D26 - Attachment - Suicide Prevention Policy.pdf

SUICIDE PREVENTION

MCP F11M-08

G.V. (Sonny) Montgomery VAMC Jackson, Mississippi 39216

Signatory Authority: Effective Date:

G.V. (Sonny) Montgomery VAMC August 20, 2020 Director

Responsible Owner: Recertification Date:

GVSMVAMC Chief, Mental Health Service August 20, 2025

1. POLICY

It is the policy of VA GVSMVAMC to diligently assess for and identify risk factors and warning signs for suicide, and to provide intervention for Veterans experiencing suicide risk with the same urgency as any other life-threatening condition. All VA GVSMVAMC personnel are responsible for identification and reporting of potential suicide risks, including environmental conditions and Veteran behaviors. Clinical staff is expected to ensure the safety of Veterans, accomplished using standardized screening and assessment tools, environmental safety precautions, and development of an individualized treatment plan for follow-up to manage identified suicide risk.

2. JUSTIFICATION

To establish policy and procedures for identifying, mitigating, and managing suicide risk of the Veteran community and enrolled Veterans served by the Department of Veterans Affairs at the G.V Sonny Montgomery VA Medical Center (GVSMVAMC).

3. RESPONSIBILITIES

a. G.V. (Sonny) Montgomery VA Medical Center Director (MCD). The MDC overall responsibility for the development of GVSMVAMC policies and procedures on the prevention and management of Veterans with suicidal behavior.

b. G.V. (Sonny) Montgomery VA Medical Center Chief of Staff (COS). The COS responsible for implementing VA GVSMVAMC policy and reporting to the MCD unusual incidents in the management of Veteran care. He/she is responsible for reviewing individual suicide Root Cause Analysis (RCA) and cumulative suicidal behavior data submitted quarterly by the SPT, with approval of recommendations as appropriate.

c. G.V. (Sonny) Montgomery VA Medical Center Associate Chief of Staff for Mental Health (ACOS/MH). The ACOS/MH will appoint a team to ensure all safety concerns in the design of inpatient psychiatric units are adequately addressed. Chief Nurse of Mental Health-is appointed to collaborate with the Chief of Staff, ACOS/MH, SPT, and the Privacy and Security Office (PSO) will coordinate regularly scheduled environmental rounds on inpatient psychiatric units to identify elements of the architecture or care processes that may lead to suicidal behavioral and follow-up as needed. The ACOS/MH has overall responsibility for establishing and communicating the policies and procedures pertaining to Veteran suicides and suicide attempts.

d. G.V. (Sonny) Montgomery VA Medical Center Education Director. The Education Director is responsible for providing, at the direction of the Chief of Staff, and in conjunction with the SPT, an ongoing active program of continuing education on the prevention and management of suicidal behavior providing appropriate levels of training for all staff throughout the GVSMVAMC who have contact with Veterans.

e. G.V. (Sonny) Montgomery VA Medical Center Suicide Prevention Team (SPT). The SPT functions to monitor the care for Veterans at high risk for suicide and serves as advisor to service line and GVSMVAMC leadership, program managers, and staff concerning suicide prevention policies and procedures, as well as suicide prevention strategies for individual Veterans. The SPT also serves as a resource for GVSMVAMC, Veterans, and the community.

1) SPT duties will generally include administrative tasks, program oversight, and responsibilities related to the Veterans Crisis Line, case management and care coordination for high risk Veterans. SPT members must be familiar with all aspects of the program and must be able to provide coverage of essential functions in the absence of other team members.

2) The SPT will ensure the suicide prevention policy is up to date and in compliance with national directives and any other requirements. The SPT will provide consultation on the development and implementation of policies and procedures related to suicide across the HCS as requested.

3) The SPT is responsible for tracking all suicide attempts using the "SBOR" template progress note. Documentation of known suicides of non-VHA enrolled Veterans will be reported via the SPT to the Center of Excellence for Suicide Prevention utilizing the web-based Suicide Prevention Application Network (SPAN).

4) The SPT is responsible for tracking and trending all cases of suicide and suicide attempts by inpatients and outpatient and providing this data on a quarterly basis to management and services/service line directors through the Mental Health Executive Leadership Team and the GVSMVAMC

Clinical Executive Board. All services/service line directors are responsible for using this data to evaluate and improve clinical processes.

5) The SPT will assist providers with identifying Veterans at high risk for suicide and with managing the care of those Veterans. Category I High Risk for Suicide HRF will be used to identify these Veterans and to notify personnel providing care of the increased risk. The SPT will assist with direct Veteran care and case management, as needed, but does not assume the role of Mental Health Treatment Coordinator for these Veterans, unless no other option exists. Refer to Section B.5 of this policy for full procedures related to the HRF.

6) The SPT will track and monitor Veterans at high risk for suicide for a period of 90 days. The SPT may make telephone contact as needed to ensure a continuum of care and will establish a US mail contact program with Veterans at high risk for suicide. The SPT will work with clinical staff to ensure Veterans are informed of monitoring and contact by the SPT.

The SPT will track no-show appointments of these Veterans and follow up with the treatment teams, as soon as possible, to ensure follow up.

7) The SPT will provide educational outreach and support to community organizations and other stakeholders.

8) The SPT will assist staff responsible for the monitoring of social media websites with follow up on comments or postings to such sites causing concern for suicide risk.

