OIA Crisis people at risk of suicide protocol.pdf

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ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
MENTAL HEALTH &
AT RISK OF SUICIDE
MHAS.A1.56
ADDICTION SERVICES
PROTOCOL

PURPOSE
It is the Bay of Plenty District Health Board (BOPDHB)  Mental Health &Addiction Service’s
(MH&AS)  policy  intent  that  people  who  present  to  acute  psychiatric  services  are  provided
with appropriate assessment and evidence based interventions. These need to be continued
for long enough to reduce suicide risk and improve mental health in the long-term.

OBJECTIVE
The  purpose  of  these  guidelines  is  to  support  best  practice  in  responding  to  people  who
present following a self-harm or suicide attempt.

SCOPE
Mental  Health  &Addiction  Service’s  Referral,  Triage,  Assessment,  Risk  Assessment
Treatment  Planning,  Service  Provision,  Discharge,  Family/  Whanau  involvement  and
Information  Sharing  mechanisms  for  all  persons  who  report/are  referred  or  notified  to  the
service with self-harm or suicidal intent and meet the threshold of Triage Categories A, B & C
as per the Mental Health & Addiction Services Triage Scale See MHAS.A1.53 Triage Scale

STANDARDS TO BE MET

TRIAGE and RESPONSE
1.  All  people  who  report  self-harm  or  suicidal  ideation  or  who  present  following  a  suicide
attempt  should  be  presumed  to  be  at  high  risk  of  further  self-harm/suicide  until  there  is
further assessment of this risk.
2.  Response times for face to face assessment of persons who report self-harm or suicidal
intent are as follows: See MHAS.A1.53 Triage Scale
2.1 Triage Category A: Immediate referral to emergency services (111)
Overdose/suicide attempt self-harm in progress
2.2 Triage Category B: 2 hours from referral/notification
Have  attempted  deliberate  suicide/self-harm  or  who  present  or  are  referred  with
Acute  suicidal  ideation  or  risk  of  harm  to  others  with  clear  plan  and  means  and/or
history of self-harm or aggression
2.3 Triage Category C: 8 hours from referral/notification
Suicidal ideation with no plan and/or history of suicidal ideation

ASSESSMENT
1.  A  mental  health  assessment  that  follows  a  self-harm/suicide  attempt  should  be
conducted  in  a  separate  interview  room  that  allows  the  person  privacy  when  disclosing
sensitive material.
2.  All  people  who  have  made  suicide  attempts/suicidal  ideation/history  of  suicidal
ideation/attempts  will  receive  a  comprehensive  assessment  See  Appendix  1:
Comprehensive Assessment Guideline.
Issue Date:
Aug 2015
Page 1 of 7
NOTE:  The  electronic  version  of
Review Date:
Aug 2018
Version No:  1
this document is the most current.
Any  printed  copy  cannot  be
Protocol Steward:  Quality & Patient
Authorised by:  Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS

ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
MENTAL HEALTH &
AT RISK OF SUICIDE
MHAS.A1.56
ADDICTION SERVICES
PROTOCOL

3.  All  people  who  have  made  suicide  attempts/suicidal  ideation/history  of  suicidal
ideation/attempts  will  have  a  Risk  Assessment  completed,  using  the  risk  assessment
form and guidelines, as part of their comprehensive assessment. See: MHAS.A1.44 Risk
Assessment
4.  The  assessment  of  risk  will  include  a  formulation  of  risk,  a  plan  to  manage  clinically
significant risks, and a relapse prevention plan  based on the formulation of risk and the
management plan.
5.  Whenever  possible clinicians should involve  whänau/family/support people/carers of the
suicidal person when working with that person.  At any time families can give information
to the clinician without this compromising the person’s privacy.
6.  Persons possessing firearms and/or a firearms license are reported to the Police as soon
as practicable following assessment if the risks of suicide/self-harm indicated that this is
warranted.
7.  If a person who is considered acutely suicidal declines involvement of others, the clinician
may override that refusal in the interest of keeping the person safe. In this situation the
appropriate  legislation  to  consider  is  the  use  of  the  Mental  Health  (Compulsory
Assessment and Treatment) Act 1992
8.  All assessments including Comprehensive and Crisis assessments that are not able to be
undertaken or completed due to the persons level of substance induced intoxication will
be  undertaken  at  the first  practicable  opportunity  as  per  MHAS.A1.23  Assessment  time
scales.
9.  People assessed in emergency departments with suicidal ideation or following a suicide
attempt whilst intoxicated should be monitored in a safe environment until they are sober.
Assessment  should  focus  on  their  immediate  risk  with  further  assessment  of  risk  when
the person is sober.

