D.11 Suicide Prevention.pdf

DEPARTMENT OF VETERANS AFFAIRS

VETERANS HEALTH ADMINISTRATION

VISN 19

SUICIDE PREVENTION AND MANAGEMENT OF SUICIDE RISK

I. PURPOSE: To create a facility policy that informs procedures for suicide prevention and management of suicide risk among Veterans. This Medical Center Memorandum (MCM) establishes guidelines for suicide risk screening, evaluation, treatment, reporting, reviewing, education, and response to suicide behaviors and death.

II. POLICY: The Eastern Oklahoma VA Health Care System (EOVAHCS) will provide a safe and therapeutic environment for Veterans as mandated standard of practice, per Suicide Prevention Coordinator (SPC) Program Manual. Therefore, EOVAHCS staff will follow a standardized approach with regard to safety, evaluation, and provision of interventions to Veterans with suicidal ideation or behavior. Collaboration between EOVAHCS care teams, service centers, and sections is required to ensure policy compliance and Veteran safety.

III. DEFINITIONS: For the purposes of documentation, reporting, and Veteran safety program work, the following definitions for suicide related behaviors, and self-directed violence classification system are utilized by Department of Defense, Centers for Disease Control and Prevention (CDC), Substance Abuse and Mental Health Services and the National Institute of Mental Health.

a. Suicide Prevention: Suicide Prevention focuses on screening, assessing, tracking, and treating Veterans who may be at risk for suicidal behavior. This includes strategies that emphasize making reasonable efforts to provide a safe environment, free of hazards that could result in self-harm, ready access to high quality mental health care, frequent monitoring, risk evaluation and safety planning for Veterans identified as high-risk, suicide prevention training for all facility staff, and community outreach and public health campaigns.

b. Inpatient: Veterans admitted to EOVAHCS for care and treatment.

c. Outpatient: Veterans who are receiving health care service from EOVAHCS or any other community-based health care provider.

d. Suicidal Self-Directed Violence (SDV): Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself with evidence, whether implicit or explicit, of suicidal intent. Note that intent to die is judged by both subjective

EASTERN OKLAHOMA VA HEALTH CARE SYSTEM MUSKOGEE, OKLAHOMA

MEDICAL CENTER MEMORANDUM 11-52 December 6, 2019

D.11 SUICIDE PREVENTION AND MANAGMENT OF SUICIDE RISK

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EOVAHCS, Suicide Prevention and Management of Suicidal Behavior Medical Center Memorandum 11-52 12/6/2019 evidence (Veteran-reported) and objective evidence behavior that suggests intent to die.

e. Non-suicidal Self-Directed Violence (NS-SDV): Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is no evidence, whether implicit or explicit, of suicidal intent.

f. Undetermined Self-Directed Violence (U-SDV): Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. Suicidal intent is unclear based on the available evidence.

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

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

i. Preparatory Behavior: Acts or preparation towards engaging in SDV, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for one’s death by suicide (e.g., writing a suicide note, giving things away).

j. Suicide Threat: Communication that suicidal behavior might occur.

k. Suicidal Ideation: Thoughts of engaging in suicide-related behavior. (Various degrees of frequency, intensity, and duration).

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

m. Lethality: Extent to which the method of self-harm is a medical danger to life.

Physical injury can indicate level of lethality due to the physical or toxic effects of the SDV act interacting with the body.

n. Interrupted By Self or Other: A person takes steps to injure self, but is stopped by self or another person prior to fatal injury. The interruption may occur at any point.

o. Suicide Risk Screen: A suicide risk screen is a brief screen that provides important information about the Veteran’s current potential for SDV. It is an appraisal of the Veteran’s subjective experience (ideation, wish, plan, and intent) and behaviors (warning signs). It is designed to cast a wide net for suicide risk and the outcome is only negative or positive. A screen is not designed to determine the level of suicide risk, but to prompt further evaluation if acute risk is indicated. When a screen is positive, additional risk evaluations are clinically indicated.

