D13. Management of At-Risk and High Risk for Suicide Patients 117-01 FINAL 2020.pdf

MANAGEMENT OF AT-RISK AND HIGH RISK FOR SUICIDE PATIENTS

Standard Operating Procedure 117-01

Southeast Louisiana Veterans Service Line(s):

Healthcare System Associate Chief of Staff, Mental Health New Orleans, LA 701 19

Effective Date:

Signatory Authority: May 31,2018 Paul Kirwin

Recertification Date:

Responsible Owner: May 31, 2023 Associate Chief of Staff, Mental Health

1. PURPOSE AND AUTHORITY

a. To address the management of immediate safety needs and the most appropriate care setting for at-risk and high risk for suicide patients throughout the health care system.

b. To ensure the safety of Veterans, staff, and the surrounding community.

Procedures for the assessment, identification and care of the at-risk and/or high-risk for suicide patient are developed to ensure the safety of the patient, staff and community at large by providing one-to-one observation, police monitoring when necessary, a patient handoff process to ensure that at-risk/high risk patients remain with a staff person throughout the process of their visit when appropriate, and that treatment interventions are initiated that are designed to reduce risk.

c. There is no governing document.

2. PROCEDURES

a. Managing the suicidal, homicidal or severely psychiatrically compromised patient at the SLVHCS main campus (except in the VAMC Mental Health Clinic):

(1) Any staff who recognizes that a patient is suicidal, homicidal, or severely psychiatrically compromised will notify the Clinic Manager/RN Manager. That staff person will remain with the patient until a safe handoff to a clinical provider occurs. If a Veteran presents for urgent MH concerns but declines to answer questions about SI or HI to the triage staff or front desk, the Veteran will be assumed to be a danger to self or others until evaluated by a provider and will be placed on a 1:1 until evaluated by a provider. Otherwise, proceed to the next step;

(2) The Clinic Manager/RN Manager will alert the Department of Veterans Affairs (VA) Police Service. If the Clinic Manager/RN Manager or a Police Officer is not immediately available and the patient is behaving in a threatening manner or is at risk for elopement, 33333 should be called;

May 31, 2018 117-01

(3) In SLVHCS outpatient clinics, the Clinic Manager/RN Manager will ensure that a clinical provider is dispatched to the patient, or that the patient is escorted to the clinical provider as appropriate. In SLVHCS inpatient non-mental health settings, the provider will enter a stat consult to the MH consult liaison psychiatrist during normal business hours. After hours or on weekends/holidays, the on-call MH provider will be contacted. The provider will assess the patient. An assessment consists of an evaluation of a patient's capacity to make decisions relative to their immediate physical safety or well-being. History may be a guide, as well as information obtained by collateral sources (friends, relatives, caregivers, etc.);

(4) If upon completion of the assessment, the provider determines the patient is suicidal, homicidal, or severely psychiatrically compromised, the patient will not be left alone, and will be escorted to the SLVHCS Emergency Department (ED)for further evaluation. VA police may be contacted to provide additional assistance to staff providing escort. Staff will make the ER personnel aware of the patient's risk for suicide.

Escorting staff should remain with the patient as he/she is taken directly to the ER for an immediate RN assessment and placed on safety precautions (i.e. 1:1 observation, notification to VA police). The ED provider is also notified of patient's condition and identifies him/her as an Urgent priority. An abbreviated Suicide Risk Assessment is completed and if appropriate, Veteran is placed under a PEC or can be admitted as a Formal Voluntary Admission (FVA). The escorting staff must inform the ED RN and Provider of the situation prior to leaving the patient. The patient must not be left alone while waiting for transportation. Once a warm handoff communication has been provided to the appropriate SLVHCS Emergency Department Staff, the following steps will apply:

(5) The provider will notify the Clinic Manager/RN Manager of suicide precautions. The Clinic Manager/RN Manager will be responsible for:

(a) Alerting all outpatient area personnel as appropriate; and

(b) Designating a staff member who will provide one-to-one supervision.

(6) An assigned attendant will remain with the patient until the one-on-one observation status is discontinued by the provider. If that disposition includes transfer to inpatient mental health, they will remain with the patient until he/she is properly transported;

(7) If the provider assesses that the patient needs to be hospitalized for a psychiatric reason and the patient does not agree to voluntary admission, the provider (physician or other legally qualified health care provider) will complete a PEC order. In all cases when a patient is PEC'd, consistent with above requirement, an assigned attendant will provide one-on-one observation until the patient is transported;

(8) The provider or designated staff will secure the safety of the patient, staff, and community as indicated using appropriate safety measures. Clinic staff will conduct a physical search of the patient's personal property for safety reasons for contraband

Management of At-Risk and High Risk for Suicide Patients 2

(weapons, sharps, explosives, illegal substances, intoxicants, medications other than those prescribed by a physician), and/or objects that could pose a threat to the staff members or the patient. These items will be confiscated and handled according to the policies of the health care system (HCS). Police Service will not conduct these physical searches unless the patient is uncooperative with a voluntary search or acts in a threatening manner toward staff such as to preclude a safe search by staff; Patients will change into a hospital gown/pajamas.