CARE PLANNING AND MANAGEMENT
1.  A MDT Review of the assessment and treatment plan of the person who has presented
with  self-harm/suicide  will  occur  within  24  hours.  The  on-call  SMO  will  complete this  on
public  holidays  and  at  weekends  where  the  regular  team  does  not  meet.  This  MDT  is
required to be minuted by the crisis service.
2.  DAO’s and crisis service staff must document their clinical rationale for using or deciding
to not use the MHA where there is a history of self-harm/suicide.
3.  Clinicians  involved  in  an  assessment  of  a  person  who  has  presented  with  self-harm  or
suicide  will  document  the  clinical  rationale  for  their  decisions  with  regards  to
admission/discharge home.
4.  Contact will be made with the person and their family/whanau (if appropriate) as soon as
practicable after presentation to ensure safety and ongoing family involvement in support
and treatment.
5.  Every person who has presented with self-harm/suicide has face to face follow-up within
72 hours following the completion of the comprehensive assessment.
Issue Date:
Aug 2015
Page 2 of 7
NOTE:  The  electronic  version  of
Review Date:
Aug 2018
Version No:  1
this document is the most current.
Any  printed  copy  cannot  be
Protocol Steward:  Quality & Patient
Authorised by:  Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS

ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
MENTAL HEALTH &
AT RISK OF SUICIDE
MHAS.A1.56
ADDICTION SERVICES
PROTOCOL

6.  A  Crisis  Alert  /  handover  to  another  clinician,  is  generated  for  any  person  assessed
following  a  self-harm  attempt  and/or  with  suicidal  intent  if  the  health  care  professional
allocated to their care will be absent from normal duties.
7.  Structured  assessment tools  such  as The  Beck Hopelessness  Scale  are  recommended
in addition to the comprehensive clinical assessment of suicide risk.

THE DECISION TO HOSPITALISE
1.  People who report self-harm or suicidal intent should be admitted as an inpatient when:
1.1 they are acutely suicidal
1.2 medical management of an attempt is required
1.3 they require more intensive psychiatric management
1.4 the establishment of a treatment alliance and crisis intervention fails and the person
remains acutely suicidal.
2.  When  no  suitable  caregivers/support  people  are  available,  respite  care  options  may  be
considered as an alternative to admission.
3.  If the person is not admitted, appropriate arrangements must be made for follow-up within
72 hours by the relevant health provider (e.g. psychiatrist, case manager, crisis service,
GP, other).

MANAGEMENT AS AN INPATIENT
1.  People  assessed  as  being  at  high  risk  of  suicide  have  an  initial  48  hour  care  plan
commenced  on  admission  that  documents  the  level  of  observation  required  to  be
undertaken by inpatient staff.
2.  Changes  to  closer  levels  of  observation  may  be  initiated  by  any  senior  clinical  team
member based on clinical assessment.
3.  Reduction  of  the  level  of  observation  must  be  approved  by  two  senior  members  of  the
clinical team.
4.  The mental state of the individuals under observation is reviewed formally at the nursing
handover  at  the  end  of  each  shift  to  ensure  that  the  level  of  support  and  observation
reflects the person’s changing risk.
5.  Senior nursing and psychiatric staff will review the level of observation at least daily when
the overall management plan is reviewed.
6.  The levels of observation and any changes are documented in the clinical notes by the
appropriate clinician. The documentation will include the date, time, clinician’s signature
and designation, the level of observation and any changes to that level.
7.  Where  possible  consistency  of  clinicians  will  be  promoted  between  inpatient  and
outpatient settings to support a reduction in longer term risk.