9) The SPT, in collaboration with the Education Director, is responsible for developing and implementing annual training for designated GVSMVAMC employees whose job assignments increase their likelihood of telephone contact with potentially suicidal Veterans. These employees will include staff working in telephone triage, Health Care System operators, the Medical Officer of the Day (MOD), Mental Health staff, and clerical staff working in outpatient clinic areas. Other staff may participate in this training if deemed desirable by the Chief of Staff, ACOS/MH or GVSMVAMC supervisory personnel. Supervisors/Service Line Directors are responsible for ensuring staff have access to training on an annual basis.

10) The SPT will develop and implement an ongoing education plan for providers, Veterans, families, and members of the community on risk factors and warning signs for suicide and treatment options.

11) The SPT is responsible for providing timely response to consultations received from the Veterans Crisis Line (VCL). Follow up to VCL consults must be initiated within 1 business day of the call and documented in the electronic medical record.

f. G.V. (Sonny) Montgomery VA Medical Center Service Line Directors are responsible for ensuring safe Veteran care, appropriate and timely documentation in the Veteran's electronic medical record, and for providing consultation to the interdisciplinary treatment team. All clinical services/service line directors are responsible for ensuring pertinent providers under their supervision are aware of the contents of this policy and are competent in carrying out the designated procedures. Supervisory staff are responsible for ensuring all designated employees complete training on an annual basis and include it as part of their employees' annual competency plan.

g. G.V. (Sonny) Montgomery VA Medical Center Clinical Staff are responsible for a careful analysis of the suicide risk potential for each Veteran. This applies to those Veterans admitted to beds within Mental Health Service, as well as non-mental health areas when indicated. This also applies to outpatients served by the GVSMVAMC. LIP and/or Clinical staff have the responsibility for following all procedures outlined in this policy according to their privileging/scope of practice, specifically:

a. Completing Suicide Risk Screenings and Comprehensive Evaluations as outlined in Appendix B: Staff Specific Guidance.

b. Identifying and reporting Veterans at high risk for suicide.

c. Follow-up with Veterans identified as being at high risk for suicide.

d. Updating treatment plans including: ongoing monitoring for suicidality, periods of increased risk, and missed or cancelled appointments.

e. Ensuring appointments are set up for follow up as appropriate.

f. Ensuring accurate diagnoses are present.

g. Addressing medication management.

h. Addressing lethal means safety.

i. Attaining collateral information including family involvement with appropriate releases as needed. Checking for next of kin and emergency phone numbers on the cover sheet in the electronic record.

j. Facilitating the development of a Suicide Prevention Safety Plan.

k. Ensuring Veterans are assessed for suicide risk for unplanned discharges from inpatient or residential treatment programs and safety plans are established and updated prior to these discharges. Safety plans include a follow up appointment the next business day, a follow up appointment within 7 business days, and phone contact within 24 hours.

l. Assessing for suicide risk and updating the suicide safety plan as appropriate prior to off campus or overnight passes during residential treatment programming.

m. Coordinating with appropriate staff when a Veteran is at risk for suicide or exhibiting suicide related behaviors; and completing SBOR in the electronic medical record.

n. Ensuring Veterans have contact information for any emergency resources necessary during their course of treatment and that these resources are placed in the Veteran safety plan. These resources may include, but are not limited to: phone numbers for the primary provider, mental health treatment coordinator, SPT, Veterans Crisis Line, local/private providers, local emergency departments, and family/friends.

o. Ensuring the mental health clinic, office, and cell phones equipped with voicemail use the standard voicemail greeting outlined in Procedure Section G.5.

p. Ensuring the immediate safety of any Veteran presenting with risk factors indicating high acute risk of suicide, or other self-harm behavior.

h. G.V. (Sonny) Montgomery VA Medical Center Chief Information Officer is responsible for ensuring the standard telephone tree logic at each medical center is configured in such a way that callers have the option to be connected to the crisis line by pressing the number 7 as outlined in Procedures Section G.4.

i. G.V. (Sonny) Montgomery VA Medical Center Clinical Area Managers are responsible for

a. Conducting a suicide prevention environmental survey every 2 years or when there is a change in purpose, renovation or new construction within the physical environment. An exception is the inpatient mental health ward which requires an environmental survey every 6 months.

b. Notifying staff of the results from the completed suicide prevention environmental survey

c. Training staff to use the applicable suicide prevention environmental checklist.

j. All GVSMVAMC Employees are responsible for:

a. Recognizing risk factors and warning signs for suicide and following established emergency procedures for their work setting to ensure Veteran safety.

b. Ensuring any Veteran experiencing risk factors or warning signs for suicide and/or expressing suicidal ideation receives a full assessment by a qualified clinical staff member.

c. Notifying the SPT of any known suicidal behavior of a Veteran and notifying VA Police of any suicidal behavior which occurred on VA property.

d. Completing Suicide Prevention training as assigned and maintaining knowledge related to SAVE.

i. All health care clinical staff must complete the required suicide risk and intervention training module in TMS and pass the post-test within 90 days of entering the position.

ii. All non-clinical staff will complete SAVE Training during New Employee Orientation (NEO).

iii. All GVSMVAMC personnel must complete annual suicide prevention refresher training in TMS.