Medical Center Memorandum 11-52 12/6/2019

p. Comprehensive Suicide Risk Evaluation (CSRE): An evidence-based clinical evaluation to determine the nature and degree of suicide risk. This systematic evaluation of a Veteran’s current potential for self-directed violence includes the following:

(1) Warning signs, evaluation of SDV ideation, intent, and plan.

(2) Assessment of suicide preparatory behavior and history of suicide attempts.

(3) Evaluation of risk and protective factors affecting suicide risk.

(4) Summary of clinical impression including assignment of chronic and acute risk for SDV.

(5) Risk mitigation plan.

IV. RESPONSIBILITIES:

a. Medical Center Director: The Medical Center Director is responsible for ensuring all EOVAHCS employees are aware of and comply with this MCM.

b. All EOVAHCS employees:

(1) Every EOVAHCS employee, to include Community Based Outreach Clinic

(CBOC) and Outpatient Clinics (OPC), is responsible for attending suicide prevention training as a new employee (New Employee Orientation) and annually thereafter (via Talent Management System). The EOVAHCS Suicide Prevention Program will provide additional training to services or individual staff as indicated or requested.

(2) All EOVAHCS employees must recognize that any Veteran may be at risk for suicide and that Suicide Prevention is the responsibility of all EOVAHCS employees.

Any EOVAHCS employee who interacts with a Veteran, either by phone or in person, who has any reason to believe that a Veteran is at risk for suicide and/or SDV must care for that Veteran and respond as though that Veteran is experiencing a medical emergency. The response level for a Veteran who is making suicidal statements but has NOT harmed self yet is considered urgent.

(a). On Site: If an EOVAHCS employee outside of the mental health service is concerned about the suicide risk of a Veteran who is on site at the medical center, they should escort the Veteran to the Emergency Department (ED). The employee must stay with the Veteran until Veteran is registered in the Emergency Department. The ED will conduct an initial screening and, if needed, a Mental Health Licensed Independent Provider (LIP) or an ED LIP with specialized Suicide Risk Identification Strategy training will complete additional evaluation, including a CSRE.

(b). On the Phone: If an EOVAHCS employee outside of the mental health service

Medical Center Memorandum 11-52 12/6/2019 is concerned about the urgent suicide risk of a Veteran who is on the phone, the employee must follow the crisis caller protocol (MCM 11-66 Crisis Caller Protocol). If a Veteran reports that they have harmed themselves or are about to harm themselves in any way, law enforcement must be contacted immediately to check on the welfare of that Veteran.

(3) CBOC/OPC employees are responsible for having training in suicide prevention as outlined in “4b1” above. Any Veteran demonstrating suicidal behavior, deemed at risk for suicide, and/or screening positive on a suicide risk screen at a CBOC/OPC requires completion of suicide risk screening and, if needed, CSRE by a LIP on site.

Employees in each CBOC/OPC are responsible for knowing how to contact the appropriate LIP, who can assess the need for involuntary psychiatric hospitalization either directly or through local police. In the event SDV is emergent, employees in each CBOC/OPC are to call 911 and request police intervention immediately. Veteran must always remain in line sight of an employee until emergency services arrives.

(4) If suicidal behaviors of any kind are observed, overheard or reported as having occurred in the past year, all employees are required to report the information immediately to a clinical staff to ensure a Suicide Behavior and Overdose Report note template is completed promptly (within 24 hours) in the Computerized Patient Record System (CPRS).

c. All EOVAHCS Clinical Staff:

(1) If any clinical staff receives information from a Veteran or any other source including a report from medical examiner, family member, EOVAHCS staff member or others about the death of a Veteran by suicide or about any suicidal behavior of a Veteran, on or off station, they are required to ensure the completion of a Suicide Behavior and Overdose Template in the CPRS System within 24 hours. The Suicide Behavior and Overdose Report Template automatically alerts the EOVAHCS Suicide Prevention Program (SPP) to ensure appropriate follow-up.

(2) If decedent affairs or administrator on duty (AOD) receives information from a

Veteran or any other source including a report from medical examiner, family member, EOVAHCS staff member or others about the death of a Veteran by suicide they are required to report this information to the SPP.

