D.31 Suicide Risk Assessment (policy) MCP 116-8.docx

SUICIDE RISK ASSESSMENT

MCP 116-8

April 8, 2020 MCP 116-8

New Mexico VA Health Care System Albuquerque, New Mexico Signatory Authority:

Andrew M. Welch, MHA, FACHE Director Responsible Owner:

Chief Behavioral Health Service

Rescinded Document:

MCP 116-8, Suicide Risk Assessment dated January 31, 2014 Effective Date:

April 8, 2020 Recertification Date:

Aprlil 30, 2025

1. POLICY

This medical center policy (MCP) establishes the New Mexico VA Health Care System (NMVAHCS) policy on Suicide Risk Assessment of potentially suicidal inpatients and outpatients presenting to this facility and using this assessment to guide intervention strategies.

2. JUSTIFICATION

This local policy exists to meet the National Patient Safety Goals mandated by the Joint Commission (JC).

3. DEFINITIONS/ACRONYMS

a. C-SSRS. Columbia Suicide Severity Rating Scale.

b. CSRE. Comprehensive Suicide Risk Evaluation.

c. JC. Joint Commission.

d. NMVAHCS. New Mexico VA Health Care System.

4. RESPONSIBILITIES

a. The Director of the Behavioral Health Care Line. The Director of the Behavioral Health Line is responsible for:

The education of mental health providers regarding risk factors for suicide and appropriate assessment of a suicidal patient.

b. Mental health providers. Mental Health Providers are responsible for:

Assessing the risk of suicide and determine the appropriate disposition.

c. Nursing. Nursing is responsible for:

(1) Contacting the medical provider (ambulatory care) or mental health provider (mental health clinics/consult-liaison service) if a patient is identified as having multiple risk factors for suicide or suicidal ideation during a nursing assessment.

(2) Maintaining the patient’s safety from self-harm until the medical or mental health provider can conduct a suicide risk assessment.

(3) Referring to Mosby’s Nursing procedure on Suicide Precautions for guidance.

5. OTHER PARAGRAPHS

a. Ambulatory Care Prevention. Mental health professionals will educate healthcare professionals on current knowledge about suicide risk and how to assess this risk. How to How to locate educational material on suicide risk assessment on the NMVAHCS intranet website under Staff Training and Development.

(1) The Clinical Reminder screens for Major Depressive Disorder and PTSD, also known as the PHQ-2+I9 and the PC-PTSD-5+I9, will be administered in the Primary Care clinics as outlined in the VA Clinical Practice Guidelines for Depression and PTSD Clinical Reminders.

(2) When either screen is positive, administer the Secondary Suicide Screen, otherwise known as the Columbia Suicide Severity Rating Scale (C-SSRS) templated as a Clinical Reminder that is triggered whenever an initial screen for Depression or PTSD scores positive.

(3) If the Secondary Suicide Screen (C-SSRS) is positive, the veteran will be referred for a comprehensive suicide risk evaluation that day by a licensed independent provider. Document the comprehensive screen using the national template for the Comprehensive Suicide Risk Evaluation (CSRE).

(4) If the provider identifies minimal risk factors for a suicide attempt, the patient the primary care clinic can manage with support from the Behavioral Health Care Line.

(5) If the provider identifies multiple risk factors for suicide, the provider will consult BEACON or Primary Care Mental Health Integration.

b. Mental Health Clinics and Psychiatry Consult-Liaison Service.

(1) If a mental health provider identifies multiple risk factors for suicide, complete the CSRE to determine the appropriate disposition.

(2) The level of risk determined as a result of this assessment will guide the level of intervention as outlined below.

(3) General suicide prevention strategies:

(a) Mental health professionals will educate primary care providers on the current knowledge regarding suicide risk and how to assess this risk.

(b) Mental health providers are educated in formal didactic sessions as to the assessment of suicide risk in mental health patients, as well as the use of available suicide risk assessment tools. Clinical trainees will receive this training during their initial orientation and will receive additional refresher training at the beginning of their psychiatry inpatient rotation.

(c) The literature is available to patients and family members regarding depression and suicide prevention strategies whenever appropriate.

(d) The level of risk identified in suicide assessment will guide clinical interventions.

(4) Outpatient suicide prevention strategies based on suicide assessment.

(a) If suicide risk is identified, high hospitalization (voluntarily or involuntarily) should be strongly considered. If the patient is not hospitalized, documentation should include clinical thought processes and statements about the decision not to hospitalize and identify alternative measures taken to ensure the safety of the patient. Legal mandates will be followed as necessary to ensure patient safety.

(b) If the risk is identified moderate and a decision made to have the patient treated as an outpatient, establish a treatment plan that will assure the safety of the patient to the greatest extent possible. This treatment plan will include the potential use of pharmacotherapy, frequent visits, and the assurance that the patient knows how to access care over 24 hours. Other interventions to assure immediate safety include:

1. Restriction of access to means of self-harm,

2. Safety planning between patient and clinician

3. Initiating supportive psychotherapy,

4. Decreasing social isolation,

5. Decreasing perturbation and agitation,

6. Establishing structured treatment goals,

7. Collaborative problem solving,

8. Help the patient to activate his/her social network.

(c) NOTE: If an outpatient treatment plan to assure patient safety proves challenging to develop, then consideration should be made for psychiatric hospitalization.

(d) If the risk identified is low, consideration should be given to the treatment of primary and secondary risk factors to the development of protective factors and continued monitoring for risk.

(5) Inpatient suicide prevention strategies based on suicide assessment:

(a) Suicide risk is assessed to identify the level of risk of a hospitalized patient.

(b) The treatment team will continue to assess the patient daily to identify changes in this risk profile.

(c) If the patient is identified as a high risk for suicide completion, immediately initiate suicide precautions.

(d) Less restrictive care to ensure safety will correlate with lower suicide risk.

(e) Attention will be paid to facilitate a comprehensive outpatient treatment plan and arranging of follow-up to protect the patient once discharged from the hospital.

6. REFERENCES

d. VA, Update to Suicide Risk Screening and Assessment Requirements, September 20, 2018;

e. VA, Suicide Risk Identification Strategy Sharepoint Site, August 30, 2018;

f. VA Risk Identification Strategy Staff Specific Guidance, September 15, 2018.

7. RESCISSION

MCP 116-8, Suicide Risk Assessment dated January 31, 2014, is rescinded.

8. REVIEW

This policy will be reviewed, at recertification and including when there are changes to the national policy or Joint Commission mandates.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of April 2025. This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes.

10. SIGNATORY AUTHORITY

/S/ Andrew M. Welch MHA, FACHE New Mexico VA Health Care System Director NOTE: The signature remains valid until rescinded by appropriate administrative action.

DISTRIBUTION: Emailed to the ABQ Clin/Admin Svc Chiefs, ABQ Clin Leadership, ABQ Secretaries Distribution Lists. MCPs are available on The NMVAHCS Document Control Repository.