Chapter 34 - Suicide Prevention and Care

3-34.1  INTRODUCTION

1. Purpose. This chapter establishes uniform clinical practice guidelines for suicide prevention and care services at Indian Health Service (IHS) facilities.
2. Background. Suicide is a serious public health problem. American Indians and Alaska Natives (AI/AN) die by suicide at a disproportionately higher rate (11.7 per 100,000) in comparison to other racial and ethnic groups. The Centers for Disease Control and Prevention report that from 2010 to 2013 suicide ranked first as a cause of death for AI/ANs ages 10 to 14, 2nd for ages 15 to 24 and 6th for 35 to 44 years. Suicide is the eighth leading cause of death among the AI/AN population.
3. Policy. It is the policy of the IHS that:
   1. All behavioral health, emergency departments and primary care clinics, including family practice, internal medicine, pediatrics, and obstetrics/gynecology, will screen patients 12 years and older for suicide, when appropriate systems exist to ensure adequate diagnosis, intervention, treatment, and follow-up;
   2. Patients who screen positive for depression or exhibit suicide warning signs will receive an assessment, intervention and referral, when appropriate; and
   3. Every facility will participate in community approaches and coordination of care for prevention of suicide.

4. Definitions.
   1. Clinical Staff. All members of the health care staff who provide direct patient care.
   2. Explicit. Fully revealed or expressed without vagueness, implication, or ambiguity; leaving no question as to meaning or intent.
   3. High Risk. Patients with warning signs, serious thoughts of suicide, a plan and/or intent to engage in lethal self-directed violence, a recent suicide attempt, and/or those with prominent agitation, impulsivity, and psychosis.
   4. Implicit. Not directly expressed; inherent in the nature of something.
   5. Intermediate Risk. Patients with suicidal ideation and a plan but with no intent or preparatory behavior. Combination of warning signs and risk factors to include history of self-directed violence (previous suicide attempt) increases a person’s risk for suicide.
   6. Licensed Independent Practitioner. All licensed and independent members of the health care team (Physician, Physician Assistant, Advance Practice Registered Nurse, Psychologist, and Social Work) accessing and documenting the medical record and who can conduct an assessment [See Indian Health Manual (IHM) Part 3, Professional Services, Chapter 1, Medical Credentials and Privileges Review Process].
   7. Low Risk. Patients with suicidal ideation who have no specific plans or intent to engage in lethal self-directed violence and have no history of active suicidal behavior.
   8. Preparatory Behavior. Acts or preparation towards engaging in self-directed violence, but before potential for injury has begun. This can include anything beyond a verbalization or thoughts, 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).
   9. Safety Plan. A written, prioritized list of coping strategies and resources for reducing suicide risk. It is a prevention tool that is designed to reduce risk for those who struggle with their suicidal thoughts and urges.
   10. Self-Directed Violence. Behavior that is self-directed and deliberately results in the specific injury goal of or including injury or the potential for injury to oneself. This does not include behaviors such as parachuting, gambling, substance abuse, tobacco use or other risk taking activities, such as excessive speeding in motor vehicles.
   11. Suicidal Ideation. Thoughts of engaging in suicide-related behavior (Various degrees of frequency, intensity, and duration).
   12. Suicidal Intent. There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill himself/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and inferred in the absence of suicidal behavior.
   13. Suicide. Death caused by self-directed injurious behavior with any intent to die as a result of the behavior.
   14. Suicide Attempt. A non-fatal self-directed potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not be fatal.
   15. Warm Hand-Off. A warm hand-off is a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real- time process of passing patient specific information from one clinical staff or licensed independent practitioner to another or from one team to another, for ensuring continuity and safety of the patient’s care.