4. DEFINITIONS

a. Category I Veteran Record Flag (PRF) High Risk for Suicide: A visual tool displayed in the electronic medical record with the primary purpose of communicating to VA staff that a Veteran is currently experiencing risk factors that put him/her at high risk for suicide.

b. Clinical Staff: Professionals providing direct Veteran care who require clinical oversight/supervision for licensure for diagnosis and treatment or other allied healthcare professionals who by educational background and privileging and/or scope of practice have been determined by VA GVSMVAMC to be capable of assessment and diagnosis. This includes MD/DO, APRN/NP, PA, PhD/PsyD Psychologist, Nursing (RN), Social Work (MSW/DSW), Mental Health Counseling, Dental (Dentists), Audiologist, Optometrist, Podiatrist, Addiction/Music/Occupational/Physical/Recreational/Respiratory/Speech/ Vocational Rehabilitation Therapy (Therapists), Chaplaincy (Residents/

Chaplains), Dietetics (Dieticians), Pharmacy (Pharmacists). The guidelines in this policy also apply to other healthcare professionals who perform assessments or provide care to support diagnosis and treatment of Veterans under the guidance of licensed clinical staff and to all Psychiatry Residents and Psychology Interns.

c. Close Observation: Continuous observation

d. Comprehensive Suicide Risk Evaluation (CSRE): A process in which a Licensed Independent Provider (LIP) gathers information about a Veteran’s suicidal thoughts, plan, intent, and suicide related behavior. The CSRE process also evaluates warning factors, individual and environmental risk factors, and protective factors to formulate an acute and chronic risk assessment and treatment plan that reduces risk and enhances protective factors (See Appendix A).

e. Direct Line of Sight Observation: A constant observation of a Veteran by staff. Staff must remain in the area with the Veteran, such that if a Veteran needs immediate intervention, the staff member can intervene and call other staff to help as needed. Observation by cameras cannot substitute for direct line-of-sight observation.

f. Hazardous Item: Any item that could pose a risk of harm to self or others.

g. High Acute Risk for Suicide: A Veteran that currently has active intent, plan, and means to die by suicide or has already engaged in suicidal behavior. There are inadequate protective factors in place likely to prevent suicidal behavior. The Veteran requires immediate intervention, such as a health and welfare check by local authorities and/or hospitalization to enhance safety.

h. Interdisciplinary Safety Inspection Team (ISIT): The team that conducts the inspection of the mental health unit using the Mental Health Environment of Care Checklist (MHEOCC). The team should include the Suicide Prevention Coordinator, Veteran Safety Manager, Facility Safety Officer, Mental Health Unit Nurse Manager, a non-mental health Unit Nurse Manager, an Inpatient Licensed Independent Practitioner, the Local Recovery Coordinator, an outpatient mental health provider, representatives from Engineering and Environmental Services, and a Pharmacist to ensure the security of medication storage areas.

i. Licensed Independent Provider (LIP): For purposes of this policy, a LIP is an independently licensed healthcare provider who by virtue of educational background and privileging and/or scope of practice has been determined by the GVSMVAMC to be capable of assessment and diagnosis, specifically in terms of evaluating and treating suicide risk (See Appendix B: Staff Specific Guidance).

j. Non-Clinical Staff: Staff who does not provide any type of treatment or testing.

k. One-to-One (1:1) Observation: The constant observation of one Veteran by one staff, unless otherwise indicated. Staff providing 1:1 observation should only be observing one Veteran at a time and have no other responsibilities during the assignment of 1:1 observation. Any staff member can initiate preventive observation. Once 1:1 observation has been ordered, only a LIP can discontinue it. While under one-to-one observation, any restroom visit requires an escort who can visually monitor the Veteran for suicidal behavior, while maintaining the dignity of the Veteran. Such restrictions on the Veteran’s freedom must be consistent with statutory and regulatory authority and be sensitive to privacy and dignity.

l. Screening for Suicide Risk: Current established screening method per VA policy. Veteran (See Appendix C).

m. Preparatory Behavior: Acts or preparation towards engaging in self-directed violence, but before 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).

n. Protective Factors: Capabilities, qualities, environment and personal resources that drive an individual toward growth, stability, and health and may reduce risk for suicide. Enhancing protective factors can be a target of intervention.

o. Risk Factors: Factors that may increase the likelihood of engaging in suicidal or self-directed violence. They may be modifiable or non-modifiable and both inform the formulation of risk for suicide. Modifiable risk factors may also be targets of intervention.

p. Secondary Screen for Suicide Risk: Screening aimed at improving specificity of suicidal risk. It consists of the Columbia-Suicide Severity Rating Scale (C-SSRS) Screener (See Appendix D).

q. Suicide Risk Stratification Table: A tool designed to help providers make determinations regarding suicide risk levels with respect to severity and temporality, as well as aid in suicide risk management clinical decision making. See https://www.mirecc.va.gov/visn19/trm/

r. Suicidal Ideation: Thoughts of engaging in suicide-related behavior.

s. Suicidal Intent: There is past or present evidence (implicit or explicit) that a Veteran 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.

t. Suicidal Plan: A proposed method of carrying out a design that can potentially result in suicide related behaviors; or a systematic formulation of a program of action that will potentially lead to suicide related behaviors.

u. Suicide: Death caused by self-inflicted injurious behaviors with an intent to die because of the behavior.

v. Suicide Attempt: A non-fatal self-inflicted, potentially injurious, behavior with an intent to die because of the behavior. A suicide attempt may/may not result in injury and may/may not be interrupted by self or other(s).