(9) A room shall be provided that offers privacy and meets the safety needs of the patient and staff. Doors will not be locked, or capable of being blocked, but may be closed to ensure that the patient is in a safe, contained environment. Objects and furnishings will be removed if they pose a threat, e.g., may be used as a weapon;

(10) The attendant will document one-on-one observation of the patient (see Attachment B) and subsequently transfer the data in CPRS. The provider/attendant and/or other involved staff complete the appropriate medical record entries in CPRS. A consult will be completed and Coordination of Care notified. The Physician's Emergency Certificate (if not voluntary for admission), Interfacility Transfer Form (VAF 10-2649A) (if going to a non-VA facility) and the Physician Certification and Patient Consent for Transfer (VAF 10-2649B) will be completed as applicable. The Clinic Nurse will notify the Clinic Social Worker, if available, of the pending transfer. The Suicide Prevention Coordinator should be alerted by being designated as an additional signer in CPRS for any patient hospitalized because of suicide risk. The Suicide Prevention Coordinator will assess the need for placement of an electronic flag for suicide precautions. The provider will complete and document in CPRS the provider to provider hand-off using the Identity, Situation, Background, Assessment, Recommendation (ISBAR-Q) format;

(11) If being transferred from a community-based outpatient clinic (CBOC), or from the SLVHCS main campus to another facility, the clinic staff and Emergency Management Service (EMS) personnel identify patient to be transferred using two forms of identification and verifies location. Clinic staff gives hand-off to EMS using ISBAR-O this needs to be spelled out and places personal effects in bag to be transported with patient. Clinic staff obtains EMS personnel unit number and completes all annotation in

CPRS;

(12) If being transferred from a CBOC, or from the SLVHCS main campus to another facility, the local community Police Department and/or Parish Sheriff's Department may be contacted for assistance in the management and/or transportation of the patient to the receiving facility if necessary; and

(13) If the provider determines that the patient does not pose a safety risk to self or others and is not severely psychiatrically compromised to the point of requiring hospitalization, the provider will discontinue the one-on-one observation and the attendant will no longer be required to stay with the patient.

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b. CBOC: Managing the suicidal, homicidal or severely psychiatrically compromised patient in a CBOC: In the event that such a patient presents, the patient must not be left alone. Contact should be made with a CBOC provider for immediate evaluation and possible admission. CBOC staff will then follow steps under 'Procedures' paragraphs 5- 13 as noted above. If the Veteran requires inpatient admission, the patient must not be left alone while waiting for transportation. If a Veteran presents for urgent MH concerns but declines to answer questions about SI or HI to the triage staff, the Veteran will be assumed to be a danger to self or others until evaluated by a provider and will be placed on a 1:1 until evaluated by a provider.

c. VAMC Mental Health Clinic: Managing the suicidal, homicidal, or severely psychiatrically compromised patient in the SLVHCS VAMC mental health clinic. In the event that a such a patient presents the patient must not be left alone. Contact should be made with the access MH provider for immediate evaluation and possible admission.

VAMC MH staff will then follow steps under 'Procedures' paragraphs 5-13 as noted above. If a Veteran presents for urgent MH concerns but declines to answer questions about SI or HI to the triage staff/front desk, the Veteran will be assumed to be a danger to self or others until evaluated by a provider and will be placed on a 1:1 until evaluated by a provider. If Veteran is deemed 'not medically stable' by a provider, the Veteran will be transferred with a warm handoff communication and documentation to the SLVHCS

ED.

d. Home Based Primary Care (HBPC): Managing the suicidal, homicidal or severely psychiatrically compromised patient in HBPC. If HBPC staff encounter such a patient in the home, arrangements will be made for the Veteran to be transported to the nearest emergency room for evaluation by either contacting family/caregiver with available transportation or by notifying local law enforcement, whichever is deemed appropriate.

HBPC staff will not, under any circumstances, transport such Veterans themselves.

HBPC staff will not leave the patient alone until law enforcement arrive and the Veteran is transported to an ED, unless the safety of the HBPC staff is at risk. HBPC staff will also notify the HBPC Provider and the receiving facility, if known. The HBPC Psychologist may be consulted for guidance and will be available to provide in-home mental health services should the veteran return home and remain actively enrolled in the HBPC program following release/discharge from the treating facility.

e. Mental Health Intensive Case Management (MHICM): Managing the suicidal, homicidal or severely psychiatrically compromised patient in MHICM. If MHICM team member encounters such a patient, the patient must not be left alone unless their own safety is jeopardized. Local law enforcement may be contacted to facilitate the patient's safety or the safety of others. This contact may result in the patient's transport to the SLVHCS ED or to a local community hospital, for evaluation. The team member will also contact the MHICM provider and, if the Vet is en route to the SLVHCS ED, MHICM will notify the SLVHCS ED.

f. Suicide Precautions for Inpatient Mental Health: As part of the admission process to the psychiatric unit, all patients will be assessed for inpatient suicide precautions, and will be re-assessed as appropriate during their stay.

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(1) When assessment indicates low risk for inpatient suicide precautions:

(a) No special precaution is indicated.

(b) Reassessments throughout the hospital stay shall be done with change in precautions as appropriate.

