Evidence Based Guidelines for Suicide Risk Management

Manager, Risk & Evaluation, BC Mental Health and Addiction Services

Dr. Tristin Wayte

From Development to Evaluation

Quality ForumMarch 9, 2012, Vancouver, BC

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Learning Objectives

By the end of the session, learners will be able to

• Develop, implement and evaluate a clinical protocol that is most appropriate for the population served by their health organization.

Knowledge Base

• What do we know about suicide risk management in the context of mental health and addictions?

• How can we use this knowledge to improve patient safety?

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Drivers

• Why should organizations focus on suicide assessment and management (SAM)?

• Why should your organization focus on SAM?

• Why now?

4

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DriversA Planning and Practice Priority for Safety

• APA (2003)• JCAHO (2008)• WHO• The Australian National

Mental Health Working Group (2005)

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Knowledge Base: What do we know?Overview

• Mental Illness & suicide risk

• 44-47% of inpatient suicides are preventable.

• Canadian Patient Safety Institute:

– A standardized approach is required in assessing suicide risk and implementing evidence-based interventions.

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Accreditation CanadaPatient Safety ROP

Tests for compliance:

…that the organization…

1. Assesses each client for risk of suicide at regular intervals, or as needs change.

2. Identifies clients at risk of suicide.

3. Addresses the clients immediate safety needs

4. Identifies treatment and monitoring strategies to ensure client safety.

5. Documents the treatment and monitoring strategies in the client’s health record.

The Provincial Suicide Clinical Framework A PHSA initiative

• Province-Wide Initiative

• Any health authority, program or service can tailor the Framework to their unique populations, while conforming to the overall structure and ensuring ROP compliance.

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Hot off the press…

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We began with a question

How do we respond to patient safety needs at each stage of a patient’s journey through our services?

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Individual professional responsibility for due diligence to flag risk to referral source and/or

coordinate emergency f/u by another agency

Individual professional responsibility for due

diligence to flag risk to referral source and/or

coordinate emergency f/u by another agency

BCMHAS Accountable for Providing and Documenting Safe Plan of Care

BCMHAS assumes patient

care

Other Agency

assumes patient

care

Discharge/Follow-up

Transitioning

Inpatient

Outpatient

Referral to BCMHAS including

inter-agency consultation

Admit or first contact

Referral triage

Other Agency

assumes patient

care

Re-evaluation as needs change

Monitoring

Treatment

Brief Assessment

Mod or High Risk

In-depth assessment

Low Risk

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Best Practice Literature Review

– Multiple populations within MH&A

– Most robust evidence for improving safety

A broad, multidisciplinary best practice literature review was completed in relation to suicide risk management

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Framework Development: Information Sources

• Peer-reviewed research literature • Best practice guidelines and practice parameters from the American

Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, the Canadian Coalition of Seniors’ Mental Health, The Registered Nurses Association of Ontario, The National Institute for Clinical Excellence, The Centre for Substance Abuse Treatment and the New Zealand Guidelines Group.

• Gray literature from similarly situated mental health and addiction services

• Accreditation Canada• Commission on Accreditation of Rehabilitation Facilities• Results from an environmental scan of current practices and

perceived gaps in suicide risk management across the health authorities

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Framework Development: Information Sources

• British Columbia Ministry of Health Services and Ministry of Child and Family Development

• General Practice Services Committee (a joint committee of the BC Ministry of Health Services, the BC Medical Association, and the Society of General Practitioners of BC)

• The Centre for Applied Research in Mental Health and Addiction (CARMHA)

• The Canadian Medical Protection Agency (CMPA)• The Suicide Prevention/Intervention/Postvention Initiative for BC

(Crisis Intervention and Suicide Prevention Centre of BC)• Data from a Province-wide environmental scan, initiated by the

Provincial Suicide Clinical Framework Steering Committee, eliciting service provider input (including direct care providers, physicians, managers and directors)

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Tools

How do users take this large literature review and apply it to a specific service within MH&A?

1. Environmental Scan Tool

2. Decision Support Matrices

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Decision Support Matrices

Decision Support Matrices summarize the best or most promising practice assessment tools and treatment options across different populations.