i. With 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.

ii. 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.

https://www.mirecc.va.gov/visn19/trm/

w. Suicide Behavior and Overdose Report (SBOR): The progress note in the electronic medical record by which clinical staff document suicide attempts, suicides, accidental and suicidal overdoses, and other undetermined self-directed violence and inform the Suicide Prevention Team (SPT) of the event (See Appendix E).

x. Suicide Prevention Team (SPT): Includes the Suicide Prevention Coordinator(s) and Suicide Prevention Program Support Assistant (in all non-clinical and administrative functions).

y. Suicide Prevention Safety Plan: A prioritized, written list of coping strategies and sources of support for Veterans to use during or preceding suicidal or other emotional crises (See Appendix F).

z. Warning Signs: Individual factors signaling an acute increase in risk the Veteran may engage in suicidal behavior in the immediate future (i.e.

minutes to days).

5. PROCEDURES:

a. Identifying Suicide Risk

(1) Early identification of suicidal ideation presents the greatest opportunity to reduce the risk of suicide attempt and death. Three direct warning signs indicate increased risk for suicide and the presence of one or more of these warning signs is a strong indication further assessment is needed:

i. Communicating suicidal thought verbally or in writing

ii. Seeking access to lethal means such as firearms or medications

iii. Demonstrating preparatory behaviors such as putting affairs in order

(2) The suicide risk screening and evaluation process is comprised of three components: Primary Screen, Secondary Screen, and Comprehensive Suicide Risk Evaluation. A positive Primary Screen indicates the need for a Secondary Screen. A positive Secondary Screen indicates the need for a Comprehensive Suicide Risk Evaluation. All screening and evaluations will be completed as required and as clinically indicated during the same calendar day.

(3) Screening for suicide risk is the responsibility of staff across multiple clinical programs and is not be the sole responsibility of mental health staff.

(4) Settings and programs may choose to conduct suicide risk screening and evaluation outside the context outlined below (see also Managing Suicide Risk). Additional guidance in some settings and programs may go above the minimum requirements and will be specified in program specific policies and procedures.

(5) Minimum Requirements for Screening:

i. Primary Care: The Primary Screen for suicide risk is incorporated into the annual screening for Depression and Posttraumatic Stress Disorder (PTSD) by adding PHQ2+I9 and Primary Care PTSD Screen which are accessed through the clinical reminder system.

ii. Emergency Department (ED): The Suicide Screen is incorporated into the National ED Triage Note.

iii. Outpatient Veteran Mental Health Clinics: The Comprehensive Suicide Risk Evaluation is completed during all intake evaluations and as clinically indicated throughout care.

iv. Inpatient Veteran Mental Health: The Comprehensive Suicide Risk Evaluation is completed within 24 hours of admission and up to 24 hours prior to discharge.

v. Pain Clinic: The Primary Screen is completed during intake evaluation and as clinically indicated throughout care.

vi. Inpatient Veteran Medical/Surgical: The Primary Screen is completed within 24 hours of admission and up to 24 hours prior to discharge.

vii. Veteran Community Living Center: A Suicide Screen will be completed within 24 hours of admission and up to 24 hours prior to discharge.

vii. Residential Rehabilitation Treatment Program (RRTP): A Suicide Screening will be completed during the initial evaluation, as well as within 24 hours of Veteran admission and discharge.

(6) Comprehensive Suicide Risk Evaluation (CSRE): A CSRE must be completed by a LIP the same calendar day for any Veteran in which it is clinically indicated. Using the current required VA documentation/template.

b. Managing Suicide Risk

(1) Once suicide risk has been identified, through positive screenings or completion of a Comprehensive Suicide Risk Evaluation, clinical staff are responsible for management of suicide risk.

(2) Due to the dynamic nature of some warning signs, risk and protective factors, suicide risk should be routinely re-evaluated. Clinical staff will document the status of suicide risk and be observant of any changes in the Veteran’s psychiatric and psychosocial status that may signal the need for a suicide risk screening, or an update to the comprehensive suicide risk evaluation. Suicide risk screening or CSRE are not required at every visit.

(3) When clinically indicated, a CSRE must be conducted and documented in the electronic medical record in accordance with current approved documentation. If documenting in a progress note, the following must be included but is not limited to:

i. Presence/Absence of suicidal ideation, plan, intent, and/or other warning signs

ii. Risk Factors: including access to lethal means, history of attempts, etc.

iii. Protective Factors: including access to care, support system, religious/cultural beliefs

iv. Evaluation of Suicide Risk by time (Acute/Chronic) and intensity (Low, Intermediate, High).

v. Strategies for mitigating personal and environmental risks appropriate for level of risk.

(4) Suicide Prevention Safety Plan (SPSP):

i. See Appendix B: Staff Specific Guidance

ii. Must be completed for Veterans with a High Risk for Suicide HRF and must be completed or updated within 7 days of the High- Risk Flag being activated or prior to inpatient discharge, whichever is later.

iii. Must be completed prior to discharge for Veterans presenting to the Emergency Department (ED) with suicidal ideation who are not admitted to the hospital.

iv. Highly recommended and a best practice for use with any Veteran expressing or displaying suicide risk factors emotional distress:

1. Should be a collaborative effort between the Veteran and clinical staff. Veterans should be encouraged to write out their plan. Family members, friends, or other supportive individuals identified by the Veteran should be included in this process whenever possible.

