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. The IHS health care providers, including employees, are trusted with the responsibility to improve the health and wellbeing of patients presenting with suicidal ideation or suicide-related behaviors. Suicide is a serious public health problem among American Indians and Alaska Natives. According to the Center for Disease Control and Prevention data, American Indians and Alaska Natives die by suicide at a disproportionately higher rate in comparison to other racial and ethnic groups.
3. Policy.  It is the policy of the IHS that:
   1. All health care clinics and departments, including behavioral health programs, emergency departments, urgent care, primary care clinics, ambulatory care, medical surgical units, residential programs, family practice, internal medicine, pediatrics, dental, and obstetrics/gynecology, will use an evidence-based suicide risk screen for all patients 8 years old and older for possible risk of suicide;
   2. Patients who present with suicide risk including symptoms or warning signs will receive a screening followed by an assessment (including a diagnosis, treatment, collaborative safety plan, and discharge follow-up included in planning); and
   3. Every facility will provide care coordination for the prevention of suicide.
4. Authorities.

   25 U.S.C. § 1665a, Indian Health Care, Behavioral health prevention and treatment services
   25 U.S.C. § 1665c, Indian Health care, Comprehensive behavioral health prevention and treatment program

5. Definitions.

   1. Acute Positive. Anyone who says “yes” to any questions on the National Institute of Mental Health (NIMH) Ask Suicide-Screening Questions (ASQ) toolkit, AND, says “yes” to Question #5:  “Are you thinking of killing yourself right now.”  An “acute” positive should be interpreted as the patient may be at imminent risk for suicide, and requires safety precautions and a full mental health evaluation.
   2. Ask Suicide-Screening Questions (ASQ). A brief (20-second) assessment that health care professionals can administer in a variety of settings, which identifies individuals that require further mental health/suicide safety assessment.
   3. Brief Suicide Safety Assessment (BSSA). A brief safety evaluation (not a full mental health evaluation) performed by a trained clinician to confirm suicide risk and determine what clinical interventions, if any, the patient may require (e.g., an urgent full mental health evaluation, a non-urgent full mental health evaluation, or no further action required at this time).
   4. Clinical Staff.  Staff members who provide direct patient care who work under the supervision of a clinical director or supervisor, physicians or qualified health care professionals.
   5. Explicit. Full details stated; leaving no question as to meaning or intent.
   6. Implicit. A meaning is hinted at or implied as opposed to being directly expressed.     
   7. Lethal Means. Objects (e.g., medications, firearms, ropes, sharp objects) that can be used to engage in suicide-related behavior.       
   8. Licensed Independent Practitioner. All licensed and independent members of the health care team (physician, physician assistant, advance practice registered nurse, psychologist, and behavioral health provider) accessing and documenting the medical record and who are qualified to provide a service [See Indian Health Manual Part 3, Professional Services, Chapter 1, Medical Credentials and Privileges Review Process].
   9. Non-Acute Positive Screen.  Anyone who says “yes” to any of the questions on the ASQ, and “no” to Question #5 on the NIMH ASQ questions.  A non-acute positive screen means the patient may have thoughts of suicide or past suicidal behavior which puts them at risk for suicide, but not imminent risk, and may require a Brief Suicide Safety Assessment to further triage the screening tool.  A non-acute positive screen is not considered an emergency as many people have thoughts about suicide but are not at imminent risk.
   10. Preparatory Behavior. Acts or preparation towards engaging in self-directed violence before potential for injury has begun.  This includes anything beyond a verbalization or suicidal 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).
   11. Safety Plan.  A written, prioritized list of coping strategies and resources for reducing suicide risk.  It is a prevention tool that is designed to lower risk for persons who struggle with suicidal thoughts and urges.
   12. 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.
   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.
   15. Suicidal Ideation.  Thoughts of engaging in suicide-related behavior.  Varies in degrees of frequency, intensity, and duration.
   16. Suicidal Intent.  A range of contemplations, wishes, and preoccupations with death and suicide.  Suicidal intent can be determined retrospectively and inferred in the absence of suicidal behavior.
   17. Suicide Risk Levels.
       1. High Risk for Suicide. Persons exhibiting behaviors that include suicidal ideation involving serious thoughts of suicide, a plan to engage in self-injury, may or may not have a history of suicide attempts, or those with prominent psychosis.
       2. Intermediate Risk for Suicide.  Persons with suicidal ideation and a plan but with no intention to act.  There may have been no recent suicide attempt, preparatory behavior, or rehearsal of the act.  The patient has the ability to abide by a safety plan and maintain their own safety
       3. Low Risk for Suicide.  Persons experiencing suicidal ideation without specific plans or intent to engage in lethal self-directed violence and have no history of active suicidal behavior.
   18. Warm Hand-Off.  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  RESPONSIBILITIES

1. Headquarters Chief Medical Officer, IHS. The IHS Chief Medical Officer (CMO) is administratively responsible for the implementation of this policy.
2. Headquarters National Suicide Prevention Consultant, IHS.  The IHS National Suicide Prevention Consultant will manage this policy including updates, responding to inquiries, and assisting the CMO with implementation.
3. Area Chief Medical Officer.  The Area CMO will monitor for compliance with this chapter in their respective area.
4. Service Unit Behavioral Health Director.  The Behavioral Health Director will be responsible for monitoring suicide-related data entered into the electronic health record, including exporting data to the National Data Warehouse by the designated deadline.
5. Service Unit Behavioral Health Director.  The Behavioral Health Director will be responsible for monitoring suicide-related data entered into the electronic health record, including exporting data to the National Data Warehouse by the designated deadline.