TRANSITION FROM INPATIENT TO COMMUNITY CARE
1.  Standards  for  Inpatient  Discharge  Planning  are  provide  in  full  in  Bay  of  Plenty  District
Health Board Mental Health & Addiction Services protocol MHAS.A1.31 Discharge from
Mental Health & Addiction Services
Issue Date:
Aug 2015
Page 3 of 7
NOTE:  The  electronic  version  of
Review Date:
Aug 2018
Version No:  1
this document is the most current.
Any  printed  copy  cannot  be
Protocol Steward:  Quality & Patient
Authorised by:  Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS

ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
MENTAL HEALTH &
AT RISK OF SUICIDE
MHAS.A1.56
ADDICTION SERVICES
PROTOCOL

Appendix 1:  Comprehensive Psychiatric/ Psychosocial Assessment

Assessment should include:
  identifying  data:  name,  gender,  age,  ethnicity,  marital  status,  sources  of  history  and
reliability of  historian/informants
  presenting problem(s): in the person’s own words
  history of present illness/episode
  past psychiatric history
  past medical and surgical history
  current medications and recent past medications
  drug allergies/sensitivities
  medical systems review
  substance use history
  forensic history
  whänau/family history
  psychosocial history
  Mental State Examination
  physical examination
  differential diagnosis
  formulation
  working diagnosis
  treatment plan.

Mental State Examination
MSE should include the assessment and documentation of:
  Behaviour
  Affect/mood
  Thought content
  Orientation
  Memory
  Insight

Family/Whanau Involvement
Seek input from the person’s whänau/family/support people if appropriate. Invite them to give
a description of their concerns about the person or any changes that they have noticed.

History of Present Illness
Obtain an account of the emergence, duration and severity of all symptoms, as well as any
precipitating  or  aggravating  factors,  such  as  worsening  of  mood  symptoms  in  relation  to
alcohol or substance use.
As illnesses such as depression are highly associated with suicidality and suicidal attempts,
one needs to be alert to symptoms of;
  lowered mood,
  anhedonia,
  sadness,
Issue Date:
Aug 2015
Page 5 of 7
NOTE:  The  electronic  version  of
Review Date:
Aug 2018
Version No:  1
this document is the most current.
Any  printed  copy  cannot  be
Protocol Steward:  Quality & Patient
Authorised by:  Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS

ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
MENTAL HEALTH &
AT RISK OF SUICIDE
MHAS.A1.56
ADDICTION SERVICES
PROTOCOL

  tearfulness,
  irritability; and
  hopelessness.
The  latter  is  a  frequent  indicator  of  increased  risk  of  suicide.  Sleep  and  appetite  changes
such as early morning wakening, weight loss, psychomotor agitation and retardation, are all
important indicators of underlying depression.

Differential Diagnosis
A  list  of  all  relevant  possible  diagnoses  should be  made,  at  least  with  reference to  the first
three Axes
of DSM IV-TR.83

Formulation
The formulation synthesises the above information, drawing together an explanation of why
this  particular  person  has  presented  in  this  particular  way  at  this  particular  time’.  A
formulation demonstrates a clinician’s understanding of factors that predisposed the person
to  becoming  suicidal  (eg,  a  whänau/family  and  personal  history  of  depression)  and  factors
that  precipitated  their  present  distress  (eg,  grief  over  a  relationship  break  up).  Factors  that
perpetuate  the  person’s  despair  are  described  (eg,  depressive  cognitions  that  they  are
‘useless’) and also any protective factors, both internal (eg, intelligent, insightful) and external
(eg,  good  and  helpful  social  supports).  The  formulation  should  put  into  context  the  current
illness in terms of their past history and social circumstances. This individual’s understanding
complements a specific working diagnosis or diagnoses, allowing a clear management plan
to be developed for the given individual to meet their needs.