2. Should be documented in the electronic medical record using the templated note: “Suicide Prevention Safety Plan” or “Suicide Prevention Safety Plan Review/Decline.”

3. Must be given to the Veteran in paper form prior to leaving the hospital or clinic on that day or mailed to Veteran if completed by phone. If completed at an alternative site without a printer, a hand-written copy can be offered to the Veteran and a printed copy can be sent by mail by a program administrator.

4. Include the SPT as additional signer(s) to the note, as well as the supervising LIP (if completed by a staff member who is not a LIP as defined above).

(5) Category I Patient Record Flag: High Risk for Suicide:

i. Communicates to all Veterans Health Administration (VHA) staff that a Veteran is at high risk for suicide and the presence of a flag should be considered when making treatment decisions. The absence of a High Risk for Suicide PRF does not indicate a Veteran is not at risk for suicide. In the event of concerns for suicide risk, referrals for a PRF are to be made to the SPT by phone, encrypted email, or as an additional signer to a progress note.

ii. The SPT ensures the usage of the PRF is limited to only those Veterans at high risk, and only for the duration of the increased risk for suicide. The PRF is reviewed every 90 days and removed as soon as it is clinically indicated to do so. The decision regarding the activation, continuation, and inactivation of the PRF is done in conjunction with the Suicide Prevention Team, Veteran and/or family members, as well as the Veteran’s treatment team.

iii. Veterans with a Category I Patient Record Flag: High Risk for Suicide must meet one of the following criteria:

1. Clinically assessed as high risk for suicide by clinical staff

2. Veteran has had a suicide related behavior (action versus ideation) that the LIP, clinical staff, and SPT deem to be of immediate and active concern

iv. Veterans with a Category I Patient Record Flag: High Risk for Suicide must:

1. Have a written Suicide Prevention Safety Plan (SPSP) within 7 days of activation of the flag or prior to inpatient discharge, whichever is later.

2. Be scheduled and seen/visited by a mental health clinical staff at least 4 times in the first 30 days of flag activation, (preferably 1x/week), and at least every 30 days thereafter for the duration of the flag.

3. Be scheduled and seen/visited by a mental health clinical provider at least 4 times in the first 30 days following any discharge from an inpatient medical or mental health unit.

4. Be contacted by clinical staff for any no-show to mental health appointments. At least 3 attempts to contact the Veteran over 3 business days must be made by clinical staff and documented in the medical record. The SPT may be contacted to discuss and determine the most appropriate follow-up for those Veterans not contacted. Contact by non-clinical staff does not qualify as sufficient follow-up for Veterans with an active High Risk for Suicide PRF.

5. Have the PRF reviewed by the treatment team and SPT at least every 90 days to determine whether it should be continued for another 90 days or inactivated. PRFs may be reactivated if high acute risk returns, but cannot remain active indefinitely in the absence of current risk factors.

PRFs for Veterans currently requiring mental health contact less than monthly will be inactivated at the end of the 90-day review period unless extenuating circumstances exist.

(6) Health and Welfare Check:

i. Clinical staff may contact local law enforcement and request a health and welfare check if, in his/her clinical opinion, the Veteran is in High Acute Risk of Suicide and there is no other reasonable, safe manner to establish the Veteran’s safety.

ii. Clinical staff must document a health and welfare check was requested in the Veteran’s electronic medical record.

Documentation should include which agency was contacted and the outcome of the welfare check. The SPT must be added as additional signers to this documentation.

(7) Crisis Response: If there is any reason to believe a Veteran is at High Acute Risk for Suicide and/or if the Veteran is uncooperative, combative or otherwise unwilling to seek help and a sense of acute danger is present, clinical and non-clinical staff will ensure Veteran’s immediate safety needs.

Never leave the Veteran alone, place a call on hold, or end a phone call. The SPT will be alerted by phone and/or additional signer to the progress note in the electronic medical record.

i. Veteran seen at G. V. Sonny Montgomery VAMC:

1. Staff will initiate 1:1 observation, conduct an environment risk assessment using the “checklist”, and complete a warm hand-off to an available LIP. Clinical Staff will document observations and actions in the Veteran’s electronic medical Record. Non-clinical staff will notify the supervisor and the SPT.

2. A LIP will complete a Comprehensive Suicide Risk Evaluation. If hospital admission is deemed necessary, the Veteran will be escorted to the ED by clinical staff and/or the VA Police Department (VAPD).

3. 1:1 observation should be maintained until the Veteran is no longer deemed a High Acute Risk by a LIP or is transferred to another appropriate setting where high acute risk is mitigated.

ii. Veterans seen in the community Veteran(e.g. Harbor House, Dental, CBOCS, ):

1. Staff will call 911 or local law enforcement. Staff will initiate 1:1 observation and use the Outpatient Clinic Suicide Prevention Environmental Checklist to assist the staff in providing a safe environment for all Veterans placed on 1:1 observation due to suicidal ideation/behavior.

a. Suicide Prevention Environmental Checklists are available on the Medical Center’s intranet homepage by selecting Patient Safety under the listings for Clinical Resources.

2. 1:1 observation should be maintained until High Acute Risk has been mitigated. If a LIP is available, he/she will complete a Comprehensive Suicide Risk Evaluation. If a LIP is not available, staff will remain with the Veteran until law enforcement arrives for a health and welfare check. If hospital admission is deemed necessary, it is recommended a secure car or ambulance be used to transport the Veteran to the nearest hospital with an emergency department.