(2) When the assessment indicates moderate risk for inpatient suicide precautions:

(a) The provider shall immediately institute appropriate safeguards to ensure the patients safety.

(b) Patient on supervision or close observation.

(c) No jewelry, belts, neckties, caps, hats, shoelaces, or suspenders will be worn.

(d) Patient will be placed on unit restriction.

(3) When the assessment indicates high risk for inpatient suicide precautions:

(a) The provider shall immediately institute appropriate safeguards to ensure the patients safety.

(b) Place patient on One-on-One (1:1) or close observation.

(c) No jewelry, belts, neckties, caps, hats, shoelaces, or suspenders will be worn.

(d) Patient will be placed on unit restriction.

(e) Excess linens will be removed from room.

(f) Staff will remove all nursing instruments from the room such as scissors, supplies, and equipment. Staff will check room and bathroom for potentially hazardous items.

(g) A visual "mouth" check will be performed by the nurse after administering medications to verify that the patient is swallowing the medications and not "cheeking" them.

(h) Staff will remain with patient during all visitations.

(i) Articles brought in by family members and visitors will be checked by staff to make sure potentially dangerous objects are not given to the patient. Visitors on the inpatient mental health unit are instructed to place purses, bags, etc. in locker area before visiting with the patient.

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(j) Upon request by departmental/unit staff, Nutrition Services will send meal trays with styrofoam cups and plastic utensils. Staff will remove any plastic wrap prior to giving patient the tray. The departmental/unit staff member assigned to the patient will make sure all utensils are removed from the patient after each meal.

(k) A provider must give an order for the patient to be able to go off the unit for medical tests/procedures deemed necessary during the time the patient is on suicide precautions. The patient must be accompanied by at least one staff member at all times.

(I) When patients are placed on suicide precaution, unit personnel will be assigned on each tour of duty to provide care. Assigned staff will follow the written procedures in the observation and assessment of patients. Any changes in behavior will be documented on the progress notes and reported immediately. Documentation and reporting will be completed according to written procedures.

(m) The assigned staff member will document the patient's behavior, emotional status, and activity level every 15 minutes. Significant verbal and behavioral interactions will be documented in the progress notes, including the continuation of suicide precautions.

(n) The treatment team shall review and modify the treatment plan to focus on reducing the patient's suicide risk.

(o) When the patient no longer expresses suicidal thoughts or behavior and has been re-assessed by a provider, an order may be given to discontinue suicide precautions. The patient will remain on the unit at least 24 hours after suicide precautions has been discontinued, prior to discharge from the hospital. The patient will be reassessed for suicide risk prior to leaving the facility. All patients who reported suicidal thoughts or behaviors will be provided suicide prevention information (for example, crisis hotline and any other supportive services) prior to being discharged from the hospital. When possible, this information will also be provided to family members of these patients, and the provision of this information to the patient and their family will be documented in the medical record.

(p) Unless it is documented that the patient refused to develop a safety plan, all patients admitted to inpatient psychiatry for suicidal ideation must have a safety plan developed and be provided a copy prior to discharge, even if they are assessed as not requiring a High Risk for Suicide flag.

(q) Every patient admitted for SI must be provided a written or typed list of their outpatient mental health appointment(s) at the time of their discharge, unless it is documented that the patient refused outpatient care.

(r) If a staff member becomes aware of an active suicide attempt, staff shall call a code and intervene appropriately per emergency response procedures.

Management of At-Risk and High Risk for Suicide Patients 6

(s) When a patient engages in suicidal behaviors, their inpatient provider will be notified immediately. A provider will respond and assess the patient at least within an hour to determine patient condition and status. An order may be written at that time to place the patient on suicidal precautions. The Joint Patient Reporting System Incident Report (JPRS) will be completed and authorities notified as appropriate and according to policy. A Suicide Behavior Report, which is a templated note in CPRS, must be completed on any patient who engages in suicidal behavior where there is intent to die.

(t) The SLVHCS inpatient psychiatry unit and the SLVHCS ED shall develop their own policy governing suicide prevention strategies specific to their respective area that may go beyond this facility policy. However, the ED and inpatient psychiatry unit policies will be in addition to, not in place of, this facility policy

(4) Managing telephone crisis calls: when a crisis call is received during business hours, the person who takes the call will.

(a) Identify himself/herself and let the caller know that he/she will get help immediately from clinical staff. The person taking the call will obtain the callers phone number, location, name and last four of his/her social. If the situation permits, the electronic record will be accessed to determine if there is an active mental health (MH) provider and any other pertinent information. If possible, the person taking the call will attract the attention of any other staff member in the area for assistance and consult other staff to assist in crisis intervention techniques as needed. Any staff who responds to a call where there is imminent danger to the life of the caller, staff or others should stay on the line with the caller and direct a coworker to call 33333 immediately (for example, if the caller states he/she has taken an overdose or engaged in any life-threatening behavior), and then notify the clinic manager and treating MH provider or SPC. If the caller hangs up at any time during the call, contact the SPC immediately or any MH provider;

(b) Ask if the caller is being treated by a MH care provider within the SLVHCS that he/she would like to talk with, or if the caller would be willing to speak with any other provider;

(c) If yes, keep the person on the line and attempt to connect the person with their MH provider. If the caller has no MH provider, do a warm handoff to any MH provider (this is easiest accomplished by using Skype for Business Instant Messaging or having a nearby colleague contact the MH front desk to reach any available MH provider to take the call. Ensure that the provider has the callers name, last four, phone number, and present location address before transferring the call. Explain to the Veteran that sometimes calls may get disconnected during the transfer, obtain the phone number that the caller is calling from, and explain that the provider will use that phone number to call the patient back immediately in the event of a disconnection.

