S02 ATTACHMENT D.30 - SOP 122-12_SUICIDE_RISK_IDENTIFICATION_AND_MANAGEMENT_SSTRATEGY_IN-PATIENT_ACUTE_CARE.pdf

SUICIDE RISK IDENTIFICATION AND MANAGEMENT STRATEGY-INPATIENT

ACUTE CARE

SOP 122-12

Veterans Health Care System of the Ozarks (VHSO) Fayetteville, AR 72703

Signatory Authority:

Associate Director of Patient Care Services

Responsible Owner:

Social Work Service

Service Line(s):

Acute and Specialty Care

Effective Date:

April 14, 2023

Recertification Date:

April 14, 2028

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures to identify and manage suicide risk on the inpatient acute care units, not including acute mental health units.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with VHA Memorandum, Eliminating Veteran Suicide: Suicide Risk Screening and Evaluation Requirements and Implementation (Risk ID Strategy), dated November 23, 2022.

2. PROCEDURES

a. Screening and Evaluation. All Veterans admitted to the inpatient acute care will have a screening for suicide risk within 24 hours of admission and within 24 hours prior to discharge using the Columbia-Suicide Severity Rating Scale (C-SSRS). A positive screen requires the documentation of a Comprehensive Suicide Risk Evaluation (CSRE) within 24 hours of the positive screen using the note template “Suicide Risk Evaluation-Comprehensive.”

(1) Nursing staff will complete the C-SSRS embedded in the nursing admission note within 24 hours of admission and again within 24 hours prior to discharge using the C- SSRS embedded in the Nursing Discharge-Education/Transfer Note.

(2) If the C-SSRS screen is positive, the RN will provide a verbal and written hand-off to attending hospitalist and the SWS LIP to complete the CSRE. See SOP 118-16, Hand off Communication.

(a) Business Hours LIP: Acute Social Worker (Weekdays 0800-1630) ext.

65065/page for a social worker overhead.

(b) After Hours/Holiday LIP: Contact the AOD for on-call SWS LIP https://dvagov.sharepoint.com/sites/VHAfav/policyreview/SOPs/Forms/Service.aspx?viewpath=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2FForms%2FService%2Easpx&id=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2FSOP%20118%2D16%2Epdf&parent=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs

April 14, 2023 SOP 122-12

(3) The LIP will complete a Comprehensive Suicide Risk Evaluation (CSRE) and use the Therapeutic Risk Management - Risk Stratification Table to help determine suicide risk levels with respect to severity (low, intermediate, high) and temporality (acute and chronic) and aid clinical decision making in respect to risk mitigation strategies appropriate to level of risk: Therapeutic Risk Management - Risk Stratification Table.

(4) If the Veteran is assessed as High Acute Risk for Suicide, the Suicide Prevention Team must be alerted for consideration of a High Risk for Suicide Patient Record Flag.

The Psychiatrist on Duty (POD) must be consulted for consideration of transfer to psychiatric unit.

(a) If the Veteran is not being transferred to inpatient psychiatric unit, additional precautions including an environmental risk assessment and other risk mitigation strategies should be employed. See also 118-15 SOP. Care and Documentation of Patients in Close Observation, 1:1, Q15 Minute Checks and Restraint/Seclusion Status.

b. Exclusions

(1) If a C-SSRS or CSRE was done in the Emergency Department within 24 hours of admission, it does not need to be repeated until discharge.

(2) Veterans with limited life expectancy (eligible for hospice) and Veterans with moderate-severe cognitive impairment are excluded from screening requirements. Staff may select “Unable to Screen” in these instances. See also Frequency Asked Questions available at: Dept. of Veterans Affairs (VA) Suicide Risk Identification Strategy - Frequently Asked Questions (FAQ).

c. Staff Specific Requirements.

(1) Documents available on the Suicide Risk Identification and Management SharePoint outlines staff with a scope of practice to complete screenings, evaluation, suicide behavior reporting, and safety planning. VHA RISK ID SharePoint.

