed via remote data).

5) Safety planning in the Emergency Department (SPED) – As required by the DUSHCO (10NC), the ED Psychiatrist will complete the Safety Plan with the Veteran and provide a copy of the Safety Plan prior to discharge from the ED for Veterans who:

(a) are assessed to be at elevated risk for suicide (intermediate to high acute or chronic risk on the C-SSRS+ or CSRE), or

(b) have a positive C-SSRS (answer “Yes” to any of items 3, 4, 5, or 8)

(c) have an active HRF for Suicide, or

(d) when clinically indicated (e.g., patient presents to the ED with SI or brought in by local police on a 5150 for danger-to-self) regardless of risk level.

k. Overdose Precautions (OD):

1) A consult is placed by clinical staff for placement of OD precautions when a Veteran has overdosed or when a Veteran has suicidal ideation involving the use of medications. The Overdose Precautions Coordinator (OPC) meets with the SPAM pharmacist to appropriately limit the Veteran's access to large quantities of medications.

2) A similar consult is placed when the Veteran’s primary provider requests that OD precautions clinical warning be removed. The OPC and the SPAM pharmacist will review the request and then remove the warning if appropriate.

l. Post-Suicide Debriefing:

The SPAM Workgroup reviews every reported suicide event and determines the need to schedule a debriefing where individual and group interventions may occur. The ACOS/Mental Health Services, or designee, will assign staff to a post-event debriefing team which could include clergy and mental health professionals to support the psychosocial needs of staff. (See Attachment I).

m. Guidance on Patients Failure to Attend Appointments (No Shows):

1) VA policy requires staff members to make multiple attempts to contact Veterans who miss scheduled mental health or substance use disorder appointments. Follow-up will be by telephone in most cases. In all cases, the first attempt must be made by a LIP or RN. Subsequent follow- up can be completed in most cases by any staff member (i.e., including non-LIPs). However, if the patient is on the high risk list, a

LIP or RN must make all attempts. All contact attempts, by LIP and non-LIP alike, must be documented in the medical record, and should typically be made on different days unless clinical judgment dictates multiple attempts within a shorter time frame. If contact is unsuccessful for a high-risk patient, a welfare check with local police may be indicated. Staff members should contact Suicide Prevention Coordinators for guidance and/or additional actions.

2) The SPAM workgroup conducts chart audits to ensure compliance with requirement to make the three calls for patients who did not show during appointments. This audit is completed on a quarterly basis.

n. Guidance on the Suicidal Caller:

1) Get the phone number and address where Veteran is located.

2) Stay calm. Notify another employee in the immediate area (written note or office communicator) that you have a suicidal Veteran on the line and they may need to call for help. They should contact the Psychiatry Resident on Call (858) 642-6353.

3) Assure the caller that help is available, validate feelings. “You sound like you are feeling bad, I am glad you called for help. I am going to stay on the line with you until help arrives.”

4) Forward or transfer the call to the Suicide Prevention Coordinator or Psychiatry Resident on Call. Stay on the line with the Veteran until the Suicide Prevention Coordinator or Psychiatry Resident on Call can accept the call and is speaking with the Veteran, or, in some cases, police have arrived.

5) Encourage the Veteran to tell you as much about the situation as they will allow (name, number, where they currently are). Don’t push too hard, allow them to do most of the talking, validate what they tell you.

Ask if they are alone, it would be helpful to have a friend/relative there (see Attachment H for the SAFE Script).

o. Discharge Procedures for patients who have a High Risk Flag (PRF) for Suicide:

1) All patients who are discharged from the Inpatient Mental Health

Service (2 South) are provided with discharge instructions which includes information on follow-up appointments, a Safety Plan to refer to in the event of crisis and the Veterans Crisis Line phone number (1-

800-273-TALK (8255).