3. If the Veteran refuses recommended transport and is transported by family, self, other support person, or other means, that choice must be documented in the medical record noting refusal to use recommended transport. When available, the Veteran will sign an IMED consent that he/she has chosen not to follow medical advice. If Veteran refuses recommended level of care and transportation and does not have the capacity to make the decision, a temporary hold must be initiated by police.

4. Clinical Staff will coordinate care with community hospitals or HCS (Health Care System) to verify admission/arrival, reason for referral, and to coordinate discharge planning.

iii. By Phone: (See also Appendix G)

1. When a Veteran contacts staff by phone and reports he/she has harmed him/herself or has access to lethal means and intent to harm self or others, staff will remain on the phone with the Veteran and alert other staff to contact VAPD, or local law enforcement, or 911. Staff may alert others using instant messaging, panic buttons, or starting an online chat with the Veterans Crisis Line at www.veteranscrisisline.net/get-help/chat

2. Staff will remain on the line with the Veteran until law enforcement or emergency responders take over the call.

3. Clinical staff will document the phone call in the Veteran’s electronic medical record and notify the SPT. Non-Clinical staff will notify their supervisor and the SPT.

c. Environment of Care:

(1) Clinical Area Managers are responsible for:

i. Conducting a suicide prevention environmental survey using the Suicide Prevention Environment of Care Survey (Non-Mental Health), (See Appendix H) ,every 2 years or when there is a change in http://www.veteranscrisisline.net/get-help/chat purpose, renovation or new construction within the physical environment. Exceptions are the inpatient mental health ward and the ED Mental Health (MH) Safe room which requires an environmental survey every 6 months.

ii. Notifying staff of the results from the completed suicide prevention environmental survey

iii. Training staff to use the suicide prevention environmental checklist.

(2) Staff will use the Outpatient Clinic Suicide Prevention Environmental Checklist or ED and Inpatient Units Suicide Prevention Environmental Checklist to assist the staff in providing a safe environment for all Veterans placed on 1:1 observation due to suicidal ideation/behavior.

i. The applicable environmental checklist will be completed at each shift change by the oncoming staff for Veterans on 1:1 observation due to suicidal ideation/behavior.

ii. Suicide Prevention Environmental Checklists are available on the Medical Center’s intranet homepage by selecting Patient Safety under the listings for Clinical Resources.

(3) Emergency Department

i. When a Veteran presents to the ED with suicidal ideation or screens positive for suicidal ideation, 1:1 observation must be initiated and maintained until the ED provider or psychiatric consultant assesses the Veteran and deems the Veteran to no longer be at High Acute Risk and that safety can be maintained with a lower level of monitoring (e.g., direct line of sight or continuous observation), or until the Veteran is transferred to another appropriate setting.

ii. ED staff will use the ED and Inpatient Units Suicide Prevention Environmental Checklist to survey and reduce risk in the area the Veteran has been placed in while on 1:1 observation due to suicidal ideation/behavior will be treated.

iii. Veterans who present with suicidal ideation/behavior and discharge from the ED must have a Suicide Prevention Safety Plan completed or updated and a referral for mental health assessment and follow-up appointment scheduled prior to discharge.

iv. The MHEOCC will also be used to provide guidance in designing space used for the evaluation of Veterans presenting to ED for mental health conditions. Rooms in the ED that must be compliant with the MHEOCC should be reviewed using the MHEOCC every 6 months.

(4) General Acute Inpatient Units

i. When Veterans are admitted to a general acute inpatient unit who have clinically indicated risk of harm to self or others, clinical staff must perform an environmental risk assessment to identify and remove hazardous items that could be used as a weapon to harm self or others without adversely affecting the Veteran’s medical care. Clinical staff will use the ED and Inpatient Units Suicide Prevention Environmental Checklist to survey the treatment area and to mitigate suicide risk.

ii. Clinical staff must also assess any object brought into a room by visitors and provide safe transport of the Veteran to other areas of the hospital when needed.

(5) Inpatient Mental Health Unit

i. An ISIT will use the MHEOCC to review all mental health units treating suicidal Veterans at least every 6 months and submit the review via the Veteran Safety Assessment Tool to the National Center for Veteran Safety each time it is completed.

ii. When Veterans are admitted to the inpatient mental health unit, staff will follow policy and procedure outlined in Inpatient Mental Health Hazardous Items Search Guidelines.

(6) All Other Clinical Settings:

i. Clinical and facility staff will assess clinical areas to identify objects that could be used for self-harm and should be routinely removed, when possible, from the area around the Veteran who has been identified as high-risk for suicide.

ii. Staff will use the Outpatient Clinic Suicide Prevention Environmental Checklist to assist in providing a safe environment for all Veterans placed on 1:1 observation due to suicidal ideation/behavior.

iii. Suicide Prevention Environmental Checklists are available on the Medical Center’s intranet homepage by selecting Patient Safety under the listings for Clinical Resources.

d. Reporting Suicidal Behavior

(1) The Suicide Behavior and Overdose Report (SBOR) is used to report and document suicidal behavior, including preparatory behaviors, suicide attempts, suicides, intentional overdoses, and undetermined suicide-related behaviors occurring in the past 12 months. This report can also be used to document accidental overdoses and adverse effect overdoses.