Remain on the line to make sure that the caller and the provider are connected before releasing the call. After transferring the call, alert the patient's team that a crisis call has been directed to the mental health care provider (give provider's name). After normal clinic hours, the same process is accomplished via a warm handoff to the Veterans

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Crisis Line, 1-800-273-8255, (press '1' at the prompt) and alert the Crisis Line staff that you have a caller in distress, provide the name and last four of the Veteran, as well as the Veterans phone number and location.

(5) The MH provider, or any staff person who responds to the call will:

(a) Determine if the caller is threatening to hurt himself/herself or others; if the patient is in imminent danger, direct patient to nearest emergency department or call 33333 as clinically appropriate;

(b) Determine if he/she has a weapon or immediate access to other lethal means;

(c) Attempt to persuade him/her to put down the weapon or give it to someone else while continuing to talk;

(d) Ask if there is a friend or relative that can be contacted;

(e) Ask if someone else is with the caller;

(f) Ask if he/she can talk with that person. This may enable the provider to get a better idea of the urgency of the situation;

(g) Attempt to persuade the caller to come to the nearest outpatient clinic if clinically appropriate (eg, patient is not at imminent risk); and

(h) Explain that it is difficult to help over the telephone, but that many resources are available within the HCS.

(i) Complete an electronic progress note and include SPC as an additional signer. If the patient is not in the VA computer system, complete a hand-written progress note and provide a copy to the Clinic Manager/RN Manager. A copy should be faxed to the SPC. Non-clinical staff will complete an VA 119, report of contact form found at http://vaww4.va.gov/vaforms/va/pdf/VA119.pdf and submit it to their supervisor who will provide a copy to the SPC and Patient Safety Manager.

(j) In the event the caller indicates he/she cannot come or refuses to come to the HCS and the clinical staff member believes that the patient may still be at risk of harming him/herself or others, they will keep the Veteran on the line while a colleague or staff member contacts 33333 to request that the police go to the location and check on his/her situation. VA staff will remain on the line until the police arrives at the patients door and the patient is speaking to the police. The staff member who called 33333 will also notify his/her Clinic Manager and the SPC that rescue was called to a patient's location.

h. Routine Assessment for Suicide Risk: The Suicide Risk Screening Process consist of a Primary Screen, a Secondary Screen, and a Comprehensive Suicide Risk Assessment.

Management of At-Risk and High Risk for Suicide Patients 8

(1) Primary Screen: This is the first suicide screen and is the PHQ-9 item 9, required within 24 hours of admission to an inpatient medical/surgical ward and within 24 hours of discharge from an inpatient medical/surgical ward. It is also required during intake evaluation in the Pain Clinic, and as clinically indicated in the pain clinic. It is also used annually in conjunction with required depression and PTSD screenings. If the primary screen is positive, then the secondary screen is required at the same visit prior to the Veteran leaving the clinic.

(2) Secondary Screen (C-SSRS): The Secondary Screen (Columbia-Suicide Severity

(3) Rating Scale, or C-SSRS) is required in the clinics where a primary screen is positive and must be completed prior to the Veteran leaving the clinic. However, in the following clinics, the Primary Screen is skipped and providers will proceed directly to the Secondary Screen: Emergency Department, Outpatient Mental Health, Inpatient Mental Health. In all other clinics the Secondary Screen must be completed at the same visit if a Veteran screens positive on the Primary Screen.

(4) Comprehensive Suicide Risk Assessment (CSRA): An assessment tool used by an LIP and as part of a comprehensive clinical assessment of patients suspected to be at increased risk of suicide. The CSRA has a separate note title in CPRS and is required to be completed by a LIP at the same visit that the Veteran screens positive on the Secondary Screen. If the Veteran is assessed using the CSRA as being at an acutely elevated risk for suicide, the Veteran will be flagged as high risk for suicide, and a safety plan note must be accomplished with the Veteran prior to the Veteran being discharged, unless the Veteran is being admitted to inpatient psychiatry, in which case the Safety Plan must be completed within 7 days of being assessed as high risk for suicide. The Safety Plan note is a separate title in CPRS.

(5) In addition, a new CSRA is required at least once every 12 months, so long as the patient continues to be seen in MH; and anytime a provider recommends initiating or removing a high risk for suicide flag in a patient's CPRS record.