(3) Qualified EOVAHCS staff, as outlined in Attachment A and in the specified mandated settings, are responsible for conducting and documenting the results for suicide risk identification utilizing standardized, evidenced-based screening and evaluation processes in accordance with national VA standards. Suicide risk screens will be required according to mandated settings and completed by qualified staff (see Attachment A). Screening involves a three-stage process:

(a). PHQ-i9: The initial phase of screening consists of one item from the

PatientHealth Questionnaire-item 9 (PHQ-i9).

Medical Center Memorandum 11-52 12/6/2019

(b). Columbia-Suicide Severity Rating Scale (C-SSRS): When the PHQ-i9 screenspositive, the secondary screen, a C-SSRS, will be completed by a qualified professional, per Attachment A.

(c). Comprehensive Suicide Risk Evaluation (CSRE): When the C-SSRS screenspositive, a Comprehensive Suicide Risk Evaluation must be completed by a qualified staff member (see Attachment A) in the mandated settings as established in section “5. Procedures” below.

Note: All three components of the suicide risk screen and evaluation must be completed within the same calendar day once the screening process has been initiated, in accordance with national VA standards.

(4) If a Veteran has been assessed as at risk for suicide by a LIP in a non-mental health unit, that Veteran must be placed on one-to-one observation according to unit specific procedures. Per VHA Directive 1167, one-to-one observation is defined as the constant observation of one patient by one staff. Staff providing one-to-one observation should only be observing one patient at a time and have no other responsibilities during the one-to-one observation assignment. While under one-to-one observation, any restroom visit requires an escort who can visually monitor for suicidal behavior. Such restrictions on the Veteran’s freedom must be consistent with statutory and regulatory authority and be sensitivity to privacy and dignity. Observation by cameras cannot substitute for one-to-one observation.

d. Chief of Behavioral Medicine Service:

(1) Chief of Behavioral Medicine Service has the responsibility for implementation of this policy and for reporting to the Director, Chief of Staff, and VISN in accordance with VA Directive 0321 (Serious Incident Reports) and 10N Guide to Issue Briefs.

(2) Chief of Mental Health, in coordination with SPP, will conduct post event reviews to provide support to staff who had contact with Veteran who died by suicide and to identify lessons learned and associated action plans to inform and improve suicide prevention efforts at EOVAHCS.

e. Suicide Prevention Program (SPP):

(1) SPP is responsible for serving as an expert resource for both EOVAHCS and the community related to Veteran suicide and suicide prevention issues.

(2) The SPP is responsible for tracking and reporting all suicidal events (not just attempts and deaths) at EOVAHCS using approved VA reporting standards.

(3) The SPP is responsible for consulting with the Mental Health Treatment

Coordinator (if the Veteran has one), referring providers and/or any other staff involved in a Veteran’s care to determine the advisability of Category I Patient Record Flag (“High Risk for Suicide Flag”, per VHA Directive 2008-036).

Medical Center Memorandum 11-52 12/6/2019

(4) The SPP is responsible for ensuring a High-Risk for Suicide Flag is placed on the electronic medical record when it has been deemed appropriate for a Veteran. The SPP is responsible for managing all requirements of the High-Risk for Suicide Flag (Per VHA Directive 2008-036) for all Veterans assigned a High Risk for Suicide Flag.

(5) The SPP is responsible for tracking Veterans with a High-Risk for Suicide Flag to ensure they all have a Suicide Prevention Safety Plan documented in CPRS prior to discharge from the psychiatric inpatient unit and completed and updated at regular intervals as outpatients. NOTE: It is the responsibility of the treating clinical staff to complete the Safety Plan.

(6) The SPP is responsible for entering all Veteran suicides using the Behavioral

Health Autopsy Program (BHAP) Chart Review Tool and submitting a Family Interview Contact (FITC) form within 30 days post mortem.

(7) The SPP is responsible for entering and maintaining Mail Contact Program information in the (SPAN) on a monthly basis.

