D.42 Suicide Completed and Attempts Reviews and Reporting 02.pdf

DEPARTMENT OF VETERANS AFFAIRS (VA)

SALT LAKE CITY HEALTH CARE SYSTEM

Salt Lake City, Utah

MEMORANDUM 00Q.70 6/13/2018

SUICIDE: COMPLETED AND ATTEMPTS REVIEWS AND REPORTING

1. PURPOSE:

To establish policies and procedures for reporting and reviewing suicide attempts and completed suicides.

2. POLICY:

The medical center will make every reasonable effort to prevent veterans, visitors and employees from carrying out impulses or plans directed toward self-harm. Completed suicide and attempted suicide will be analyzed by a multi-disciplinary team who will make recommendations for system change.

3. DEFINITIONS:

a. Suicide Prevention: Efforts to prevent suicide and suicide attempts that encompasses two general processes. The first includes efforts to prevent veterans who are at high-risk from attempting suicide or self-harm behaviors.

The second is making every reasonable effort to provide a safe environment of care free of hazards that could result in self-harm.

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

c. Suicidal intent: There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and in the absence of suicidal behavior.

d. Physical Injury: A (suspected) bodily lesion resulting from acute overexposure to energy (this can be mechanical, thermal, electrical, chemical, or radiant) interacting with the body in amounts or rates that exceed the threshold of physiological tolerance. In some cases an injury results from an insufficiency of vital elements, such as oxygen. Acute poisonings and toxic effects, including overdoses of substances and wrong substances given or taken in error are included, as are adverse effects and complications of therapeutic, surgical and medical care. Psychological injury is excluded in this context.

D.42 SUICIDE: COMPLETED AND ATTEMPTS REVIEWS AND REPORTING

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MEMORANDUM 00Q.70

e. Interrupted by Self or Other: 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.

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

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

h. 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.

i. Inpatients: Veterans admitted to the VA Salt Lake City Health Care System (VASLCHCS) for care and treatment.

j. Outpatients: Veterans who are receiving health care service from the VASLCHCS as their primary source of care.

4. RESPONSIBILITIES:

a. Every medical center employee is responsible for reporting any person in the medical center or on the premises who demonstrates suicidal behavior. Suicidal behavior will be immediately reported to the provider in charge of the patient’s care or the VA Police. In the Community Based Outpatient Clinics (CBOCs), it is appropriate to call 911.

b. VA regulations require that all suicide completions, while in a VA 24 hour care facility or an outpatient suicide that occur within 72 hours of discharge from a 24 hour care facility or if an outpatient suicide is committed within 168hr/7days after discharge from acute mental health admission, an RCA will be conducted be reviewed by conducting a Root Cause Analysis (RCA). Other suicide attempts or completions will be evaluated and determined if an RCA is necessary.

Conducting an annual review of suicide attempts according to the National Center for Patient Safety (NCPS) guidelines. This review will be conducted by Suicide Prevention Oversight Committee (SPOC) and be referred to a RCA team as needed; at the facility level which is an interdisciplinary group.

c. SPOC membership will consist of individuals who express interest in the phenomenon of suicide and have a willingness to serve for at least two years on the review team. The members appointed to the RCA team by Patient Safety in collaboration with the Chairman of the Suicide Prevention Oversight Committee. The disciplines of psychiatry, psychology, social work, and MIRECC along with primary care, medicine, nursing and VA police and will be considered for membership. Patient Safety will serve as an advisor to the panel.

d. The VASLCHCS Center for Learning will provide annual training on the recognition, management of, and reporting of suicidal behavior/events, through the TMS (Talent

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Management System) for all clinical care providers. Employees new to the VA will receive mandatory face to face suicide prevention training from the Suicide Prevention Team.

5. PROCEDURES:

a. Background:

Suicide is considerably more common in the VA population than in the general population. Suicidal risk factors may include, but are not limited to:

(1) A history of suicidal threats or attempts;

(2) Male gender;

(3) Chronic medical illness (especially chronic pain);

(4) Use of alcohol or other central nervous system depressants;

(5) Depression, hopelessness or severe anxiety;

(6) Social isolation; and

(7) Easy availability of firearms.

b. Clinical Procedures

All clinical staff should take reasonable measures to prevent a suicide once an assessment determines that a significant threat exists.

(1) Staff that becomes aware of suicidal behavior while in an inpatient setting will immediately seek help for the veteran while maintaining constant observation of the patient until released of that responsibility. Under no circumstances should imminently suicidal patients be left unattended.

(2) Staff that becomes aware of serious suicidal behavior in veterans who are not on the premises (CBOC, contracted nursing home, or homeless), are responsible for exercising reasonable care to protect the welfare of the veteran. This may include the notification of civil authorities if the danger is seen as imminent.

(3) Patient Rights

The rights and liberties of the patient must be observed at all times. Staff will adhere to all appropriate Utah laws concerning involuntary hospitalization and transportation if it becomes necessary to involuntarily hospitalize the patient.

(4) Reporting Suicide Completions or Suicide Attempts

(a) Reports of suicide completions or suicide attempts should be made in the Medical Record by completing the template note: Suicide Behavior Report.

Completion of that report generates notification to the Pentad, Patient Safety Manager, and

Suicide Prevention Coordinator. The Patient Safety Manager files an incident report for any inpatient events to in the National Center for Patient Safety Database.

(b) The first clinical person who becomes aware of suicidal behavior or learns of a completed suicide, whether in an inpatient or outpatient setting will complete the CPRS note, utilizing the shared template title: Suicide Behavior Report.

6. REFERENCES:

Medical Center Memorandum 00Q-63, Patient Safety Improvement Program, March 6, Blue Ribbon Panel on Suicide Prevention in the Veteran Populations, Executive Summary, June 2008 VHA Handbook 1050.1, VHA National Patient Safety Improvement Handbook, May 23, Comprehensive Accreditation Manual for Hospitals, Joint Commission

Medical Center Memorandum 116.05, Prevention and Management of Suicidal and Self- Harm Behaviors.

7. RESCISSIONS: Medical Center Memorandum 00Q.70 dated February 16th, 2011.

8. RECERTIFICATION DATE: This Policy is scheduled for recertification on or before the last work day of June 2021

9. FOLLOW-UP RESPONSIBILITY: Patient Safety Manager (00/PS)

SHELLA STOVALL, MNA, RN

Director /S//