D.15 f. SUICIDE BEHAVIOR AND OVERSODE REPORT - ATTACHED.pdf

• Behaviors with suicidal or undetermined intent. (For this note template, suicidal ideation is not considered a behavior; only behaviors, including preparatory behaviors, should be reported.)

• Any overdoses, including accidental, intentional, and adverse effect overdoses.

Only one event at a time can be reported within this template. If the patient reports multiple events that have not already been reported, please do the following:

1. Enter the first event in the SBOR template

2. For the second event that needs to be reported, create a new historical visit.

3. Within that new historical visit, enter an SBOR note for the second event

Repeat steps 2 and 3 for any additional events that need to be reported.

*Date of event (enter as MM/DD/YYYY e.g., 01/15/2019): ___________________________

Date is approximate

Person(s) reporting information: (Select all that apply.)

Self-report

Family member: ____________________________

Outside agent: ____________________________ VA staff: ______________________________

Other: ________________________________

*Event Type Being Reported (Select only one.)

o Non-Suicidal Overdose Event [skip to Reported Patient Status] o Accidental overdose o Severe adverse effect (i.e., patient took medication as prescribed, with significant side effect such as severe somnolence or confusion; could be due to medication interaction) o Suicidal behavior, OR possible suicidal behavior with unknown intent (including suicidal overdose events)

[If yes, answer the following questions]:

*Did Veteran have suicidal intent for this event?

o Yes o Unknown to author

*Was the behavior being reported preparatory only?

Preparatory Behavior: Acts or preparation towards engaging in Suicidal Self-Directed Violence, but before potential for injury has begun.

Examples of preparatory behaviors include practicing with an unloaded firearm, stockpiling medications, writing a suicide note.

o No o Yes o Unknown to author

*Did the event reportedly result in injury?

Injury: damage or harm done to the body caused by external force.

o No o Yes. Description of injury*: ____________________________________________ o Unknown to author

D.15 f) SUICIDE BEHAVIOR AND OVERSODE REPORT

Suicide Behavior and Overdose Report Use this template to report both drug overdoses and suicidal behaviors, specifically:

D.15 f) SUICIDE BEHAVIOR AND OVERSODE REPORT - 36C26225R0004

Was treatment plan modified because of the event?

o No o Yes _________________________________________________________________ o Unknown to author

*Reported patient status at time of event:

o Outpatient o Inpatient o Mental Health Residential Rehabilitation Treatment Program (RRTP) o VA Community Living Center (CLC) o VA Contracted Community Residential or Transitional Bed o Other: ____________________________________________________________ o Unknown to author

*Did this event reportedly occur on VA property?

o No o Yes

Reminder: If this event involved suicidal or undetermined intent, you must directly notify the Suicide Prevention team and supervisor, by phone or IM, to initiate mandated reporting within 1 hour.

o Unknown to author

*Did the event reportedly occur within 7 days of discharge from a VA inpatient or residential care facility?

o No o Yes

Reminder: If this event involved suicidal or undetermined intent, you must directly notify the Suicide Prevention team and supervisor, by phone or IM, to initiate mandated reporting within 1 hour.

o Unknown to author

*Was the event reportedly interrupted?

Interrupted by self or other is defined as: a person takes steps to injure self but is stopped by self/another person prior to fatal injury. The interruption may occur at any point.

In the case of overdose, naloxone administration counts as an interruption.

o No o Yes, by self. Explain: ________________________________________________________ o Yes, by other. Explain: ________________________________________________________ o Unknown to author

*Reported outcome of event (Select all that apply).

Died

Hospitalization ________________________________________________________

Remained outpatient

Other ________________________________________________________ Unknown to author

*Method(s) used for this event (Select all that apply.)

o Unknown to author o Not applicable – event was preparatory only with no method(s) involved o Event reported as:

Overdose (Select all that apply.) [if not reporting an overdose, skip to other method types]

Acetaminophen/Other NSAIDS

Alcohol

Amphetamine/other psychostimulants

Anticonvulsants (click to expand)

Barbiturates

Gabapentin/Pregabalin Other anticonvulsants: ____________________________________________

Unknown anticonvulsants

Antidepressants (click to expand)

Tricyclic Antidepressants (e.g. amitriptyline, amoxapine, clomipramine, desipramine, imipramine, trimipramine, doxepin, maprotiline, protriptyline)