(2) Staff must complete required training courses as outlined:

(a) VHA Memorandum, Agency-Wide Required Suicide Prevention Training, dated May 11, 2022 and amended June 21, 2022, Mandatory Suicide Risk and Intervention Training.

(b) VHA Memorandum, Lethal Means Safety (LMS) Education and Counseling, dated March 17, 2022, Lethal Means Safety (LMC) Education and Counseling.

(c) VHA Memorandum, Update to Use of National Standardized Suicide Prevention Safety Plan Progress Notes, dated August 17, 2022, Suicide Prevention Safety Plan Progress Notes.

3. ASSIGNMENT OF RESPONSIBILITIES

https://www.mirecc.va.gov/visn19/trm/docs/RM_MIRECC_SuicideRisk_Table.pdf https://dvagov.sharepoint.com/sites/VHAfav/policyreview/SOPs/Forms/Service.aspx?viewpath=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2FForms%2FService%2Easpx&id=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2F118%2D15%20SOP%2Epdf&parent=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs https://dvagov.sharepoint.com/sites/VHAfav/policyreview/SOPs/Forms/Service.aspx?viewpath=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2FForms%2FService%2Easpx&id=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2F118%2D15%20SOP%2Epdf&parent=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FRisk%20ID%20FAQ%204%2E0%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FRisk%20ID%20FAQ%204%2E0%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID https://dvagov.sharepoint.com/sites/ECH/srsa/SitePages/Risk-ID-Resources.aspx https://dvagov.sharepoint.com/sites/vhasuicidepreventioncoordinators/SitePages/Education-and-Training.aspx https://dvagov.sharepoint.com/sites/vhasuicidepreventioncoordinators/SitePages/Education-and-Training.aspx https://dvagov.sharepoint.com/sites/vhasuicidepreventioncoordinators/SitePages/Education-and-Training.aspx https://dvagov.sharepoint.com/sites/vhasuicidepreventioncoordinators/SitePages/Policy-and-Directives.aspx https://dvagov.sharepoint.com/sites/vhasuicidepreventioncoordinators/SitePages/Policy-and-Directives.aspx

a. Attending Hospitalist: Responsible for completing the CSRE if SWS LIP is not available to complete CRSE. Attempt to complete a CSRE must be documented. (See link): C-SSRS/CSRE Unable or Unwilling

b. Supervisory Staff: Responsible for ensuring compliance of SOP to Suicide Prevention Committee and ensuring staff are competent to carry out the SOP.

c. Clinical Staff: Completes required trainings/competencies and ensures that all Veterans are screened, evaluated, and treated for suicide risk as established by this

SOP.

d. Suicide Prevention Coordinator: Serves as advisor to service line concerning suicide prevention policies and procedures and provides education, training, and consultation to all staff. Responsible for monitoring and reporting compliance of SOP to Supervisory Staff.

4. DEFINITIONS

a. Hand Off Communication: standardized, written and verbal interactive communication between organizations or providers to which the patient is accepted, transferred or discharged which allows the opportunity for questioning between the giver and receiver of patient information. A provider is anyone assuming care for a patient.

See also SOP 118-16

b. Licensed Independent Provider (LIP): For purposes of this SOP, an LIP is any clinical staff with a scope of practice to complete a Comprehensive Suicide Risk Evaluation (CSRE) as defined by Risk ID Staff-Specific Guidance found at: Staff Specific Guidance

5. RECORDS CONTROL

All records will be maintained and inventoried in accordance with MCP 04-03 and RCS 10-1. Records will be inventoried on the Social Work Service record file and inventory plan.

