/ CHHS17/143

Canberra Hospital and Health Services

OperationalProcedure

Initial Management, Assessment and Intervention for People Vulnerable to Suicide

Contents

Contents

Purpose

Alerts

Scope

Section 1 – Initial Management

General principles for all CHHS staff

Non-admitted persons

Canberra Hospital inpatient (not including mental health inpatient units)

Canberra Hospital Emergency Department (ED) presentations

Section 2 – Clinical Assessment using the Suicide Vulnerability Assessment Tool

Suicide Vulnerability Assessment Tool (SVAT)

Who can complete the SVAT

MHJHADS requirements

Section 3 – Intervention

MHJHADS requirement

Canberra Hospital Inpatient (not including mental health inpatient units)

Section 4 – In the event of a suicide or attempted suicide

Section 5 – Providing follow up care to attempt survivors

Section 6 – Privacy and consent

Section 7 – Staff Training Requirements

ACT Health Requirements

MHJHADS Requirements

Section 8 – Support for staff

Implementation

Related Policies, Procedures, Guidelines and Legislation

References

Definition of Terms

Search Terms

Purpose

To provide guidance to all Canberra and Hospital Health Services (CHHS) staff on the initial management, assessment and intervention for a person vulnerable to suicide (e.g. expresses suicidal ideation, and/or exhibits suicidal behaviour or intent).

The procedure outlines the minimum expectations to be followed by staff as a basis for ensuring that, regardless of the context,the interventions forpeople who are at risk of suicidal behaviour are consistent, integrated and coordinated across the service, irrespective of point of contact.

Back to Table of Contents

This Standard Operating Procedure (SOP) describes for staff the process to

Scope

Alerts

  • All staff have an obligation to respond to any incident in which a person is expressing suicidal ideas or exhibiting suicidal behaviours.
  • All staff are required to approach all identified suicide intent as a significant and imminent risk. Staff experiencing any uncertainty regarding acute risk should immediately discussthis with their supervisor.
  • If a person who is vulnerable to suicide is assessed as high risk to self and does not consent to be a voluntary patient, there is provision under the Mental Health Act 2015 to detain them under an Emergency Detention (ED3) Order.
  • Staff responding to persons vulnerable to suicide need to be aware of, and take into account any particular needs of:
  • Children and adolescents – where possible specialist child and adolescent mental health services should be contacted to provide assessment and/or care coordination. Consultation with child protection services may be required.
  • Aboriginal and Torres Strait Islander people – for whom contact with specialist health services such as the Mental Health, justice Health and Alcohol and Drug Services, Aboriginal and Torres Strait Islander Liaison Service and/or Winnunga Nimmityjah Aboriginal Health Serviceshould be offered.
  • Culturally and linguistically diverse populations – use of independent translator services should be used to facilitate optimal assessment and care.
  • Older persons – who may have easy access to large amounts of medications.
  • Lesbian, Gay, Bisexual, Transgender, Intersex, – who may have experienced negative attitudes surrounding their gender identity or sexuality. Clinicians should create a comfortable and stigma free environment.
  • Post-natal and pregnant women – consideration needs to be given to any dependent infants who may be impacted directly or indirectly by a vulnerable mother.
  • All staff should avoid using stigmatising terminology such as ‘committed suicide’ ‘successful/unsuccessful suicide’ or ‘failed attempt’. Appropriate terminology to use is ‘died by suicide, death by suicide, ‘ended his/her life’, and ‘attempted to end his /her life’.
  • Management, assessment and intervention for a person vulnerable to suicide must be founded on best available evidence-based practice and include appropriate follow-up care. ACT Health Management must ensure that in reference to persons exhibiting suicidal intent that:
  • A proactive approach to suicide prevention occurs
  • Staff are aware of patient safety policies and procedures
  • A range of interventions are available for the referral and management of persons with suicidal behaviour including psychiatric, psychological, social and physical treatment
  • A structure is in place to provide support to staff who are reporting a person’s suicidal behaviour.