(8) The SPP is responsible for conducting and recording no less than six community outreach program events through the (SPAN) on a monthly basis.

(9) The SPP is responsible for participating in the Mental Health Environment of

Care (MHEOC) Safety Survey. The SPP is required to assist the MHEOC Safety Survey team in determining actions that should be taken to improve the mental health inpatient environment and in conducting environmental risk assessments on all MHEOC Rounds to mitigate risk across EOVAHCS.

(10) The SPP is responsible for ensuring all SPC At Risk for Suicide Consults are completed within identified time frame.

(11) The SPP is responsible for ensuring all consult referrals sent to them from the Veterans Crisis Line (VCL) are appropriately responded to within three business days.

(12) The SPP is responsible for building relationships with local and state suicide prevention organizations, local crisis line organizations, and local Veteran Service Organizations (VSO’s) to build collaborations which address suicide prevention with a public health approach.

(13) The SPP will work with Mental Health Medical Support Assistants (MSA) to track any no-show appointments by High-Risk Category I Veterans and ensure follow-up with the Veterans as soon as possible to facilitate rescheduling.

(14) The SPP will track appointment completions to ensure compliance with required number of appointments and timeframes for all Veterans on a High Risk for Suicide Flag (per VHA Directive 2008-036).

Medical Center Memorandum 11-52 12/6/2019

(15) The SPP will ensure all staff who care for Veterans who are at risk for suicide complete training on completing the Suicide Risk Identification Strategy and Suicide Prevention Safety Plans. SPP is also responsible for training non-mental health staff on how to respond to urgent and emergent suicide risk concerns.

f. Patient Safety and Risk Manager:

(1) Patient Safety will follow requirements of VHA Handbook 1050.01 VHA

National Patient Safety Improvement Handbook for individual Root Cause Analysis (RCA) related to suicides and suicide attempts.

(2) Risk Manager in collaboration with Peer Review Committee will follow Veterans

Health Administration (VHA) Directive 1190 requirements for review of suicides and suicide attempts.

g. EOVAHCS Chaplain: EOVAHCS Chaplain will contact family or identified support of deceased Veteran to provide condolences and work with SPP to provide a list of resources for any additional support.

V. PROCEDURES:

a. EOVAHCS employs a standardized, evidence-based screening process in accordance with Eliminating Veteran Suicide: Implementation of Suicide Risk Screening and Evaluation Memorandum, Deputy Under Secretary for Health Operations and Management, November 2, 2018 and as detailed here:

https://vaww.visn19.portal.va.gov/sites/ECHCS/srsa/_layouts/15/start.aspx#/ .The three-stage suicide risk screening and evaluation process, Suicide Risk Identification Strategy, will be conducted on all Veterans presenting to identified departments for their initial visit and every year thereafter or sooner as clinically indicated (see Attachment A).

The primary suicide risk screen is item 9 from the Patient Health Questionnaire-9. This item is incorporated into existing clinical reminders for Depression and Posttraumatic Stress Disorder. This primary screen is intended to broadly screen for individuals who may be at increased risk for suicide. All positive PHQ-i9 screens require completion of a C-SSRS screen by a qualified professional within the same day of primary screen administration. All positive C-SSRS screens require completion of a CSRE by an LIP on the same calendar day. Specific procedures for each service follow.

NOTE: Please note that in addition to the specific procedures outlined below for each service, the Suicide Risk Identification Strategy can be implemented at any time with a Veteran as clinically indicated.

(1) Emergency Department (ED): The Suicide Risk Identification Strategy will be utilized for all Veterans who present to the ED regardless of complaint. The secondary C-SSRS will be completed during the initial nursing triage assessment. All positive secondary screens will require nursing to alert the medical provider about the positive screen. The CSRE and a Suicide Prevention Safety Plan must then be completed by an LIP with specialized Suicide Risk Identification Strategy training in the ED, or the On-https://vaww.visn19.portal.va.gov/sites/ECHCS/srsa/_layouts/15/start.aspx#/

Medical Center Memorandum 11-52 12/6/2019

Call mental health provider (between 1630 – 0600). Once initiated, the Suicide Risk Identification Strategy must be fully completed on the same calendar day.