2) All patients who are discharged after being admitted for suicidal ideation and are flagged as a high risk for suicide (PRF) are scheduled for four follow-up appointments in the first 30 days (face-to-face or by telephone) with the Suicide Prevention Coordinator or other Mental

Health LIP.

p. Patients who are identified as high risk for suicide (PRF) on non-mental health inpatient units are discharged with a safety plan. The discharge nurse notifies the Suicide Prevention Coordinator by co-signing the SPC to the discharge note and documenting in the discharge instructions note that the safety plan was completed and the Veteran was provided or declined a copy of the Safety Plan.

q. Suicide Assessment and Management on 2 South Inpatient Mental Health Services: See Attachment J.

6. REFERENCES:

a. Report/Suicide Prevention Workgroup, National Center for Veteran Safety, current edition.

b. Practice Guidelines for the Assessment and Treatment of Veterans with Suicidal Behaviors, American Psychiatric Association, November 2003.

c. Jacobs DG, Brewer ML. Application of the APA Practice Guidelines on Suicide to Clinical Practice, CNS Spectrums 2006, p 447-454

d. Suicide Risk: Assessing the Unpredictable, in Textbook of Suicide Assessment and Management. Edited by Simon, RI and Hales, RE.

American Psychiatric Press, 2006, pp 1-32.

e. The Joint Commission’s Comprehensive Accreditation E-Edition Manual, current edition.

f. DUSHOM. Guidance on Patients Failure to Attend Appointments (No Shows). Dated June 25, 2013.

g. DUSHOM. Eliminating Veteran Suicide: Suicide Risk Screening and Evaluation Requirements and Implementation (Risk ID Strategy). Dated November 13, 2020.

7. REVIEW DATE: January 2024.

8. FOLLOW-UP RESPONSIBILITY:

a. ACOS/Mental Health Services

b. Suicide Prevention and Management Workgroup/Suicide Prevention Coordinator

9. RESCISSION: MCM 11-24 dated September 20, 2020.

10. DATE APPROVED BY MEC: January 20, 2021.

X Kathleen Kim

KATHLEEN KIM, MD, MPH

CHIEF OF STAFF/ MEDICAL DIRECTOR

Signed by: Kim, Kathleen M.

X

ROBERT M. SMITH, MD

DIRECTOR

Signed by: Robert M Smith 134261 Attachment: A, B, C, D, E, F, G, H, I, J Distribution: SharePoint

Attachment A January XX, 2021

Screening and Evaluation of Suicide Risk

Suicide Screen (C-SSRS)

Required annually for all VASDHS patients. May be completed by most non-LIP clinical staff.

CSRE

Required on same calendar day if C-SSRS is positive; required prior to admission and discharge from MH RRTPs. LIP only.

Attachment B January XX, 2021

Attachment C January XX, 2021

Columbia Suicide Severity Risk Screen (C-SSRS)+

Attachment D January XX, 2021

Comprehensive Suicide Risk Evaluation (CSRE)

CSRE National

Template

The National Template is being finalized. This attachment will be updated with the final version.

Attachment E January XX, 2021

Suicide Prevention Safety Plan

Patient Safety

Plan.pdf

Attachment F January XX, 2021

Suicide/Suicide Behavior Report (SBOR)

Type SBR in CPRS and it will bring the report up.

Attachment G January XX, 2021

Procedures for Research

1. The R&D Committee, or its designated Institution Review Board of Record, will identify the level of Suicide Risk Assessment and Management required for all protocols that involve informed consent of human subjects, and assign one of the following categories:

a. Studies that DO NOT have as their primary intended subject population Veteran or non-Veteran participants with a psychiatric diagnosis, emotional/behavioral complaint, or chronic pain complaint.

For studies in this category, the only requirement is for suicide risk awareness, accomplished by completion of the “Suicide Risk Management Training for Clinicians” in the Talent Management System by the Principal Investigator, all Co-Investigators and study staff with human subjects contact. This training must be completed before a given individual may begin working with human subjects.

b. Studies that DO have as their primary intended subject population Veteran or non-Veteran participants with a psychiatric diagnosis, emotional/behavioral complaint, or chronic pain complaint, but DO NOT have a requirement for documentation of study activity in CPRS (e.g. observational studies).