SSRIs (e.g. citalopram, fluoxetine, fluvoxamine, escitalopram, paroxetine, sertraline, vilazodone, asenapine)

SNRIs (e.g. duloxetine, venlafaxine, desvenlafaxine, Levomilnacipran, milnacipran)

Atypical Antidepressants (e.g. bupropion, mirtazapine, trazodone, vortioxetine, nefazodone)

MAO Inhibitors (phenelzine, tranylcypromine, isocarboxazid, selegiline)

Other antidepressants: ____________________________________________

Unknown antidepressants

Antihistamines (click to expand)

Diphenhydramine/Hydroxyzine

Other antihistamine: ____________________________________________ Unknown antihistamines

Antipsychotics (click to expand)

Typical Antipsychotics (e.g. chlorpromazine, fluphenazine, haloperidol, loxapine, molindone, perphenazine, pimozide, thioridazine, thiothixene, trifluoperazine)

Atypical antipsychotics (e.g. aripiprazole, olanzapine, lurasidone, paliperidone, risperidone, quetiapine, ziprasidone)

Clozapine

Other antipsychotics: ____________________________________________

Unknown antipsychotics

Benzodiazepines (click to expand)

Alprazolam/Lorazepam/Diazepam

Chlordiazepoxide Clonazepam

Estazolam/Flurazepam/Temazepam/Oxazepam

Midazolam

Other benzodiazepine: ____________________________________________ Unknown benzodiazepines

Non-Benzodiazepine sedatives/hypnotics (click to expand)

Eszopliclone

Ramelteon

Zolpidem

Zaleplon Other sedatives/hypnotics: ____________________________________________

Unknown sedatives/hypnotics

Cannabis

Central Muscle Relaxants (click to expand)

Baclofen

Cyclobenzaprine

Metaxalone Methocarbamol/Carisoprodol

Tizanidine

Other central muscle relaxants: ____________________________________________

Unknown central muscle relaxants

Cocaine (click to expand)

Mood Stabilizers (click to expand)

Carbamazepine

Divalproex/valproate/valproic acid Lamotrigine

Lithium

Other mood stabilizer: ____________________________________________

Unknown mood stabilizers

Prescription Opioids (click to expand)

Fentanyl Hydrocodone

Methadone

Morphine Oxycodone

Suboxone, Subutex, Buprenorphine

Other prescription opioids: ____________________________________________

Unknown prescription opioids

Non-Prescription Opioids (click to expand)

Heroin Carfentanil

Illicitly manufactured fentanyl

Other non-prescription opioids: _________________________________________

Unknown non-prescription opioids

Other/Non-opioid/Non CNS pharmaceuticals other than listed above (click to expand)

Antihypertensive Anticoagulants

Antidiabetic agents (e.g., insulin)

Other: ________________________________________________________

Unknown to author

*Was naloxone reported to be administered to the patient? [if No or Unknown, skip to page 6] o Unknown to author o No o Yes

Which were the sources of naloxone that were reportedly administered to the patient? (Select all that apply.)

Patient’s outpatient naloxone prescription

Other lay person’s naloxone

VA facility-stocked naloxone (including VA Police)

Emergency Department/Urgent Care Center (ED/UCC)

Mental Health Residential Rehabilitation Treatment Program (MH RRTP) Outpatient Clinic/Community Based Outpatient Clinic (CBOC)

Automated External Defibrillator (AED) cabinet

VA Police

Other VA facility-stocked naloxone (specify) Non-VA services naloxone (specify, e.g., Emergency Medical Services, Fire

Department)

Other (specify): ____________________________________________

Approximate date naloxone was reportedly used (enter as MM/DD/YYYY e.g., 02/01/2017): _________________________________________________

Naloxone was reportedly administered by:

Self (patient) VA facility staff (including VA Police) Comment: __________________________

Layperson bystander

Non-VA emergency responder

Other: ____________________________________________ Declined to answer

Number of naloxone doses administered? (e.g., one nasal spray = 1 dose) o 1 o 2 o 3 o 4 o 5+ o Unknown

What was the reported outcome of the naloxone use?

The patient survived

The patient died

Unknown Other: ____________________________________________

Are there any negative consequences reported in relation to the naloxone use/overdose event?

