NMVAHCS MCP 116-8 Suicide Risk Assessment.pdf

SUICIDE RISK ASSESSMENT

New Mexico VA Health Care System

Albuquerque, NM

MCP 116-8

Signatory Authority

Director NMVAHCS

Rescinded Document

MCM 116-8, Suicide Risk Assessment dated August 2020.

Service Line

Behavioral Health Service

Effective Date

April 2021

Responsible for Updates

Chief Behavioral Health Service

Recertification Date

April 30, 2026

1. POLICY

This Medical Center Policy (MCP) establishes the New Mexico VA Health Care System

(NMVAHCS) policy on Suicide Risk Assessment of potentially suicidal inpatients and outpatients presenting to this facility and using this assessment to guide intervention strategies.

2. JUSTIFICATION

This local policy exists to meet the National Patient Safety Goals mandated by the

Joint Commission.

3. SUMMARY OF CHANGES

a. Added Homicidal Ideation.

b. Updated the writing of Orders.

4. DEFINITIONS/ACRONYMS

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

b. CSRE. Comprehensive Suicide Risk Evaluation.

c. Homicidal Ideation. The ideas of physical harm or death of another person to detailed and fully formulated plans without the act itself.

d. JC. Joint Commission.

April 2021 MCP 116-8

e. NMVAHCS. New Mexico VA Health Care System.

5. RESPONSIBILITIES

a. The Director of the Behavioral Health Care Line. The Director of the Behavioral

Health Line is responsible for:

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

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

Assessing the risk of suicide and determine the appropriate disposition.

c. Nursing. Nursing is responsible for:

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

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

(3) Referring to Elsevier skills site for guidance on Suicide Precautions.

d. Health Care Providers. Health Care Providers are responsible for:

(1) Instituting behavioral monitoring precautions whenever indicated by a patient's potential risk for suicidal behavior. If psychiatry has not yet assessed a patient or psychiatry has evaluated and the patient attempts to leave the hospital, the

Attending Physician or LIP or resident should enter a text order indicating the patient is on a 5-day psychiatric hold. If psychiatry has already assessed the patient and determined that they are an acute danger to themselves, then

Psychiatry should enter the hold order.

(2) In the attending Physician or LIP's absence, the resident physician or

Registered Nurse must initiate suicide precautions when their assessment of the patient indicates a need. A Physician or LIP’s order should be obtained as soon as possible after the fact.

(3) Ensuring the patient's condition is monitored continuously and that the need for precautions is re-evaluated per policy and rewritten or as needed, every 24 hours.

(4) Generating the required order to reduce the level of behavioral monitoring precautions when indicated.

6. REQUIREMENTS/STANDARDS

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

(1) The Clinical Reminder screens for Major Depressive Disorder and PTSD, also known as the PHQ-2+I9 and the PC-PTSD-5+I9, will be administered in the

Primary Care clinics as outlined in the VA Clinical Practice Guidelines for

Depression and PTSD Clinical Reminders.

(2) When either screen is positive, a secondary screen will be administered. The

Secondary Suicide Screen, otherwise known as the Columbia Suicide

Severity Rating Scale (C-SSRS) is templated as a Clinical Reminder that is triggered whenever an initial screen for Depression or PTSD scores positive.

(3) If the Secondary Suicide Screen (C-SSRS) is positive, the veteran will be referred for a comprehensive suicide risk evaluation that day by a licensed independent provider. Documentation of the comprehensive screen completion uses the national note template for titled Comprehensive Suicide

Risk Evaluation (CSRE).

(4) If the provider conducting the CSRE identifies minimal risk factors for a suicide attempt, the patient may be managed by the Primary Care Clinic with support from the Behavioral Health Care Line.

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

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

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

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

(3) General suicide prevention strategies:

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

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

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

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

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

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

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

Other interventions to assure immediate safety include:

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

2. Safety planning between patient and clinician

3. Initiating supportive psychotherapy,

4. Decreasing social isolation,

5. Decreasing perturbation and agitation,

6. Establishing structured treatment goals,

7. Collaborative problem solving,

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

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

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

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

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

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

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

(d) If a patient has made a suicide attempt, preparatory behaviors, self-directed violence, or statements of intent to harm one’s self it must be reported to the attending Physician or LIP’s, resident or, if after regular business hours or on weekends, to the Physician on Duty (POD).

(e) Suicide attempts, self-directed violence, rehearsal and preparatory behaviors must be documented in the patient’s chart utilizing the Suicide

Behavior and Overdose Report, a templated note in Electronic Health

Record.