(6) The completed CSRA will include a summary statement in which the provider makes a clinical judgement about the patient's current potential for suicide and a recommendation regarding the need to assign the patient a High Risk for Suicide Flag in CPRS and members of the Suicide Prevention Program will be alerted in CPRS to the need for a high risk for suicide flag if a flag is recommended.

i. High Risk Flag Requirements: Initiating, Extending, or Removing a High Risk for Suicide Flag:

(1) The SLVHCS Suicide Prevention Program staff will initiate a Category I High Risk for Suicide Flag:

a. Whenever a provider assesses a Veteran as being at an acutely elevated risk for suicide using the CPRS note title "Suicide Risk Evaluation-Comprehensive";

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b. Whenever a Veteran is admitted to a hospital due to self-directed violence with intent to die.

c. Anytime a provider or the suicide prevention team believes that such a flag is clinically appropriate.

(2) The High Risk for Suicide Flag must be initiated in Vista as soon as possible but no later than one business day after such determination by the SPC that a providers recommendation for a high risk for suicide flag is appropriate. The flag must be reviewed at least every 90 days by the Veteran's provider with a recommendation from the provider to either remove the flag at the end of the ninety-day review period or to extend the flag an additional 90 days. This review must be documented in the patients chart with the providers justification for continuing or removing the flag. If the provider has not made a recommendation by the end of the ninety-day review period, the flag may be extended an additional 90 days or until the provider can make a clinical determination (for example, at the next clinic visit). Providers are responsible for making a recommendation to the suicide prevention team in a timely manner as the ninety-day review period is ending.

(3) High Risk for Suicide Flags will be removed upon the recommendation of the patient's treating provider on or around the end of the 90 day review period, (for example, the 90th day may fall on a weekend, holiday, etc), unless extended until a provider makes a recommendation. If the Veteran has not been seen in any VA for mental health (for example, repeat no-shows, cancellations by patient, and does not respond to efforts to contact), the SPC team will staff case prior to removing or extending the flag.

Process for Transferring High Risk Flag ownership to another VAMC

a. The transferring site SPC is responsible for:

1. Facilitating the transfer of care for patients who are moving to a new VA facility;

ii.Coordinating with the receiving SPC to transfer the HRS-PRF and scheduling initial appointments with mental health personnel for the patient;

iii. Confirming that the patients' new address and contact information has been updated in the HER.

iv. Notifying the receiving site SPC about:

1). The patient's projected move date;

2). The scheduled first appointment at the new site; and

Management of At-Risk and High Risk for Suicide Patients 10

3). Other information that is relevant to the patient and their care.

NOTE: Only after the tasks for transferring an HRS-PRF have been completed may the SPC transfer to a new site of care.

b. Receiving site SPC must:

I. Accept transfer of the HRS-PRF once all the transferring site's requirements have been met, and

ii. Attempt to contact patients who do not show for their first appointment at the new site.

c. Any patient who is flagged as high risk for suicide must have a current Mental Health Treatment Coordinator (MHTC) identified in CPRS;

d. Any patient who is flagged as high risk for suicide must have a safety plan note

e. completed within 7 days of being flagged if admitted to VA inpatient psychiatry at the time of the high risk flag recommendation, otherwise a safety plan note must be completed prior to the patient leaving the clinic, the same-day they are assessed as requiring a high risk for suicide flag. If a patient is being transferred to non- VA inpatient psychiatry, a safety plan will be accomplished prior to their being transferred, or a note must indicate why the note was not accomplished (i.e. patient refused, actively psychotic, etc).

(6) Any patient flagged as high risk for suicide must have contact with a MH provider at least four times in the first 30 days after a flag has been initiated and at least monthly afterwards until the high-risk flag is removed. However, if the contact is by phone, the note must indicate that the Veteran agreed to or requested that the visit be by phone and the reason (i.e. lack of transportation, pt refused follow up appointments, etc).

(7) Any patient flagged as high risk for suicide and who no-shows for a scheduled mental health appointment, the provider must document at least three attempts to contact the Veteran and must alert the Suicide Prevention Coordinator if the Veteran is not contacted the same day of the missed appointment.

(8) Any patient who is assessed with the SRA will be provided the contact information for the Veteran's Crisis Line (1-800-273-8255);

(9) The presence or absence of access to guns will be documented in the SRA on all patient's accessed as high or moderate risk for suicide, and providers shall document that discussion occurred regarding limiting access to guns and other lethal means; and

(10) A Suicide Behavior and Overdose Report (SBOR), a separate note title in CPRS, will be completed by the clinical provider who first learns of a patient suicide or a

Management of At-Risk and High Risk for Suicide Patients 11 suicide attempt in which the provider determines that the patient had some degree of intent to die, within the previous 12 months. If the patient is inpatient at a non-SLVHCS facility following a suicide attempt, the SBOR may be completed at the first outpatient visit so that additional data can be obtained for the SBOR. However, if the overdose or suicidal behavior is captured in a Comprehensive Suicide Risk Assessment note, a separate SBOR is not required.

i. Suicide Safety Plan or Crisis Response Plan:

(1) The Safety Plan can be completed by any provider in any service. It is designed to provide patients with a reliable means of managing suicidal urges and reducing their risk of self-harm. The Safety Plan is developed as a collaborative effort between the patient and provider, and a copy is provided to the patient to take home.

The Safety Plan is a separate note title in CPRS, and

(2) Every patient who is assessed as being at High Risk for Suicide must have a safety plan completed during the same clinical encounter in which the risk is identified and documented in CPRS, if the patient is able to participate in safety planning. If a patient is flagged while at a non-VA facility, the safety plan must be completed at the first SLVHCS visit after a high-risk flag is initiated. The patient must be given a copy of the safety plan the same day it is completed.