1) Studies in this category must meet the requirements specified in 1.A above, and these additional requirements:

2) The Principal Investigator must submit to the VASDHS Institutional Review Board (IRB) or the R&D Committee (for protocols reviewed by the VA Central IRB) a completed version of the “Protocol for Responding to Research Participants Requiring Clinical Assessment of Suicidality”, which is available in the OnRAMP protocol submission system. At a minimum this form should include contact information for the Suicide Prevention Coordinators and the Veterans Crisis Line, but may also include contact information for any VASDHS clinical staff members who will provide suicide risk assessment (identified, fully-privileged clinical staff member(s) could be, but is not required to be, a member of the study staff)

3) Once approved by the VASDHS IRB or the R&D Committee, the Principal Investigator must ensure that all research staff with human subjects contact read, understand, and follow the study-specific criteria and procedures for referral of subjects for assessment of suicidality when indicated.

c. Studies that DO have as their primary intended subject population Veteran or non-Veteran participants with a psychiatric diagnosis, emotional/behavioral complaint, or chronic pain complaint, and DO have a requirement for documentation of study activity in CPRS (e.g. interventional studies).

1) Studies in this category must meet all requirements specified in 1.a and 1.b above, and these additional requirements:

Attachment G January XX, 2021

2) The Principal Investigator him/herself must be a fully-privileged VASDHS clinical staff member, or if not then ensure the presence of such a staff member among the research study staff.

3) The responsible clinical staff member (whether the Principal Investigator or a designated member of the study staff) must accept responsibility to conduct all Suicide Risk Assessment, Management, and Documentation in CPRS for the study according to the policies and procedures of MCM 11-24, items 5a-5e and 5h.

2. The VASDHS IRB and/or R&D Committee must document in the approval letter issued to the Principal Investigator, and in their meeting minutes, the level of suicide risk assessment and management required for the study.

3. The Associate Chief of Staff, Research & Development (R&D) or designee will:

a. Ensure ALL research employees with human subjects’ contact duties complete suicide risk management training before approving them to work directly with human subjects.

b. Ensure recording and tracking of all training in suicide risk management required of employees with human subjects contact duties.

Attachment H January XX, 2021

Guidance for Interacting with Veterans at Risk for Suicide

Things to consider when talking with a Veteran at risk for suicide

▪ Remain calm

▪ Listen more than you speak

▪ Maintain eye contact

▪ Act with confidence

▪ Do not argue

▪ Use open body language

▪ Limit questions-let the Veteran do the talking

▪ Use supportive, encouraging comments

▪ Be honest-there are no quick solutions but help is available

SAFE Script for a Suicidal Caller

Caller: "Hello…I'm feeling very depressed…I am thinking about ending it all"

VA Staff: "You sound as though you are feeling really bad. I'm glad you called us for help.

Can you tell me what number you are calling from?

Can you tell me where you are right now?

Are you having thoughts of ending your life today? (If yes, proceed)

Do you have a plan in mind on how you would harm yourself?

Do you have access to any weapons or things that could potentially be used to hurt yourself?

I am going to stay on the line with you, but I would also like to bring someone onto the call who will be able to help you."

If Caller says: "Yes, that would be ok."

VA Staff: "Good, I am going to stay on the line with you, while we get the help you need." Ask about safety: "Are you safe right now?" If they are driving, ask them to pull over and stop while you talk with them. "Is there someone with you?" Allow veteran to do most of the talking. Acknowledge what they're saying. Validate their feelings.

If Caller says: "NO"

VA Staff: "I understand that it may be hard for you to talk about what's going on right now, but you deserve the best professional help we have here. I'm really glad you called to tell us how you are feeling." Whichever way the caller responds, it is your goal to get a Suicide Prevention Coordinator or the Psychiatry Resident on Call or the

Veterans Crisis line involved immediately.

Suicide Prevention Coordinators

When suicide prevention assistance is needed, please attempt contact the via MS

Teams.

**Create your own Suicide Prevention Chat contact and add everyone on the team.

The suicide prevention coordinators (and their phone numbers) are as follows:

Dawn Miller, 858-964-8154

Shannon Vitale, 858-226-5795

Kimberly Beckstead, 858-731-7624

Julie Witte-Landau, 619-855-2403

Dana Furtado, 619-855-2410

Keely Wright, 858-210-9054

J. Marie Obaña, 858-336-6269

You can also email the entire team for anything, SDCVAMCSuicidePrevention@va.gov.