Profound opioid withdrawal Explain:

Rare or other life threatening injuries (e.g., seizures, arrhythmias, severe hypertension, cardiac arrest) Comment:

Falls Arrest/incarceration of patient

Arrest/incarceration of person administering naloxone or bystander

Issues with the police/paramedics/fire department Comment:_________________

Anger

Other (specify): ____________________________________________

Unknown: ____________________________________________

None

Additional Comments: ____________________________________________

THIS SECTION TO BE COMPLETED BY PATIENT’S TREATMENT PROVIDER

Click checkbox above to expand section if you are patient’s treatment provider; if not patient’s treatment provider, continue to Overdose Prevention Education below [skip to Overdose Prevention]

What risk factors are present that could increase the risk of overdose?

Previous overdose Comment:

Discuss circumstances surrounding current and previous overdoses to identify potential patters and ways to mitigate risk and improve patient safety

Periods of abstinence from opioids (e.g., detoxification, inpatient or residential treatment, incarceration)

Discuss how periods of abstinence can decrease tolerance and increase risk for overdose as well as strategies to decrease risk, including medication for opioid use disorder.

Opioid tapering

Discuss how opioid tapering can decrease tolerance and increase risk for overdose as well as strategies to decrease risk (e.g., slow taper, consideration of Opioid Use Disorder diagnosis and treatment)

Substance use disorder (SUD)/substance misuse (including opioid use disorder and alcohol use disorder) Plan: Discuss substance misuse and offered SUD treatment, including Medication for Opioid Use Disorder and Alcohol Use Disorder, and counseling

Substance misuse/SUD being addressed in treatment plan

Referral for SUD treatment

Initiated medication for SUD Specify:

Discussed with the patient and the patient refuses substance use or SUD treatment/referral

Mental health (e.g., PTSD, depression, anxiety, schizophrenia, bipolar disorder) Comment: ____________________________________________

Mental health being addressed in treatment plan Referral for mental health treatment

Discussed with the patient and the patient refuses mental health treatment/referral

Use of Sedatives (e.g., benzodiazepines) Comment:

Discuss risk associated with use of sedatives

Discuss alternative treatments

Discuss tapering/discontinuation Unmet pain management needs

Patient scheduled for follow-up to address pain management needs

Patient declined follow-up for pain management needs at this time

Use of non-prescribed opioids Discuss risks associated with use of non-prescribed opioids and ways to mitigate risk and improve patient safety

Use of prescribed opioids o Opioids prescribed only from the VA

Discuss how there is no safe dose of opioids and that risk increases with increased dose and other co-morbidities

Ask the patient to consider strategies to improve opioid safety, including alternative pain management approaches Treatment considerations (check each treatment that will be recommended)

Consider non-opioid treatments for pain

Change in opioid treatment plan Slow taper (e.g., 5-20% reduction every 4 weeks; see

Opioid Taper Decision Tool)

Other: ________________________________________

No change in opioid treatment plan o Opioids prescribed only from non-VA sources

Discuss how there is no safe dose of opioids and that risk increases with increased dose and other co-morbidities

Ask the patient to consider strategies to improve opioid safety, including alternative pain management approaches Treatment considerations (check each treatment that will be recommended)

Discuss overdose with outside provider and ways to improve patient safety

Consider non-opioid treatments for pain o Opioids prescribed from both VA and non-VA sources

Discuss how there is no safe dose of opioids and that risk increases with increased dose and other co-morbidities

Ask the patient to consider strategies to improve opioid safety, including alternative pain management approaches Treatment considerations (check each treatment that will be recommended)

Discuss overdose with outside provider and ways to improve patient safety

Review consent for long term opioid therapy with the patient

Consider non-opioid treatments for pain

Change in opioid treatment plan Slow taper (e.g., 5-20% reduction every 4 weeks; see

Opioid Taper Decision Tool)

Other: ________________________________________

No change in opioid treatment plan Medical – (e.g., sleep disordered breathing, renal disease, pulmonary disease, liver disease) Comment: _______________________________________

History of falls

Emergency department visits History of HIV

Homelessness

Family stressors

Financial concerns and unemployment Other Comment: ____________________________________________

*What changes to the patient’s treatment plan were enacted based on the overdose event and/or use of naloxone?

Referral

*Does the patient need immediate care?