(2) Inpatient Mental Health: The Suicide Risk Identification Strategy will be completed with all Veterans who are admitted to the inpatient mental health unit at time of admission, unless strategy has already been completed in ED within in 24 hours of admission. The Strategy will be completed again at time of discharge from the inpatient unit. Once initiated, the Suicide Risk Identification Strategy must be fully completed on the same calendar day. Veterans will also be provided with assistance developing a Suicide Prevention Safety Plan while on the inpatient unit. The inpatient treatment team will be responsible for the Suicide Prevention Safety Plan completion.

(3) Outpatient Mental Health: The C-SSRS will be completed with all Veterans during initial intake to mental health and annually thereafter. The C-SSRS should also be completed with Veterans as clinically indicated. All positive C-SSRS screens will require a CSRE to be completed by an LIP on the same calendar day. Substance Abuse Disorder (SUD), Post Traumatic Stress Disorder (PTSD), and Psychosocial Rehabilitation and Recovery Center (PRRC) Clinical Teams are included clinics in the outpatient mental health department.

(4) Care Management and Social Work Services: The Suicide Risk

Identification Strategy completion is required in the following Care Management and Social Work clinics: Housing and Urban Development-VA Supportive Housing (HUD- VASH) and Transition Care Management (TCM). The C-SSRS will be completed with all Veterans during initial intake and annually thereafter. The C-SSRS should also be completed with Veterans as clinically indicated. All positive C-SSRS screens will require a CSRE to be completed by an LIP on the same calendar day. For purposes of this MCM, the Care Management and Social Work Services clinics fall under outpatient mental health requirements in attachment A.

(5) Inpatient Medical Units: The Suicide Risk Identification Strategy will be utilized for all Veterans who are admitted to inpatient medical units, unless already completed within 24 hours of admission. The primary PHQ-i9 screen and secondary C- SSRS (if needed) will be completed during the initial nursing combined assessment. All positive secondary screens will require completion of the CSRE by an LIP on the inpatient unit or by a Mental Health provider using the mental health consult process.

Once initiated, the Suicide Risk Identification Strategy must be fully completed on the same calendar day.

(6) Primary Care: Clinical Reminders for Depression and PTSD contain primary PHQ-i9 risk screen. These clinical reminders are completed during nursing contact at each initial primary care visit and annually thereafter. Following a positive primary screen, nursing staff will alert the Veteran’s medical provider who will then complete the secondary (C-SSRS) suicide risk screen. In a CBOC, all positive secondary screens require primary care staff to contact Primary Care Mental Health Integration clinician (PCMHI) for completion of the CSRE. Where PCMHI staff are not available, all positive secondary screens require primary care staff to contact LIP (i.e. PACT social worker or

Medical Center Memorandum 11-52 12/6/2019 primary care provider) for completion of the CSRE. Once initiated, the Suicide Risk Identification Strategy must be fully completed on the same calendar day. If there is not a LIP available on site, CBOC/OPC employee must coordinate a telehealth appointment with mental health to complete CSRE on the same calendar day.

(7) Home Based Primary Care (HBPC): Three staged Suicide Risk Identification

Strategy utilized by primary care clinics will also be followed in HBPC setting. The primary PHQ-i9 screen should be completed by a Licensed Clinical Social Worker or Psychologist as part of the admission or annual depression and/or PTSD screenings.

These LIPs can then complete the secondary C-SSRS screening, as well as the CSRE on the same calendar day if positive screenings require it. Once initiated, the Suicide Risk Identification Strategy must be fully completed on the same calendar day. The Suicide Risk Identification Strategy should also be implemented as clinically indicated in

HBPC.

(8) Pain Clinic: Three staged Suicide Risk Identification Strategy will be utilized in the pain clinic. The primary PHQ-i9 screen is completed at the initial assessment by the LIP. The LIP can then complete the secondary C-SSRS screening, as well as the CSRE on the same calendar day if positive screenings require it. Once initiated, the Suicide Risk Identification Strategy must be fully completed on the same calendar day.