3-34.2  RESPONSIBLITIES

1. Chief Medical Officer, IHS. The IHS Chief Medical Officer is administratively responsible for the implementation of this policy.
2. National Suicide Prevention Consultant, IHS. The IHS National Suicide Prevention Consultant assists in the implementation of this policy by providing training and technical assistance resources, including policy consultation and expert review.
3. Area Chief Medical Officer. The Area Chief Medical Officer or his/her designee collects copies of IHS policies in his/her respective area, monitors those policies for compliance with this chapter, and submits to the IHS National Suicide Prevention Consultant.
4. Area Behavioral Health Consultant. The Area Behavioral Health Consultant or his/her designee is responsible for tracking and monitoring of the Resource and Patient Management System (RPMS) Suicide Reporting Form (SRF) (Manual Exhibit 3-34-A) compliance and provides technical assistance and resources related to suicide prevention and care. The RPMS SRF is used to provide required information for Government Performance and Results Act reporting requirements on suicide related events.
5. Behavioral Health Director. The Behavioral Health Director or his/her designee is responsible for ensuring the suicide related data is entered into the RPMS and, to determine if any data is missing or if the data was not entered. The Behavioral Health Director will ensure facility or program will send Behavioral Health System exports from RPMS to the National Data Warehouse by the 15th of each month.

3-34.3  UNIFORM CLINICAL CARE GUIDELINES

1. Screening. All patients from ages 12 and older will be screened for depression and suicide risk, when staff-assisted supports are in place, to assure accurate assessment, diagnosis, effective treatment, and follow-up.
   1. Screening tools will be used as indicated based on age, acuity or chronicity of suicide, and dependent on the level of care.
   2. Results of the suicide screen will be reviewed by a licensed independent practitioner.
   3. Upon a positive suicide screen, the patient will receive a suicide risk assessment by a licensed independent practitioner.
   4. The suicide risk assessment should be completed within 24 to 48 hours.
   5. Patients with either a positive depression and/or a positive suicide screen will receive emergency crisis contact information for the patient and/or family or patient identified support person.
2. Suicide Risk Assessment. All suicide risk assessments will include risk status, immediately available resources and foreseeable change and include the following components:
   1. Medical history;
   2. Psychiatric history;
   3. Past suicide related behaviors including previous attempts;
   4. Substance abuse history;
   5. Psychosocial history to include life stressors, and impulsivity;
   6. Family psychiatric history to include history of suicide;
   7. Mental status examination;
   8. Current medications;
   9. Treatment plans;
   10. Discharge or Disposition with Risk and Protective Factor Mitigation Plan;
   11. Follow up appointments and/or Referrals with Emergency Contact Information; and
   12. Access to lethal means.
3. Levels of Suicide Risk. The licensed independent practitioner will assess the level of suicide risk based on the patient’s level of care, intent, access to lethal means, and previous suicide attempts using the following categories:
   1. High Risk;
   2. Intermediate Risk; or
   3. Low Risk.

   The licensed independent practitioner will clearly document treatment and interventions for follow up based on risk level assigned.