i. See Appendix B: Staff Specific Guidance

ii. Must be completed within 1 business day of learning of the event. Clinical staff is encouraged to contact the SPT for assistance with completing the SBOR if needed. If more than one staff member is informed of the event, it is preferable the person with the most direct, thorough knowledge of the event complete the SBOR.

iii. A chart review should be conducted, including reviewing remote data, to ensure a duplicate report is not created.

iv. The SPT and Veteran Safety Manager should be identified as additional signers to all SBORs.

v. The SPT must review the SBOR within 1 business day to determine if additional documentation and follow-up is needed.

vi. The Narcotics Review Team and / or Stratification Tool for Opioid Risk Management (STORM) Review Team should be notified via the SBOR template of any overdoses, accidental or intentional. The Narcotics Review Team/STORM Review Team will review each overdose event and provide recommendations for safe prescribing and overdose education.

vii. The Point of Contact (POC) for the Adverse Drug Event Reporting System (ADERS) should be notified via the SBOR template of any Adverse Drug Events reported. The POC will follow-up with providers completing the report to ensure the event was recorded in the ADERS system per local procedures.

(2) Heads Up & Issue Briefs are used to notify leadership within the organization regarding a situation/event/issue, including:

i. Reporting Suicide or Suicide Attempts

1. On VA property and/or in a VA inpatient or residential facility,

2. With congressional or media interest,

3. Involving VA or community police in the incident or the events leading up to it, or

4. Within 7 days after discharge from a VA inpatient or residential care facility.

ii. The SPT will complete a Heads-Up message notifying leadership of events meeting the above criteria within 2 hours of learning of the incident and complete an Issue Brief usually within 24 hours (not to exceed 48 hours).

iii. The Suicide Prevention Coordinator, Veteran Safety Manager, HCS Director, and HCS Quality Manager will follow guidelines of the 10N Guide: VHA Issue Briefs for conducting a Root Cause Analysis and/or Quality Peer Review.

(3) Behavioral Health Autopsy Program and Family Interview Contact Form (BHAP/FIT-C) systematically collects information for all Veteran deaths by suicides reported to VHA clinicians and Suicide Prevention Teams.

i. The SPT will complete a BHAP/FIT-C for all suicides known to the healthcare system within 30 days of when the health care system became aware of the death.

ii. The BHAP/FIT-C will be reviewed by mental health leadership prior to electronic submission to the National Suicide Prevention Office.

B. Training and Education

(1) New Employees

i. Non-Clinical Staff will receive SAVE (i.e., Signs and Symptoms, Ask The Most Important Question , Validating, and Encouraging/Expediting Treatment) training during New Employee Orientation provided in person by the Suicide Prevention Team.

ii. Clinical staff must complete the Talent Management System (TMS) Training “Suicide Risk Management Training for Clinicians” within 90 days of entry on duty date.

iii. Clinical area managers are responsible for training new employees to use applicable Suicide Prevention Environmental Checklists.

(2) Mandatory Annual Training

iv. Non-Clinical Staff must complete the TMS-based annual refresher training “Operation SAVE Refresher”. Compliance with this requirement will be monitored through TMS.

v. Clinical staff must complete the TMS based annual refresher training “Suicide Risk Management Training for Clinicians”.

Compliance with this requirement is monitored through TMS.

vi. Clinical area managers should provide annual refresher training to all employees to use applicable Suicide Prevention Environmental Checklists.

(3) Additional face to face and TMS trainings are available and recommended for clinical and non-clinical staff including training related to Suicide Risk Screening and Evaluation, Suicide Prevention Safety Planning, Lethal Means Counseling, Environment of Care, and responding to crisis calls. Staff requesting additional training should contact the SPT.

c. Outreach & Safe Messaging

(1) Outreach: The SPT will promote a public health approach to suicide prevention by providing or attending education outreach events each month with at least one of those events being a SAVE Training. The SPT will also collaborate with community organizations and other stakeholders to promote suicide prevention.

(2) Safe Messaging: The SPT will work with the Public Affairs Officer to follow safe messaging guidelines. These guidelines will help encourage Veterans to seek help without unknowingly reinforcing beliefs, behaviors, or stereotypes that could hinder Veterans from reaching out for help.

(3) Social Media: The SPT will assist staff responsible for the monitoring of social media websites with follow-up on comments or postings to such sites causing concern for suicide risk.

(4) Mental Health Clinic, Office, and Cell Phones equipped with voicemail must use the following internal and external voicemail greeting:

i. “Hello. You have reached the phone of [insert name and title]. If you are having a medical or mental health emergency, hang up and dial 911. If you are having thoughts of suicide, please hang up and call 1-800-273-8255, then press 1 at the prompt to reach the veterans crisis line. That number again is 1, 800, two, seven three, eight, two, five, five, and then press 1 for the veterans’ crisis line. Otherwise, please leave a brief message and i will return your call when i am able during regular business hours.”

ii. When a clinical staff is on leave, the message must be updated to include the name and number of the person(s) providing coverage.

(5) Personal Cell Phones: Providing Veterans with mental health staff members’ personal cell phone numbers is strictly prohibited.