Yes

Warm handoff to PCMHI or Mental Health team

Escort to emergency department Other: ____________________________________________

No

Refer to primary care provider

Refer to PCMHI or mental health provider Refer to substance use disorder (SUD) provider

Refer to pain specialist

Other: ____________________________________________

None Patient declined referral

Additional comments: ____________________________________________

*Overdose Prevention Education (select one) o Education could not be provided (e.g., outside scope of practice, or patient/caregiver was not present). Skip to Naloxone Prescription.

o Education provided: (if selected, continue to the remaining questions in this section)

Prescriber and/or trained clinical staff discussed overdose prevention and, among patients with opioid overdose, reinforced opioid overdose prevention, recognition, and response education and naloxone use and disposal (e.g., by providing and reviewing VA pamphlets below).

For patients with opioid overdose, because patient is still at risk for overdose, a new naloxone prescription is recommended as well as training/education of potential bystanders on signs/symptoms of opioid overdose.

For patients with suicidal overdose, discussion of access to lethal means and safety planning are recommended.

Education provided to:

Patient

Patient’s caregiver or other designee

The following resources were shared VA resources

VA pamphlet for patients prescribed opioids

VA pamphlet for patients with opioid use disorder

VA Opioid Overdose Education and Naloxone Distribution (OEND) DVD Video Resources

Youtube video: Introduction to Naloxone for People Taking Prescribed Opioids

Youtube video: Introduction to Naloxone for People with Opioid Use Disorders

Youtube video: How to use the VA Naloxone Nasal Spray

D.15 f) SUICIDE BEHAVIOR AND OVERSODE REPORT - 36C26225R0004 https://vaww.portal2.va.gov/sites/mentalhealth/OEND/Resource%20Library/VA%20National%20brochure%20Opioid%20Safety.pdf https://vaww.portal2.va.gov/sites/mentalhealth/OEND/Resource%20Library/VA%20National%20Opioid%20Overdose%20Prevention.pdf https://www.youtube.com/watch?v=NFzhz-PCzPc https://www.youtube.com/watch?v=NFzhz-PCzPc https://www.youtube.com/watch?v=-qYXZDzo3cA https://www.youtube.com/watch?v=-qYXZDzo3cA https://www.youtube.com/watch?v=0w-us7fQE3s

Youtube video: How to use the VA Auto-Injector Naloxone Kit

Other: ____________________________________________

Used teach back to ensure information provided was clearly understood.

*Naloxone prescription o Order naloxone prescription o Provider notif ied of request for naloxone prescription o Patient declined naloxone prescription o Naloxone prescription not needed at this time o Not applicable - Patient does not have an indication for naloxone (e.g., overdose was not opioid-related and patient does not currently use opioids or have a past history of opioid use) o Unable to assess need for possible naloxone prescription; provider notified of possible need for naloxone prescription

Physical Injury (Select all that apply.)

Burnt Self

Carbon Monoxide

Stabbed/Cut Self (including slit wrist) Drowning

Electrocution

Explosion

Ingest Poison/Chemical Hanging

Jump from Height

Jump in front of Auto/Train

Suffocation Other, describe: ____________________________________________

Unknown to author

Firearm (Select all that apply.)

Firearm to Body

Firearm to Head Other, describe: ____________________________________________

Unknown to author

Automobile/Motor Vehicle (Select all that apply.)

Drove into Object

Drove off Road

Other, describe: ____________________________________________

Unknown to author

Injury by Others (i.e., inducing others to cause injury)

Attempted induce law enforcement into killing her/him

Other, describe: ____________________________________________ https://www.youtube.com/watch?v=-DQBCnrAPBY

Unknown to author

Other method used (Select all that apply.)

Other, describe: ____________________________________________

Unknown to author

*Description of event:

*SBOR review to be completed by:

Suicide Prevention team (for any event involving suicidal or undetermined intent, as well as death by overdose (whether accidental or intentional) Send email to Suicide Prevention Team (use encryption if including patient information)

Overdose Review team (for any accidental or intentional overdose event)

VA Adverse Drug Event Reporting System (VA ADERS) Facility Points of Contact (Pharmacy – for any adverse drug event; i.e., patient took medication as prescribed with significant side effects)

Note: Please follow the standard procedures at your facility to notify the VA ADERS Points of Contact (Pharmacy) of this report.

Mental Health Residential Rehabilitation Treatment Program team (for any suicide or overdose event that occurred on a residential unit)

Note: Please follow the standard procedures at your facility to notify the MHRRTP team of this report.

To facilitate care coordination and ensure treatment providers are aware of this event, please include Primary Care and (if applicable) Mental Health Providers listed in CPRS as additional signers of this note.