(3) Every patient admitted to SLVHCS inpatient psychiatry will have a safety plan completed prior to discharge, unless it is documented that they refused to participate in developing a safety plan.

(4) Every patient presenting to the ED who is assessed as being at either a 'High' Acute or 'Intermediate' Acute risk level, or a 'High' Chronic risk level, will have a safety plan developed and be provided a copy, prior to leaving the ED. In addition, every patient who is seen in the ED and reports suicidal ideation, the ED will notify the suicide prevention team via a provider-to-provider E-consult.

(5) Safety plans must include the phone numbers of family and friends for support unless it is documents that the patient declined to provide them. It is not sufficient to write on the safety plan 'number in phone'.

Consults from the Veteran's and Military Crisis Line (VMCL)

a. The SPC team will attempt to respond to all consults from the VMCL within one business day and will document this in the crisis line application.

b. The goal is to close on VMCL consults as soon as possible but no later than three business days, unless there are good clinical reasons for leaving the consult open longer (for example, patient not enrolled in CPRS so unable to close consult, unreachable, and acutely suicidal at time of call). Consults when completed will be transferred from the crisis line application into CPRS and the Veteran's mental health provider alerted. If no MH provider, the PCP will be alerted to the call.

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c. The SPC team will have a monthly schedule showing which SP team member is responsible for responding to VMCL consults each week, and will ensure that consults are responded to even if the assigned provider is out. This can be addressed via the daily SP team huddle or by another method to be determined by the SP team.

d. Any VMCL consults that are derived from calls to the White House, Congress, VA officials, or that involve media interest, will result in immediate notification of the Chief of Psychology or his/her designee for consideration of elevation to SLVHCS leadership.

Involuntary Commitments: All involuntary psychiatric commitments will conform to Louisiana laws and procedures in effect at the time of the commitment. No SLVHCS provider shall rescind another SLVHCS provider's PEC without an in-person evaluation of the patient by a psychiatrist.

i. Employee Training:

(1) Physicians, mid-level providers, psychologists, registered nurses, social workers, pharmacists and dentists, as well as any employee serving in the capacity of case manager will complete the Talent Management System (TMS) course titled:

'Suicide Risk Management Training for Clinicians' (VA6201) within 90 days of their Enter On Duty (EOD) date.

(2) Every twelve months after completing the above course, all clinical staff must annually complete the TMS course titled 'Suicide Risk Management Training for Clinicians — Refresher' (VA29376)

(3) All other employees will complete Operation S.A.V.E. training within 90 days of their Enter On Duty (EOD) date. This is in-person training given as part of New Employee Orientation.

(4) Every twelve months following completion of Operation S.A.V.E., all non-clinical employees must complete the TMS course 'Operation SAVE Refresher'

(VA30535).

(5) Continued education is provided through informational material distributed throughout the medical center. In-services and train ings for general suicide prevention awareness, assessment, intervention and treatment, and may be requested of the Suicide Prevention Program. In addition, there are multiple free CEU/CME's available on suicide prevention in TMS for VA employees.

k. Admission Steps for Mental Health Patients:

1. Notify Clinic Manager who will contact the Nurse Manager and VA Police, and will assign a staff person to remain with the patient for one-on-one observation. If a PEC, VA police are to be present with designated staff person for the 1:1 observation.

Do not inform the Veteran about the PEC until after the police arrive at the clinic location

Management of At-Risk and High Risk for Suicide Patients 13 of the Veteran. If the Veteran is a FVA, no PEC form is required. Staff will search the Veteran and his/her belongings for any contraband or items that could be used to harm self or others. Have nursing take and document the patients vital signs in CPRS.

2. Enter consult into CPRS for an Admission Request/ER Referral.

3. Interfacility Transfer Form needs to be completed in CPRS if the Veteran is to be transferred to another facility. This is a template note with its own note title. Since we don't know the receiving facility or doctor at this time, enter in those areas "To Be Determined By CoC". Your clinical note in CPRS on the patient visit stating why inpatient admission is necessary needs to be accomplished at this time also.

4. If this is a non-voluntary admission, complete the PEC. If the Veteran is a voluntary admission and is being transferred to another facility, have the patient sign the Consent to Transfer Form. If not voluntary, a physician will have to sign the part of this form that states the patient is not voluntary but requires transfer. Also, a physician must sign the top of the form that states the Veteran is medically stable for transfer. This step is the only part of the process that requires a physician's signature. The Consent to Transfer Form is not required if the Veteran is being admitted to SLVHCS inpatient psychiatry from the New Orleans VAMC main campus. A PEC form can be signed by any licensed physician, psychologist, or psychiatric Nurse Practitioner. Social workers or psychologists can fill out all the other forms to help speed the process for the physician when they realize patients they are seeing need admission — this will help to save time in the admission process. Fax the Consent to Transfer form (if needed) along with the completed PEC form (if not voluntary) to Coordination of Care at 405-456-7552.

5. Contact Coordination of Care and let them know you have a psychiatric admission, that everything is in the computer, and that you just faxed the Consent to Transfer (if applicable) and PEC form (if applicable). This is everything they need in order to look for a bed.