4. Patient Safety. The licensed independent practitioner will determine the least restrictive environmental care setting that provides maximal safety.
   1. All patients determined to be at high risk for suicide will not be left alone, will remain in direct line of site of clinical staff or under 1:1 observation, depending on severity. Patients will be provided immediate access to care through an emergency department or crisis resources. Patients will be kept away from anchor points for hanging and material that can be used for self-injury.
   2. If staff safety is at risk, clinical staff will assure patient safety by notifying security, and/or requesting law enforcement presence, as needed.
5. Discharge. A patient will receive follow-up within 24 to 48 hours of discharge from an inpatient psychiatric unit, hospital, or emergency department setting after a suicide attempt or suicide related behaviors. Follow-up may include:
   1. Follow-up within seven days with behavioral health or identified treatment team;
   2. Caring contact by letter from behavioral health or identified treatment team on a locally established time frame; and
   3. Intensive case management services by behavioral health or identified treatment team.
6. Discharge Planning. A collaborative discharge plan will be developed to allow a patient at risk for suicide to be discharged from inpatient care or the emergency department in order to mitigate the increased risk of suicide post discharge. Notification must be assured between site of care and the behavioral health or identified treatment team providing services. Patients who are discharged from acute care (such as hospitalization, Emergency Department) for suicide will be:
   1. Re-assessed for suicide risk within 24 to 48 hours of discharge;
   2. Provided with an appointment scheduled with a behavioral health licensed independent practitioner within seven days of discharge;
   3. Provided suicide prevention and emergency crisis information to the patient and/or family members or support persons;
   4. Provided a personalized safety plan with available support systems contact information;
   5. Transitioned to an appropriate level of care with warm hand-off between services; and
   6. Provided with education regarding suicide, stigma, treatment options, management strategies (include families/caregivers where appropriate) and access to lethal means restriction for a safe environment.
7. Safety Planning. The licensed independent practitioner will establish a personalized safety plan for all patients at risk for suicide as part of discharge planning, regardless of inpatient or outpatient status that includes:
   1. Coping strategies and sources of support that patients can use to alleviate a suicidal crisis, including:
      1. Recognizing warning signs of an impending suicidal crisis;
      2. Employing internal coping strategies;
      3. Utilizing social contacts and social settings as a means of distraction from suicidal thoughts;
      4. Utilizing family members or friends to help resolve the crisis;
      5. Contacting mental health professionals or agencies; and
      6. Restricting access to lethal means.
   2. Safety Plans will be written in accordance with level of care.
   3. Safety plans will be updated regularly, including post discharge and at transfer between services.
   4. The use of a safety plan is the preferred strategy for preventing suicide. There is no empirical evidence for the usage of "no harm" or "no-suicide" contracts.
8. Suicide Surveillance. The RPMS SRF will be completed by clinical staff when a patient is identified with suicidal behaviors during their clinical visit. Once a licensed independent practitioner or clinical staff is made aware that a suicide event has occurred, the RPMS SRF will be completed within 48 hours (See Manual Exhibit 3-34-A).
   1. The RPMS SRF will be completed upon notification of one or more of the following events:
      1. Ideation with Plan and Intent;
      2. Suicide Attempt;
      3. Completed Suicide/Death by Suicide;
      4. Attempted Suicide with Attempted Homicide;
      5. Attempted Suicide with Completed Homicide;
      6. Completed Suicide with Attempted Homicide; and
      7. Completed Suicide with Completed Homicide.
   2. All fields in the RPMS SRF are required except Local Case Number.
   3. If there are sections of the RPMS SRF where information is not known or options are not listed, choose "Unknown" or "Other" (with specification) as appropriate.
   4. The RPMS SRF should be completed as part of a visit or within 48 hours of the visit. However, the data is not part of the patient’s clinical record and does not populate in the RPMS Visit File.
   5. The RPMS SRF does not take the place of clinical documentation. Clinical services in response to suicide events should be documented per local policy and procedure by completing an encounter/visit and using the appropriate Purpose of Visit and Current Procedural Terminology codes.
   6. All clinical staff will be trained on how to complete the RPMS SRF during new employee orientation.
   7. Each site, facility, or program will send Behavioral Health System exports from RPMS to the National Data Warehouse by the 15^th of each month.
   8. IHS facilities and programs are recommended to use RPMS community alerts, where available, for tracking of patients during a period of heightened risk for suicide.

3-34.4  EDUCATION AND TRAINING

1. Clinical Staff. All clinical staff will receive annual training on how to recognize and respond to patients who are practicing or preparing for suicide, expressing suicide related ideation, reporting suicide attempt(s) and behaviors, or are at risk for suicide.
2. Behavioral Health Providers. All behavioral health providers will receive training on the recognition, assessment, treatment, and management of patients at risk for suicide.

3-34.5  QUALITY IMPROVEMENT

IHS facilities will ensure continuous quality improvement efforts include the evaluation of suicide prevention and treatment services and processes, review adverse and sentinel events to provide opportunities to identify and improve the healthcare system, and put processes, procedures and practices in place to ensure patient safety, and support clinicians in the event of a patient’s death by suicide.