(f) If the patient appears to have injured himself/herself, a Physician or LIP must examine the patient in a time frame appropriate to the clinical situation.

(g) Since patients who have made suicide attempts or attempted self-directed violence are often at risk of a more serious attempt, behavioral monitoring precautions must be instituted (see Attachment A) until the treating psychiatrist or the POD has examined the patient at which time orders about further management of the patient will be entered.

(h) As long as the patient is considered to be at increased risk of suicide and is on suicide precautions, an assessment of suicide risk must be completed every 24 hours and documented within the medical record.

(i) An Electronic Patient Event Report should be initiated for each suicide attempt or gesture.

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

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

7. REFERENCES

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

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

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

8. RESCISSION

MCP 116-8, Suicide Risk Assessment dated August 2020.

9. REVIEW

This MCP will be reviewed 120 days before recertification or sooner if when there are changes to governing documents cited in references above.

10. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of April 2026.

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.

SIGNATORY AUTHORITY

/S/ Andrew M. Welch, MHA, FACHE Director

NOTE: Signature remains valid until rescinded by appropriate administrative action.

August 2020 MCP 116-8 Appendix A

A-1

SUICIDE AND HOMICIDAL PRECAUTIONS FOR INPATIENTS

Initiation of Suicidal or Homicidal Precautions:

1. Behavioral monitoring is initiated upon a Physician or LIP’s written order. The levels of monitoring available are as follows: Every 15 (q15) minute checks, one-to-one supervision, and seclusion with one-to-one supervision. The appropriate level of monitoring is chosen by the Physician or LIP as a clinical judgment, with the goal to assure the patient's safety while respecting the least drastic means principle.

2. When a Registered Nurse (RN) considers a patient an imminent suicide risk, he/she will place the patient on one-to-one nursing observation, then inform the Physician or

LIP. The Physician or LIP order specifying the level of behavioral monitoring to follow must be subsequently obtained.

3. Both the Physician or LIP and the RN will document in the progress notes the reasons for initiating behavioral monitoring suicide precautions.

4. New Mexico State Law is followed in the involuntary hospitalization of suicidal patients.

5. Risk factors of homicidal behaviors that should warrant behavioral monitoring but not seclusion or restraint include: history of violence on an inpatient unit, current use of threats and intimidation towards staff that indicate homicidal ideation, and/or possession of weapons.

Procedure:

1. Safety of Environment

a. Patients will be placed in a room where the window will not open and is impact-resistant.

b. The patient and his belongings will be searched for potentially dangerous items; i.e., medications, sharp instruments, coins, ties, belts, glass, matches, lighters, etc. The patient is placed in hospital pajamas and clothing is secured in the clothing room.

c. The patient will be supervised by a nursing staff member, who will monitor the patient at the level ordered by the Physician or LIP.

August 2020 MCP 116-8 Appendix A

A-2

d. Smoking is not permitted when a patient is on suicide precautions. Electric razors will be used with supervision.

e. Use electronic oral thermometer.

f. Visitors may be restricted by a Physician or LIP’s order. If permitted to visit, visitors will be instructed not to give patients any sharp instruments, matches or medications.

g. Suicidal patients on non-psychiatric inpatient units whose conditions permit may be transferred to a psychiatric unit upon the recommendation of their attending

Physician or LIP and the consulting psychiatrist. Suicidal patients who cannot be transferred will receive individual attention in as safe an environment as possible.

2. Documentation:

a. Orders for every 15-minute checks or 1:1 monitoring must be rewritten, if indicated, every 24 hours. Orders for seclusion must be rewritten every 4 hours

(follows MCP 11-78, Restraint and Seclusion).

b. Nursing personnel are responsible for observing and recording significant changes in the patient’s behavior and performing ongoing assessment of suicidal ideation.

Any significant behavior changes, or new or increased suicidal ideation must be reported to the Physician or LIP immediately or as indicated by the patient’s treatment plan.

c. As long as the patient is on suicide precautions, a clinical review of suicide risk must be performed every 24 hours and documented. After the initial assessment, subsequent assessments should note which risk factors have changed. The psychiatrist is responsible for completing this assessment.

d. A Physician or LIP order is necessary to discontinue behavioral monitoring. Upon discontinuing suicidal precautions, the clinician must document a reassessment of suicidal risk. The reassessment should be documented in a progress note with a justification for discontinuing suicide precautions.