6. REFERENCES

a. VHA Memorandum, Eliminating Veteran Suicide: Suicide Risk Screening and Evaluation Requirements and Implementation Update (RISK ID Strategy), dated November 23, 2022.

b. VA VHSO Nursing SOP: Care and Documentation of Patients in Close observation, 1:1, Q15 minute checks, and restraints/Soc status VHSO SOP 118-15.

c. Suicide Risk Identification and Management SharePoint site.

d. Rocky Mountain MIRECC for Suicide Prevention. Therapeutic Risk Management

– Risk Stratification Table.

https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?FolderCTID=0x012000E86563DBD1AE964BB1325C495848890F&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FC%2DSSRS%20and%20CSRE%2FCSRE%2F4%2E%20CSRE%5Fand%5FC%2DSSRS%5FGuidance%5FRe%5FUnwilling%5For%5FUnable%2Epdf&viewid=2f3bb8b8%2Df766%2D41cb%2D92df%2D75733baf99c5&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FC%2DSSRS%20and%20CSRE%2FCSRE https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?ga=1&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FStaff%20Specific%20Guidance%2FRisk%20ID%5FStaff%20Specific%20Guidance%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FStaff%20Specific%20Guidance https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?ga=1&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FStaff%20Specific%20Guidance%2FRisk%20ID%5FStaff%20Specific%20Guidance%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FStaff%20Specific%20Guidance https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?ga=1&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FMemos%2F11%2D23%2D22%20Eliminating%20Veteran%20Suicide%20Suicide%20Risk%20Screening%20and%20Evaluation%20Requirements%20and%20Implementation%20Update%20%28Risk%20ID%20Strategy%29%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FMemos https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?ga=1&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FMemos%2F11%2D23%2D22%20Eliminating%20Veteran%20Suicide%20Suicide%20Risk%20Screening%20and%20Evaluation%20Requirements%20and%20Implementation%20Update%20%28Risk%20ID%20Strategy%29%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FMemos https://dvagov.sharepoint.com/sites/ECH/srsa/Shared%20Documents/Forms/AllItems.aspx?ga=1&id=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FMemos%2F11%2D23%2D22%20Eliminating%20Veteran%20Suicide%20Suicide%20Risk%20Screening%20and%20Evaluation%20Requirements%20and%20Implementation%20Update%20%28Risk%20ID%20Strategy%29%2Epdf&parent=%2Fsites%2FECH%2Fsrsa%2FShared%20Documents%2FRisk%20ID%2FMemos https://dvagov.sharepoint.com/sites/ECH/srsa/SitePages/Risk-ID-Resources.aspx https://www.mirecc.va.gov/visn19/trm/docs/RM_MIRECC_SuicideRisk_Table.pdf https://www.mirecc.va.gov/visn19/trm/docs/RM_MIRECC_SuicideRisk_Table.pdf

e. VA Suicide Prevention SharePoint.

f. VHSO SOP 118-16 Hand-Off Communication.

7. REVIEW

Reviewed annually or when there are changes to the governing document.

8. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of April 2028.

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

9. SIGNATORY AUTHORITY

Amy S Huycke Associate Director of Patient Care Services

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

DISTRIBUTION: Via Intranet https://dvagov.sharepoint.com/sites/vhasuicide-prevention https://dvagov.sharepoint.com/sites/VHAfav/policyreview/SOPs/Forms/Service.aspx?viewpath=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2FForms%2FService%2Easpx&id=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs%2FSOP%20118%2D16%2Epdf&parent=%2Fsites%2FVHAfav%2Fpolicyreview%2FSOPs

APPENDIX A

INPATIENT ACUTE CARE WORK FLOW

SW LIP/RN or Provider

(recommended prior to discharge)

SW LIP or Provider RN Hand-off to

SW LIP & Provider RN (Admit &

Discharge)

C-SSRS Positive CSRE

Safety Plan

Lethal Means Counseling

Follow-up appointments

Admission: If C-SSRS was completed in ED within 24 hours of admission, a C- SSRS does not need to be completed again until discharge.

LIP Responsible for CSRE:

• Business Hours: (0800-1630): LIP Social Worker ext 65065/page overhead

• After Hours LIP: AOD for On call Social Worker LIP contact