Back to Table of Contents

Scope

This procedure applies to all CHHSstaff who may be involved in the initial management, assessment and intervention for persons vulnerable to suicide. This includes:

  • Medical officers
  • Nursing and midwifery
  • Allied health
  • Administration and other non-clinical staff.

Back to Table of Contents

Section 1 – Initial Management

If a member of staff has any concerns that a person is:

  • Exhibiting suicidal intent
  • In possession of a weapon
  • Undertaking potentially lethal activity (i.e. suicide attempt is in progress),

they have a duty of care to manage the person the person’s immediate safety needs and coordinate any an appropriate response in a timely manner; this may include calling 000 for assistance. An appropriate response may be influenced by the location of the person and the person’s presentation.

Non-clinical staff should always notify their immediate supervisor or clinical staff for support around decision-making when initially responding to a person exhibiting suicidal behaviour or intent. While not all people will require a notification to an emergency service or mental health service, staff must always exercise a low threshold when responding to these situations. ACT Mental Health Triage can be contacted 24/7 for advice or assistance on 1800 629 354 free call or 6205 1065

Staff should also contact the carer (parent/guardian/legal decision maker) if the person of concern is 16 years or younger. Mandatory reporting to Care and Protection on 1300 556 728 (24 hours) should also take place for instances of self-harming/suicidal behaviour in this age group.

General principles for all CHHS staff

For admitted persons, keep the person under close observation until a Mental Health, Justice Health, Alcohol and Drug Services (MHJHADS) clinician from the Mental Health Consultation Liaison Service, Psychiatric Registrar or the Crisis Assessment and Treatment Team (CATT) can assess them.

Non-admitted persons

(e.g. outpatients, visitors, people at community health facility or in general community)

Staff should contact Mental Health Triage in the first instance on 1800 629 354 free call or 6205 1065, who will assist the referrer in terms of a course of action which may include review by CATT or presentation to the Emergency Department (ED).If the person is known to be a current ACT Health mental health service client, then that service may be contacted.

In the event of an immediate, life threatening situation where the person is unable to be immediately and safely taken to the ED, emergency services should be contacted via ‘000’ for assistance.

Canberra Hospital inpatient (not including mental health inpatient units)

Staff should contact the Mental Health Consultant Liaison service during business hours on 6244 3204 or the Psychiatry Registrar after hours through the hospital switchboard on 6244 2222.

Canberra Hospital Emergency Department (ED) presentations

The Canberra Hospital Emergency Department has a variety of options to access mental health reviews that include direct face-to-face consultation with the ED Mental Health Clinician, the Child and Adolescent Mental Health Services, the Psychiatry Registrar, the Mental Health phone consultation service and the ED medical doctors. The various options will depend on the level of risk (plan, intent and actual attempt considered higher risk), the age of the patient and their legal status as per the Mental Health Act 2015.

Back to Table of Contents

Section 2 – Clinical Assessment using the Suicide Vulnerability Assessment Tool

Assessment of suicide vulnerability is underpinned by the following principles (adapted from Granello, 2010):

  • Assessment occurs in the unique context of the person and their situation
  • It informs management, care and treatment
  • It is an ongoing process
  • Errs on the side of caution
  • It is collaborative
  • It relies on evidence based clinical judgement
  • It takes all threats, warning signs and risk factors seriously
  • It forms part of treatment
  • It occurs within a cultural context, different cultures have risk factors associated with suicide vulnerability
  • The assessment is well documented.

Within CHHS, formal suicide vulnerability assessment may be indicated:

  • Prior to any change in treatment setting (i.e. a person moving from inpatient to outpatient setting) and/or at closure from services
  • If there are abrupt or significant changes in a person’s clinical presentation
  • If symptoms are worsening, despite treatment
  • If the person is anticipating or experiencing significant interpersonal loss or significant stressors
  • If there is an onset of physical illness.