6. 1:1 status should be done with FVA for suicidal risk or PEC. 1:1 observation needs to be documented on the Record of Close Observation in OPC, Attachment C to this policy.

7. If Vet is being transferred to a non-VA facility, complete the Community Hospital Referral Form (CHRF) and have the provider or Clinic Manager sign. This document MUST have the logo in color to be verifiable and acceptable, do not use a black and white copy.

8. Once a potential admitting facility has been located, the provider will be contacted by Coordination of Care with contact information regarding which hospital will be receiving the Veteran. A provider-to-provider handoff will be arranged by Coordination of Care. Document the accepting physician's name and that the hand-off occurred, using the ISBAR-Q format described below.

9. A copy of the Veteran's notes from today's visit, their demographics sheet, and recent vitals should be sent with the Veteran along with the Community Hospital

Management of At-Risk and High Risk for Suicide Patients 14

Referral Form and PEC if applicable. This is generally given to the ambulance or medical transport staff. If admitted from the SLVHCS main campus to the SLVHCS MH inpatient unit, the paper will be sent with the staff transporting the patient to the SLVHCS MH inpatient unit.

10. The Provider must remain on-site until the patient departs the clinic. A nurse may need to stay on-site as well, and this is determined on a case-by-case basis.

11.Staff completes clinical hand off when ambulance arrives (or if patient is at the SLVHCS main campus), when Veteran is handed off to the SLVHCS inpatient MH unit staff using the ISBAR-Q format:

(a) Information - Identify the patient and provider

(b) Situation - Chief Complaint

(c) Background - History

(d) Assessment - Evaluation

(e) Recommendation - Plan of Care

(f) Questions - Opportunity given to ask or respond to questions.

12. Clinic staff enters transportation pickup time (or transfer time if at SLVHCS main campus being transferred to SLVHCS MH unit) in CPRS. Close Observation Sheet and Physician Emergency Certificate, Physician Emergency Certificate and Community Care Referral Form (as applicable) are to be given to Nurse Manager or appropriate person to be scanned into the system.

a. At-Risk Patient: One who is incapacitated because of frailty, or physical or mental impairment. Patients are considered incapacitated if, at a minimum, they:

(1) Are reporting suicidal or homicidal thoughts, acutely psychotic, agitated, self-injurious, or otherwise appear to present a danger or threat to self or others, but have not been assessed;

(2) Are legally committed;

(3) Have a court appointed legal guardian;

(4) Lack cognitive ability (either permanently or temporarily) to make relevant decisions; or

(5) Have physical or mental impairments that increase their risk of harm to self or others.

(6) Present for mental health concerns but decline to answer questions to triage staff or front desk clerks about Suicidal Ideation (SI) or Homicidal Ideation (HI).

Management of At-Risk and High Risk for Suicide Patients 15

b. High Risk for Suicide Patient: A patient who shows significant SI or who threatens or attempts to kill himself/herself and has been assessed by a Licensed Independent Practitioner (LIP) as being at High Risk for Suicide using the SLVHCS High Risks for Suicide Note Template. Some important characteristics of suicidal patients are listed below (this is not an all-inclusive list):

(1) The patient has made a recent attempt to kill himself/herself;

(2) The patient has a history of previous serious suicidal attempts that resulted in hospitalization;

(3) The patient is preoccupied by suicidal thoughts and has planned a method that he/she believes will result in his/her death;

(4) The patient experiences "command" auditory hallucinations instructing him/her to injure himself/herself with such means as will result in death;

(5) The patient has impaired impulse control and/or agitation, perhaps as a result of mental illness or substance abuse; or

(6) The patient has a history of a serious affective disorder, schizophrenic disorder, or post-traumatic stress disorder (PTSD) with any of the above features.

c. Inpatient Suicide Precautions: A series of steps designed to reduce the risk of self-harm on inpatient mental health units.

d. Self-injurious or Self-mutilating Patient: A self-injurious or self-mutilating patient is defined as one who seriously threatens or attempts to injure himself/herself without lethal suicidal intent. Patients who may be assessed at risk for intentional self-injury may manifest the following characteristics:

(1) The patient has made an actual attempt to harm him/herself without lethal intent or by means which indicate a lack of serious intent;

(2) The patient has a history of frequent previous attempts to harm himself/herself without lethal intent; or

(3) The patient has a history of impulsive behavior, antisocial or borderline personality disorder or substance abuse disorder with any of the above features.

e. Safety Plan: A brief clinical intervention and a valuable adjunct to risk assessment which is developed in collaboration between a patient and his/her provider;

and which is composed of a prioritized list of coping strategies and sources of support that patients can use during or preceding a crisis.