3-34.3  UNIFORM CLINCIAL PRACTICE GUIDELINES

1. Screening. All patients aged 8 years and older will receive a screening to identify suicide risk at every visit within Emergency Departments and Urgent Care; upon admission into a medical surgical unit or residential programs; and every three months in all other health care clinics and departments to assure accurate assessment, diagnosis, effective treatment, and follow-up services, as clinically indicated.
   1. The NIMH ASQ tool will be used as mandated.
   2. Results of the suicide screen will be reviewed by a licensed independent practitioner.
   3. Upon an acute positive suicide screen, the patient will receive a suicide risk assessment by a licensed independent practitioner.
   4. Upon a non-acute positive suicide screen, the patient may receive a suicide risk triage such as the Brief Suicide Safety Assessment, as determined by a licensed independent practitioner.
   5. The suicide risk assessment must occur before the patient is discharged/dispositioned or within 24 to 48 hours after discharge/disposition.
   6. Patients receiving a suicide risk screen will receive emergency crisis contact information for the patient and family or patient-identified support person/caregiver.
   7. Patients who refuse screening and choose to leave services against medical advice (AMA) will receive emergency contact information and receive behavioral health follow-up within 24 to 48 hours.  If the patient is determined to be a risk to self or others, local process should be followed to ensure patient safety.
2. Suicide Risk Assessment.  All suicide risk assessments will be evidence-based and include risk status, immediately available resources, and include the following components:
   1. Medical history;
   2. Psychiatric, mental, and behavioral health 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 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 for Suicide;
   2. Intermediate Risk for Suicide; or,
   3. Low Risk for Suicide.
      
      The licensed independent practitioner will clearly document treatment and interventions for follow-up based on the risk level assigned.
4. Patient Safety.  The licensed independent practitioner will determine the least restrictive environmental care setting that provides maximal safety.
   1. Low Risk for Suicide and Intermediate Risk for Suicide will follow the clinical pathway process identified as part of the NIMH ASQ.
   2. All patients determined to be at High Risk for Suicide will be placed on safety precautions as per the standard of care for management of suicidality:
      1. Not be left alone until a higher level of care is determined and obtained;
      2. Remain in direct line of site of clinical staff or under 1:1 observation;
      3. Be provided immediate access to care through an emergency department or crisis service; and
      4. Be kept away from anchor points for hanging and material that can be used for self-injury.
   3. If staff safety is at risk, clinical staff will assure patient safety by notifying security, and requesting law enforcement presence, as needed.
5. Discharge and Follow-up.  A patient at High Risk for Suicide will receive an appointment or notification for follow-up within 24 to 48 hours of discharge from an inpatient psychiatric unit, hospital, or emergency department setting after suicide preparatory behaviors or suicide attempt.  Follow-up will include:
   1. Follow-up within 7 days with outpatient behavioral health or identified treatment team;
   2. Caring contact by letter:  a brief, non-demanding expression of care and concern at specified intervals over a year or more to patients who have been suicidal, 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 or who will provide 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 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 and caregivers where appropriate) and access to lethal means restriction for a safe environment (e.g., medication locked box, barrel locks for firearms, keeping ammunition separate from firearms).
7. Safety Planning.  The licensed independent practitioner or appropriate clinical staff will collaborate with the patient to establish a personalized safety plan for all patients at risk for suicide as part of discharge or disposition planning, regardless of inpatient or outpatient status.
   1. The Collaborative Safety Plan will include 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 including the Police; and
      6. Counseling on restricting access to lethal means (e.g., locked boxes for medications, barrel locks for firearms, separating firearm from ammunition).
   2. Safety Plans will be written in accordance with level of care.
   3. Safety Plans will be updated regularly, including post discharge or disposition and at transfer between services and upon change in risk status.
   4. The use of a Collaborative Safety Plan is a mandated strategy for preventing suicide.
8. Suicide Surveillance.  Suicide screening and suicide risk assessment will be completed by appropriate staff in accordance with education and scope of competence.  When a patient is identified with suicide-related behaviors during their clinical visit, a licensed independent practitioner or appropriate clinical staff (e.g., nurse, nurse practitioner, physician assistant, MD/DO) is made aware that suicide-related behavior has occurred.  The licensed independent practitioner or appropriate clinical staff will ensure all appropriate documentation related to the suicide-related behavior will be entered in accordance with local processes, accreditation standards and procedures for appropriate reporting and storing data (e.g., in the Behavioral Health System or Electronic Health Record) to be exported to the National Data Warehouse by the 15th of each month.

3-34.4  EDUCATION AND TRAINING

All clinical staff, licensed independent practitioners, and behavioral health providers are required and responsible for obtaining the following training and education to maintain competency in suicide prevention and care within the IHS:  

1. Minimum one hour of annual training on suicide prevention gatekeeper practices on how to recognize and respond to suicide; and
2. Minimum four hours on standard of care for management of suicidality to include assessment, management, and treatment of patients at risk for suicide and how to respond to patients who are practicing, preparing for suicide, expressing suicide-related ideation or intent, collaborative safety planning, reporting suicide attempt(s) and behavior(s), and lethal means counseling and restriction.

3-34.5  QUALITY IMPROVEMENT.  The IHS facilities will ensure continuous quality improvement efforts.  This will include:

1. The evaluation of suicide prevention and treatment services and processes;
2. The review of adverse and sentinel events to provide opportunities to identify and improve the health care system; and
3. Putting processes, procedures, and practices in place to ensure patient safety and support clinicians in the event of a patient’s death by suicide.