**If you call an SPC and we don’t answer, PLEASE leave a message. We are on the phones all day, every day, and if a call is missed from the medical center or a

CBOC without a message we can’t call back.

Veterans Crisis Line

If for some reason a suicide prevention coordinator is unable to help you or transferring the Veteran’s Crisis Line makes more sense, please provide a warm transfer to the crisis line: 1-800-273-8255 Press “1”. Stay on the line until you are connected to the crisis line. Give the responder a “warm handoff” before disconnecting the call.

Welfare Checks

If you feel Veteran is in imminent danger of self-harm and has refused transport to the nearest ED, you should contact (or have someone nearby contact) the local San Diego

Police Department (619) 531-2000 or 911 and request a welfare check. Make sure you ask Police Dispatch for the incident number for follow-up on the welfare check.

mailto:SDCVAMCSuicidePrevention@va.gov

Please include as much information as possible in an email to the Suicide Prevention

Team, SDCVAMCSuicidePrevention@va.gov.

Psychiatry Resident On Call

Psychiatry Resident on call’s telephone number is (858) 642-6353 in the instance the other options fail.

Remember

Take notes of the contact. Anything significant they say specific to the reported suicidality, i.e. plan, access to weapons, and try to get their name, last 4, address and especially the number they are calling from. This information will be important to have in case the call is dropped or the police need to “ping” their phone for location.

Work with your neighbor. If you are alone, reach out to someone while you have the person on the phone. A direct message to someone letting them know you have someone on the line with SI and you may need assistance.

mailto:SDCVAMCSuicidePrevention@va.gov

Attachment I January XX, 2021

Standard Procedure After a Suicide Event

1. SPC puts in SBOR if not already done, alerting administrative staff and decedent affairs.

2. SP team writes IB if needed

3. SPC contacts Medical Examiner’s office and requests investigative report

4. SPC notifies and offers support to:

a. MHTC

b. PCP

c. Any MH LIPs who have had contact with Veteran in previous 30 days

d. Additional staff may be notified if SPC believes indicated

5. If SPC or other staff member believes it is indicated, s/he contacts the VASDHS EAP program at 800-822-4847 to request an on-site debriefing for staff impacted by suicide-related events

a. Additionally, staff may request individual counseling (up to 6 sessions) by calling the number above

6. SPC notifies chaplaincy for support and help with outreach and condolences to family

7. SPC completes Behavioral Health Autopsy Program (BHAP) report

8. SPAM reviews event and:

a. Recommends whether peer review and/or RCA should occur; PIMS decides

b. Educates staff about anything that could have been done differently

c. Includes in annual summary report

9. Suicide prevention team post-event processing if needed

Attachment J January XX, 2021

Management of the Suicidal Patient on the Inpatient Mental Health Unit

1. PURPOSE: To establish the 2 South procedure for assessing the suicide risk of a patient and identifying and implementing nursing interventions to reduce the risk of self-harm.

2. POLICY: RN staff assesses the patient’s suicide risk at the time of admission to 2 South and throughout the hospital stay. The nursing staff implements immediately safety interventions when a patient is at risk for suicide.

3. DEFINITIONS:

a. Suicide Risk/Danger to Self- any subjective or objective observations and assessments of the patient’s statements, behavior, or history that would suggest the patient is acutely suicidal and may, or will, attempt suicide or self-harm.

b. One-to-one observation (1:1) - the highest level of patient observation on the acute inpatient unit. 1:1 observation is used for acutely suicidal patients who are expressing self-harm ideation or exhibiting self-harm behaviors. The staff member assigned to observe the patient always has the patient within their eyesight and has immediate physical access to the patient. One-to-one observation for suicidal or self-harm behaviors requires a staff member trained in managing suicidal patients, and who always maintains direct visual observation of the patient, approximately 5 to 7 feet from the patient.

c. One-to-one protocol- how staff conducts a 1:1 observation that includes a behavioral worksheet that serves as a basis for RN shift documentation (see 2 South Patient Supervision and Levels of Observation Policy, Attachments A, B).