6. REFERENCES

a. Department of Veteran Affairs. Assistant Deputy Under Secretary for Health for Clinical Operations Memorandum, Suicide Prevention in Emergency Departments (SPED): Suicide Safety Planning and Follow Up Interventions, September 7, 2018.

b. Department of Veteran Affairs. DUSHOM Memorandum, Suicide Awareness Training (VAIQ# 7780988), April 11, 2017.

c. Department of Veteran Affairs. DUSHOM Memorandum, Suicide Behavior and Overdose Report Computerized Veteran Record System (CPRS) Note Template Implementation, April 8, 2019.

d. Department of Veteran Affairs, DUSHOM Memorandum, Suicide Risk Screening and Assessment Requirements, May 23, 2018.

e. Department of Veterans Affairs, VHA Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Veterans, May 12, 2017.

f. Department of Veteran Affairs, VHA Directive 2008-036, Use of Veteran Record Flags to Identify Veterans at High Risk for Suicide, July 18, 2008.

g. Department of Veteran Affairs, VHA Directive 1101.05(2), Emergency Medicine, September 2, 2016, Amended March 7, 2017.

h. Department of Veteran Affairs VHA Directive 1071, Mandatory Suicide Risk and Intervention Training for VHA Health Care Providers, June 27, 2014.

i. Risk Stratification Table, Rocky Mountain MIRECC for Suicide Prevention,

j. The Joint Commission, National Veteran Safety Goal for Suicide Prevention, Issue 18, Nov. 27, 2018.

k. The Joint Commission, Special Report: Suicide Prevention in Health Care Settings: Recommendations Regarding Environmental Hazards for Providers and Surveyors, June 2018.

l. Self-Directed Violence Classification System, Rocky Mountain MIRECC for Suicide Prevention. https://www.mirecc.va.gov/visn19/docs/SDVCS.pdf

7. RESCISSION

Not applicable.

8. REVIEW

This MCP must be reviewed at minimum at recertification and including when there are changes to the governing document, VHA Directive 1234. This review is documented on the GVSMVAMC Facility SharePoint site Medical Center Policies and Memoranda (see NOTE: This is an internal VA Web site that is not available to the public.)

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of July 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 and controls.

10. SIGNATORY AUTHORITY

/s/ David M. Walker, MD, MBA, DFAPA G.V. (Sonny)VA Medical Center Director Date Approved: August 20, 2020

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

DISTRIBUTION: Emailed to the All Employee G.V. (Sonny) Medical Center Email Distribution List on August 31, 2020. MCPs are available at: GVSMVAMC Facility SharePoint site Medical Center Policies and Memoranda https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?vie wpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx

NOTE: This is an internal VA Web site that is not available to the public.

APPENDICES:

A. Comprehensive Suicide Risk Evaluation B. Staff Specific Guidance C. Primary Screen for Suicide Risk D. Secondary Screen for Suicide Risk E. Suicide Behavior Report F. Suicide Prevention Safety Plan G. Crisis Response by Phone https://www.mirecc.va.gov/visn19/docs/SDVCS.pdf https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx

H. ED & Non-Mental Health Inpatient Units Suicide Prevention Environmental Checklist

APPENDIX A: COMPREHENSIVE SUICIDE RISK EVALUATION

Appendix A.docx

APPENDIX B: STAFF SPECIFIC GUIDANCE

Primary

Screen

Secondary

Screen

Comprehensive

Evaluation

SBOR **SPSP

*MD/DO1 Yes Yes Yes Yes Yes

*Licensed

Psychologist

(PhD/PsyD)2

Yes Yes Yes Yes Yes

*NP/CNS/PA3 Yes Yes Yes Yes Yes

*Clinical Pharmacy

Specialist

Yes Yes Yes Yes Yes

*LCSW/LMSW/LISW4 Yes Yes Yes Yes Yes

*LMFT/LPMHC5 Yes Yes Yes Yes Yes

Rehabilitation

Counselor

Yes Yes++ No+++ Yes Yes

Addiction Therapist Yes Yes No Yes Yes

RN6 Yes Yes+ No Yes Yes

LPN7 Yes No No No No

Peer Support

Specialist

Yes No No No No

VRS8 Yes No No No No

UAP9 Yes No No No No

*For purposes of this policy, denotes Licensed Independent Providers (LIP)

**Must also complete TMS Course VA-36232 Suicide Safety Plan Training Recording

+RN’s can administer the secondary screen via Mental Health Assistant but they cannot administer the secondary screen via the Clinical Reminder System because it contains disposition

++Rehabilitation Counselors can administer the secondary screen via Mental Health Assistant, or when licensed and included in local bylaws as an independent practitioner, via the Clinical Reminder. +++Yes, for RCs who hold state licensure and are included in local bylaws as an independent practitioner

1Medical Doctor/Doctor of Osteopathic Medicine; 2Doctor of Philosophy/Doctor of Psychology; 3Nurse Practitioner/Clinical Nurse Specialist/Physician’s Assistant; 4Licensed Clinical Social Worker/Licensed Master of Social Work/Licensed Independent Social Worker; 5Licensed Marriage and Family Therapist/Licensed Professional Mental Health Counselor; 6Registered Nurse; 7Licensed Practical Nurse;

8Vocational Rehabilitation Specialist; 9Unlicensed Assistive Personnel including Health Tech, Medical Assistant, Nursing Assistant. Note: A trainee in ANY of these categories may complete each step marked with a “Yes” with an appropriate co-sign

APPENDIX C: PRIMARY SCREEN FOR SUICIDE RISK

Patient Health Questionnaire-9 (PHQ-9):…