Suicide Vulnerability Assessment Tool (SVAT)

MHJHADS has elected to use the Suicide VulnerabilityAssessment Tool (SVAT) to assess aperson’s suicide vulnerability. The SVAT emphasises an individualised approach that is meaningful and supported by evidence and highlights the importance of planning appropriate interventions and follow-up that address specific suicidal thoughts and/or behaviours. The SVAT can be found in the MHJHADS electronic clinical record (otherwise known as MHAGIC) and also on the Clinical Forms Register.

The assessment should be completed face to face where possible and the formulation developed from a bio-psycho-social perspective, incorporating strengths and supports as well as vulnerability factors. It should be documented using the SVAT and be included in the person’s clinical record – both on MHAGIC , and in the hard copy clinical record if the person is to be admitted under the care of a CHHS team that is not within MHJHADS.

The SVAT is completed in two parts. Part 1 provides for a brief overview of a person’s suicide vulnerability including space to document a management plan and any consultation that took place as part of the assessment. Part 2 provides space for clinicians to detail their formulation of a person’s suicide vulnerability taking into account static, dynamic, future vulnerability factors, strengths and supports. MHJHADS intake services (Mental Health Services Triage, Alcohol and Drug Intake, Emergency Department Triage etc) will (when potential risk is identified ) at a minimum, complete Part 1 of the document including a risk management plan developed in collaboration with the person identified as potentially vulnerable to suicide. Intake and triage services are not required to fill out a SVAT if they are answering general inquiries or undertaking administrative functions related to a person’s care. Services that have ongoing involvement with a person are expected to complete all of the SVAT and maintain a current management plan outlining appropriate treatment and interventions that link with the identified suicide vulnerabilities.

Who can complete the SVAT

The following CHHS staff may complete the SVAT, accessible from the Clinical Forms Register:

  • Mental Health, Justice Health, Alcohol and DrugServices (MHJHADS) clinical staff
  • Other clinicians across CHHS divisions who have received appropriate SVAT training.

MHJHADS requirements

MHJHADS staff are expected to have fully familiarised themselves with the SVAT tool and attended the divisions suicide intervention training (or equivalent) prior to working with potentially vulnerable persons. All clinical staff of MHJHADS must use the SVAT to document their assessment of a person’s suicide vulnerability.

MHJHADS program areas using the SVAT without MHAGIC access must develop local business rules that address appropriate storage of the completed tool, how to keep the content contemporaneous and accessible in an emergency situation.

For MHJHADS staff, formal suicide vulnerability assessment must also be completed using the endorsed SVAT:

  • At the time ofall crisis contacts
  • At the time of triage/admission/intake into a service
  • At the time of hospital presentation or admission
  • At the time of full assessment, 3 month review/discharge
  • If there is evidence of suicidal planning or intent.

Back to Table of Contents

Section 3 – Intervention

All MHJHADS clinical staff are required to access regular supervision and consultation regarding the formulation and management of a person’s suicide vulnerability through the multi-disciplinary review process, consultation with their Team Leader/Manager, Psychiatry Registrar or Consultant Psychiatrist.

After hours clinical escalation of a person’s risk vulnerability should be discussed with the on-call Psychiatry Registrar and/or the Director on-call.

An appropriate treatment plan, as documented in the SVAT, for a person should be determined by several factors, including:

  • Assessed level of vulnerability as formulated by the clinical reasoning and opinion of the clinician/s, and
  • Careful consideration of the degree of support available to the person; as well as their legal status under the Mental Health Act 2015.

The MHJHADS clinician in consultation with the person’s treating clinical team is responsible for the implementation and documentation of a management plan in the patient’s clinical record.

Consideration of the environment where the interventions will occur is also critical. Acute suicide vulnerabilitymay require high levels of supported management (i.e. in an inpatient setting), while in other situations supported, home-based care may be appropriate. The at risk person and, where appropriate, the person’s family, carers and social supports should be involved in the development of anymanagement and treatment plans, and especially where the person will be remaining in their usual accommodation or other community based environment.If a person who is vulnerable to suicide is assessed as high risk to self and does not consent to be a voluntary patient, there is provision under the Mental Health Act 2015 to detain them under an Emergency Detention (ED3) Order.