4. RESPONSIBILITIES:

a. The Nurse Manager (NM) is responsible to ensure that relevant policies and procedures are followed, and that environmental and safety requirements are met to reduce suicide risk to patients hospitalized on 2 South.

b. The Clinical Nurse Specialist (CNS)/Clinical Nurse Educator (CNE) is responsible to educate staff in suicide assessment, interventions, and provide clinical supervision.

c. Registered Nurse (RN) is responsible for the competent assessment, supervision, and provision of nursing interventions with suicidal patients in accordance with policy.

d. Licensed Vocational Nurses (LVN) are responsible for the competent implementation of interventions for suicidal patients in accordance with policy.

e. Unlicensed Nursing Staff (Nursing Assistant):

a. Provides one-to-one face-to-face supervision of the suicidal patient.

b. Monitors the patient’s behavior and documents on one-to-one flowsheet.

c. Provides observation results (SBAR) to the RN at least hourly and more frequently, as indicated.

5. PROCEDURES:

a. A Registered Nurse (RN) completes the suicide risk screen and assessment (C-SSRS and HBIPS risk assessments) at the time of admission as part of the nursing admission process on all patients admitted to 2 South and documents it in the patient’s electronic medical record. If it is positive, the nurse will notify the admitting physician.

b. The RN notifies the physician immediately of all patients who are assessed as suicide risk.

c. Patients who are acutely or imminently suicidal are admitted to B-Pod and placed on a 1:1 level of observation. All other patients who have expressed suicidal ideation but are not assessed as acutely or imminently suicidal are placed on a 15-minute level of observation.

d. Upon admission to the unit, the patient’s belongings are separated immediately from the patient. The patient is asked to put on pajamas so that staff can thoroughly conduct a skin assessment, search the patient and their belongings, and contraband found during the search is stored away from the patient for safekeeping.

e. The RN initiates an individualized treatment plan that addresses the self-harm behavior for each patient who presents for admission as harmful to themselves. As part of the treatment plan, a Suicide Safety Plan is completed with the patient during the patient’s hospitalization and reviewed and given to the patient prior to discharge.

f. The RN initiates one-to-one observation whenever a patient is assessed (on admission or at any time during their hospitalization) to be imminently a danger to self (suicidal) and the physician is called immediately to see the patient and must see the patient within 2 hours.

g. The RN notifies the physician immediately for any patient during their hospitalization that demonstrates a significant change in their suicide risk assessment status. This includes patients going on a 1:1 status or being removed from a 1:1 status.

h. Nursing staff providing 1:1 supervision must provide 1:1 level of observation whenever the patient must leave the immediate parameters of the unit, including the dining room, patio, treatment room, or for necessary treatments, tests, or appointments.

i. Whenever possible, suicidal patients on 1:1 observation is placed in the bed closest to the door/hall. Exceptions may be made for female patients or for patients with medical or mental health needs that require a single room.

j. Patients on a 1:1 level of observation for suicidal behavior are provided a safe environment free of contraband, a special isolation tray with plastic eating utensils, frequent interactions with staff as tolerated, and a suicide risk assessment by an RN each shift. With consent of the patient, family and visitors are educated regarding the level of observation required during visiting hours and contraband precautions.

k. The one-to-one order is renewed each 24-hours by the physician after consulting with nursing and reassessing the patient.

l. RNs must conduct ongoing assessment of patients at risk for harm to themselves and document results of the assessment at least one time per shift. Documentation must be made on the Nursing Narrative Note or 24-Hour Nursing Assessment Note. Reassessment occurs when there are significant changes in the clinical condition, changes in the level of observation, and before discharge.

m. All off-unit appointments, tests and procedures are evaluated by the physician, patient’s nurse, Charge RN in conjunction with the Nurse Manager or designee as to critical need. If it is determined that going off the unit is critical to treatment, a determination is made as to the safest mode of transportation and staff level of escort and supervision.

Attachment K January XX, 2021

Mental Health Careline SOP 1, Suicide Prevention Program, May 15, 2020

MHCL SOP1 SPP

5.14.20.pdf