Issue Date:
Aug 2015
Page 6 of 7
NOTE:  The  electronic  version  of
Review Date:
Aug 2018
Version No:  1
this document is the most current.
Any  printed  copy  cannot  be
Protocol Steward:  Quality & Patient
Authorised by:  Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS

ASSESSMENT AND MANAGEMENT OF PEOPLE
Protocol
MENTAL HEALTH &
AT RISK OF SUICIDE
MHAS.A1.56
ADDICTION SERVICES
PROTOCOL

Appendix 2:  Levels Of Observation In Inpatient Units

Level 1: General Observation
All  inpatients  will  have  this  minimum  baseline  of  observation  to  monitor  and  report  on
significant changes in the patient’s mental, physical and behavioural state.

Level 2: Frequent observations (NB MHS requirement for 15 min observations)
This  is  required  for  the  person  who  is  considered  to  be  at  a  significantly  increased  suicide
risk compared with the average psychiatric inpatient, or where the extent of risk is uncertain.
It  is  recommended  that  the  timing  of  observations  be  varied  to  ensure  the  person  cannot
predict the exact time of the next observation. If a person is assessed as requiring one of the
above levels of observation, details of this must be carefully and systematically documented.
People  who commit suicide  while engaged in mental health services are likely to have had
their level of care reduced before they commit suicide (ie, to have been judged as being at
decreased risk).
Recommendations
It is vital to review regularly the mental state of the individuals under such close observation.
This should be done formally at the nursing handover at the end of each shift. Senior nursing
and  psychiatric  staff  should  review  the  level  of  observation  at  least  daily  when  the  overall
management  plan  is  reviewed.  The  levels  of  observation  and  changes  to  this  should  be
documented separately in the clinical notes, with counter-signatures from senior staff and the
responsible  clinician.  The  documentation  will  include  date,  time  and  signature,  level  of
observation,  stop  date  and  role  of  each  person  signing.  Changes  to  closer  levels  of
observation  may  be  initiated  by  any  senior  clinical  team  member.  Reduction  of  the  level  of
observation must be approved by two senior members of the clinical team.

Level 3: Same room and in sight
This is for the person at high risk of suicide who is expressing active suicidal intent but where
there  is  less  concern  about  impulsive  self-destructive  behaviour.  The  person  may  have
recently  carried  out  an  act  of  deliberate  self-harm  or  have  unpredictable  psychotic  states.
This  requires  constant  visual  observation  on  a  1:1  basis,  with  the  nurse  in  the  same  room
and in sight of the person.

Level 4: Constant observation & within reach 1:1
This  is  for  the  person  at  extremely  high  risk  of  suicide  who  is  expressing  active  suicidal
intent.  He/she  may  have  recently  carried  out  an  act  of  deliberate  self-harm,  have
unpredictable psychotic states and/or be impulsive and aggressive. This requires observation
within  reach  of  the  person  for  safety  purposes.  On  some  occasions,  more  than  one  nurse
may be required.

Seclusion Observations
Observation and care of consumers in seclusion are subject to Health & Disability Services
(Restraint Minimisation and Safe Practice) Standards NZS 8134.2:2008 and are fully detailed
in MHAS.A1.45 Seclusion in Mental Health.
Issue Date:
Aug 2015
Page 7 of 7
NOTE:  The  electronic  version  of
Review Date:
Aug 2018
Version No:  1
this document is the most current.
Any  printed  copy  cannot  be
Protocol Steward:  Quality & Patient
Authorised by:  Business Leader &
assumed to be the current version.
Safety Coordinator, MH&AS
Clinical Director, MH&AS