The Suicide Risk Identification Strategy should also be implemented as clinically indicated in the pain clinic.

VI. REFERENCES:

a. VA’s Integrated Approach to Suicide Prevention: Ready Access to Quality

Care. Suicide Prevention Coordinator Guide, January 5, 2018.

b. VHA Handbook 1050.01 VHA National Patient Safety Improvement Handbook, March 4, 2011.

c. Department of Veterans Affairs Office of the Inspector General. Implementing

VHA Mental Health Initiatives for Suicide Prevention; May 10, 2007.

d. Safety Plans for High Risk Veterans memorandum, Under Secretary for Health, July 13, 2010.

e. VHA Directive 2008-036, Use of Patient Record Flags to Identify Patients at High Risk for Suicide, July 18, 2008.

f. High Risk for Suicide Patient Record Flag Changes memorandum, Deputy

Under Secretary for Health Operations and Management, October 3, 2017.

g. VHA Directive 1190, Peer Review for Quality Management, November 21, 2018.

Medical Center Memorandum 11-52 12/6/2019

h. Eliminating Veteran Suicide: Implementation of Suicide Risk Screening and Evaluation memorandum, Deputy Under Secretary for Health Operations and Management, November 2, 2018.

i. VA Directive 0321, Serious Incident Reports, June 6, 2012.

VII. FOLLOW-UP RESPONSIBILITY: Chief, Behavioral Health Service

VIII. RESCISSION: None

/s/

MARK E. MORGAN, MHA, FACHE

Medical Center Director

Appendix A - Suicide Risk Identification Strategy.

DIST: C, D (all clinical)

LEFT BLANK ON

PURPOSE

Medical Center Memorandum 11-52 Appendix A

SUICIDE RISK IDENTIFICATION STRATEGY

Minimum Requirements by Setting

Setting Screening and/or Evaluation Requirements Identified in the Memo

Primary Screen

Secondary Screen (C-SSRS) based upon Positive Primary Screen or Program Requirement

Comprehensive Evaluation (CSRE) based upon Positive Secondary Screen or Program Requirement

Emergency Department and Urgent Care

Screening is part of the National Emergency Department Triage note

Primary Care and other NEXUS Clinicsa

PCMHI

Annually in conjunction with required depression and PTSD screening

PHQ-2+I9*

PC PTSD-5+I9*

Outpatient Mental Healthb

During intake evaluation and annually thereafter

As clinically indicated

Inpatient Mental Health**

Screening within 24 hours of admission and updated CSRE 24 hours before discharge

Pain Clinic During intake evaluation

PHQ-9 Item 9

Inpatient Medical/Surgical

Screening within 24 hours of admission and updated PHQ-9 Item 9/C- SSRS/CSRE 24 hours before discharge

PHQ-9 Item 9

Medical Center Memorandum 11-52 Appendix A-2 a This includes, but is not limited to: Home-Based Primary Care b This includes, but is not limited to: Mental Health Clinics; PTSD Clinical Teams; Substance Use Disorder Treatment Programs; Psychosocial Rehabilitation and Recovery Centers; Mental Health Intensive Case Management

*PHQ-9 Item 9: Patient Health Questionnaire Item Number 9; PHQ-2+I9: Patient Health Questionnaire 2 Question Depression Screen plus Item 9 from PHQ-9 for suicidal ideation screen; PC-PTSD-5+I9: Primary Care Posttraumatic Stress Disorder Screen-DSM-5 version plus Item 9 from PHQ-9 for suicidal ideation screen; C-SSRS: Columbia – Suicide Severity Rating Scale Screener; CSRE: Comprehensive Suicide Risk Evaluation

** Note: For the admission requirement, process can be completed in ED or by inpatient mental health as long as it is within 24 hours of admission.

Medical Center Memorandum 11-52 Appendix A

Medical Center Memorandum 11-52 Appendix A

Medical Center Memorandum 11-52 Appendix A-3