  • Do not rely solely on a person’s statement that they “guarantee” their safety.
  • Do not give undue weight to protective factors in the face of significant vulnerability factors.
  • Alcohol or drug intoxication should not preclude early assessment of a person’s suicide risk, particularly as it can increase impulsiveness and the risk of self-injury in the short term.
  • Where available seek information from collateral sources including carers and GPs to assist in making a comprehensive assessment.
  • Consult with peers and document these consultations on the SVAT.
  • Risk formulation and management plans should be documented clearly on the SVAT.

Vulnerable persons should be provided with written information regarding available community resources. This may include, but is not limited to:

  • Help lines and triage numbers
  • Dates of review appointments
  • A plan for whom to contact in a crisis.

Family members should also be provided withemergency contacts, advisedto remove potentially lethal meansof self-harm and asked to monitorthe person’s whereabouts. They should be asked tocontact services if there are any sudden changes in the person’s behaviour, or if they have concerns about the sustainability of home based care.

Timeframes for follow-up of people identified as vulnerable should be outlined in the Management Plan section of the SVAT and review of their suicide vulnerability completed as indicated. Family members and carers should be offered the opportunity to provide information to the treating team, whenever possible and as appropriate.

After hours, people who may be vulnerable to suicide can be supported by the Crisis Assessment and Treatment Team (CATT). After hours support can be arranged via the Mental Health Services Triage 1800 629 354 or internally on 6205 1065.

MHJHADS requirement

Clinicians working with suicidal people are required to participate in regular professional supervision in accordance with the MHJHADS Clinical Supervision Policy.

Canberra Hospital Inpatient (not including mental health inpatient units)

A psychiatric assessment must be arranged prior to discharge for those patients who have been assessed as being at risk. The assessment must be clearly documented in the patient clinical record.Mental Health Triage is also available for follow up for discharged patients who will refer onto the appropriate mental health service for review.

Back to Table of Contents

Section 4 – In the event of a suicide or attempted suicide

All staff are to be familiar with and comply with the incident reporting policies and procedures in the event of a suicide or attempted suicide by a person accessing CHHS services. All CHHS staff are required to be familiar and comply with the Significant Incident Procedure.In addition, MHJHADS staff will need to comply with theMHJHADS: Incidents Reportable to the Executive Director and Intervention Following the Death of a Person procedure. accessible from the Policy Register.

All suicide or attempted suicide events within CHHS facilities are to be immediately reported to the Team Leader/Manager (in business hours) or the Mental Health Director on call via the CHHS switch on 6244 2222 (after hours). For persons found deceased, a Riskman and ACTPAS notification of death are also to be completed by the clinician in receipt of the information.

Post-vention

Post-vention is a term used to describe supporting those bereaved by suicide. CHHSprovides post-vention follow-up to persons bereaved after the death of a person engaged with the service. Post-vention care is coordinated through the MHJHADS Discipline Principal of Social Work in consultation with the Operational and/or Clinical Director of the program area.

Back to Table of Contents

Section 5 – Providing follow up care to attempt survivors

A history of suicide attempt/s is a significantvulnerability factor for future suicide attempt. Improving the care a person receives after a suicide attempt is important in reducing future vulnerability and aidingrecovery.

Staff must recognise that the period immediately following an attempt represents a critical time in the person’s recovery and requires a high level of monitoring and clinical care. Staff should never minimise the experience of the person or the significance of an attempt.

People who have survived a suicide attempt will have at a minimum one face to face home visit/contactfrom mental health services followingtheir attempt and their care should be discussed with a psychiatrist. Ongoing risk review is critical and ACT Healthstaff must ensure that the person is linked with ongoing treatment and support prior to discharging them from the service.

In isolation, phone based follow-up is not an acceptable standard of post attempt care.

Back to Table of Contents

Section 6 – Privacy and consent