Management of At-Risk and High Risk for Suicide Patients 16

f. Suicide Behavior and Overdose Report (SBOR): Required documentation in computerized patient record system (CPRS) of a an overdose, accidental or intentional, or a suicide attempt or of significant suicidal behavior, in which the provider determined that the patient had at least some level of intent to die at the time of the event. The SBOR is a separate note title in CPRS. The SBOR should be accomplished by the provider who first learns of the behavior.

g. Suicide Prevention Application Network (SPAN): SPAN receives data from Veterans Health Administration (VHA) suicide prevention coordinators relating to suicidal ideation and suicidal behavior of Veterans (see reference).

h.The Suicide Risk Screening Process consist of a Primary Screen, a Secondary Screen, and a Comprehensive Suicide Risk Assessment.

i. Primary Screen: This is the first suicide screen and is the PHQ-9 item 9, required within 24 huors of admission to an inpatient medical/surgical ward and within 24 hours of discharge from an inpatient medical/surgical ward. It is also required during intake evaluation in the Pain Clinic and as clinically indicated in the pain clinic. It is also used annually in conjunction with required depression and PTSD screenings. If the primary screen is positive, then the secondary screen is required at the same visit prior to the Veteran leaving the clinic.

j. Secondary Screen (C-SSRS): The Secondary Screen (Columbia-Suicide Severity Rating Scale, or C-SSRS) is required in the clinics where a primary screen is positive and must be completed prior to the Veteran leaving the clinic. In the following clinics, the Primary Screen is skipped, and providers will proceed directly to the Secondary Screen: Emergency Department, Outpatient Mental Health, Inpatient Mental Health. In all other clinics the Secondary Screen must be completed at the same visit if a Veteran screens positive on the Primary Screen.

k.Comprehensive Suicide Risk Assessment (CSRA): An assessment tool used by an LIP and as part of a comprehensive clinical assessment of patients suspected to be at increased risk of suicide. The CSRA has a separate note title in CPRS and is required to be completed by a LIP at the same visit that the Veteran screens positive on the Secondary Screen. If the Veteran is assessed using the CSRA as being at an acutely elevated risk for suicide, the Veteran will be flagged as high risk for suicide, and a safety plan note must be accomplished with the Veteran prior to the Veteran being discharged, unless the Veteran is being admitted to inpatient psychiatry, in which case the Safety Plan must be completed within 7 days of being assessed as high risk for suicide. The Safety Plan note is a separate title in CPRS

3. ASSIGNMENT OF RESPONSIBILITIES

a. Medical Center Director (MCD) or designee Responsible for ensuring that awareness training on management of at-risk and high risk for suicide is integrated into initial orientation and other ongoing training of all staff.

Management of At-Risk and High Risk for Suicide Patients 17

b. Chief of Staff (COS) Responsible for the implementation of this policy at all SLVHCS locations.

c. Clinic Managers/Registered Nurse (RN) Managers Responsible for the implementation of this policy and procedures in their respective clinic settings. Any staff member who initially identifies a patient as at-risk is responsible for remaining with the patient until the patient has been handed off to a clinical member of the health care team for a clinical evaluation. The clinical provider remains responsible in directing the overall care of the patient including, if indicated, a Physician Emergency Certificate (PEC) order.

d. Associate Director (AD) or designee Responsible for security of construction sites and environmental hazards.

4. REFERENCES

Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department, Annals of Emergency Medicine. Volume 69, No.4: April 2017

5. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of May 2023.

In the event of contradiction with national policy, the national policy supersedes and controls.

6. SIGNATORY AUTHORITY

Paul Kirwin Associate Chief of Staff, Mental Health

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Saved on Intranet for all employee access.

Management of At-Risk and High Risk for Suicide Patients 18

Clinic/RN Manager will alert VA police and will contact Mental Health.

Find another provider in the clinic and/or escort to ED.

Continue to stay with the Pt until a provider is able to assist or escort to SLVHCS ED if no MH provider on unit. If lnpt non-MH unit, enter STAT consult to psychiatry liason consultant.

Yes

OP'

Yes

V

Conduct Suicide Risk Assessment: Evaluate ideation, plan status, level of intent, and availability of means. Evaluate mental status determine adequacy of judgment.

Evaluate risk and protective factors: previous attempts, substance abuse, impulsivity, social support, life quality changes, level of hopelessness, etc.

Remain with the PT Alert Clinic/RN Manager

Clinical Pathway for Suicide Prevention: Clinic

Pt is in the clinic and reports in response to screening questions or spontaneously that he/she is seriously thinking about suicide.

Pt is in the clinic and acts or shows physical signs suggestive of suicidal behavior.

May 31, 2018 SOP 117-01 Attachment A

High-to-Severe risk: Pt has a specific suicide plan, intent, and access to lethal means or a vague plan and impaired judgment. In either case risk is increased if Pt has made previous attempts, has a substance abuse problem, a history of impulsive action, lacks social support or is overcome with hopelessness.

Moderate Risk: Pt frequently has thoughts of suicide but no specific plan or access to lethal means.

Pt has fair to good judgment, no active substance abuse or other major risk factors. Pt has social support and can articulate reasons for wanting to live.

V

Low Risk: Pt has occasional thoughts of suicide but no plan or intent.

Pt is interested in solving problems, exhibits good judgment, does not have an active substance abuse problem or other major risk factors. Pt has good social support and can articulate reasons for wanting to live.

Care Plan: Hospitalization Issue a PEC if necessary.

Close observation by nursing staff.

Police officer remains present.

Add SPC to note as additional signer

Care Plan: Intensive Outpatient Develop a safety plan.

Set…