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Decision Support Matrix ExampleBrief Assessment

Children Adolescents Adults Geriatric

Urgent/Emergency Child Hopelessness Scale

Beck Hopelessness ScaleRisk of Suicide Questionnaire Beck Suicide Intent Scale

Beck Hopelessness ScaleScale for Suicide Ideation Beck Suicide Intent Scale** Linehan Reasons for Living Inventory++

None identified

Inpatient/Day Hamilton Rating Scale for Depression (Suicide Item)#Geriatric Suicidal Ideation Scale

Tertiary Care

Outpatient/ Community

Child Suicide Potential Scales

Hopelessness Scale for Children

Beck Hopelessness Scale Hopelessness Scale for ChildrenIS PATH WARM

Scale for Suicide Ideation

IS PATH WARM

SAD PERSONS

Zung Depression Scale Geriatric Suicidal Ideation ScaleSAD PERSONS

Withdrawal Management

None identified IS PATH WARM Beck Hopelessness Scale

IS PATH WARM

None identified

Residential Programs

None identified Suicide Probability ScaleIS PATH WARM

Scale for Suicide Ideation

Geriatric Suicidal Ideation Scale

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Implementation Tools

An Action Roadmap was developed, in consultation with experts in change management.

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Assessment

Treatment

Monitoring

Transfer/ Continuity

of Care

Policy/ Procedure

Referral, assigned

duties, patient movement,

documentation observation

Tool/Clinical Assessment

Selection

Treatment Protocol

Development

Educate Tool Training Psychology

Psychiatry Nursing

Allied Health Care

Educate/ Communicate

Policy/Procedure

Educate Treatment Protocol Training

PsychologyPsychiatry

NursingAllied Health

Care Administrative

LeadsClinical Leads

Implementing Change

Support & Maintain Change

EvaluateEducation

CommunicateImplementation

EvaluateChart Audit

CommunicateROP Awareness

Continuous Quality

Improvement

Preparing for Change

Action Roadmap

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Evaluation Tool

An Evaluation Framework was developed, based on an extensive literature review of similar initiatives in like jurisdictions

The Evaluation Framework also provides a logic model for tracking and measuring expected short and long term outcomes.

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Logic Model – Project Goal Identify safety risks inherent in client population

Project ObjectivesInputs(resources/ budget lines)

Activities(activities, tasks, strategies)

Outputs(deliverables)

Short-Term Outcomes

Long-Term Outcomes

To assess each client for risk of suicide at regular intervals, or as needs change

To identify clients at risk of suicide

To address clients' immediate safety needs

To identify treatment and monitoring strategies to ensure client safety

To document treatment and monitoring strategies in client's health record

Planning staff resources: executive leadership, project leader, quality analyst, communications, change management & learning and development representatives, sub-committee leads/experts & members, administrative support

Implementation staff resources: Planning staff, plus all direct care staff time

Material resources: assessment tools

Development and implementation of a suicide risk management protocol for each site/population

Communication initiative developed and implemented

# of sites with developed and implemented protocols

% of clients assessed for risk of suicide at intake

% of clients assessed for risk at regular intervals, or as needs change

% of clients with appropriate documentations of treatment strategies

% of clients with appropriate documentations of monitoring strategies

Improved clinical consistency in suicide risk assessmentImproved clinical consistency in suicide treatment strategies.Improved consistency of suicide monitoring strategiesImproved consistency in documentation practices related to suicide risk management.

Reduction of suicide/self-harm-related safety events within BCMHAS

Logic Model – Education GoalProvide staff with the appropriate training to meet project objectives

Education Objectives

Inputs(resources/ budget lines)

Activities(activities, tasks, strategies)

Outputs(deliverables)

Short-Term Outcomes

Long-Term Outcomes

To increase knowledge related to suicide risk management

To increase skills related to suicide risk management

To increase confidence related to suicide risk management

To demonstrate satisfaction with suicide risk management training

Planning: Learning & development staff timeImplementation: L&D staff plus all direct care staff time

Education initiative developed and implemented

# of education sessions

% of direct care staff trained

Increased knowledge related to suicide assessment, treatment and monitoring

Increased skills related to suicide assessment, treatment and monitoring

Increased confidence to assess, treat & monitor suicide risk

Satisfaction with training related to suicide risk management

Reduction of suicide/self-harm-related safety events within BCMHAS

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Thank you!

Contact

Dr. Tristin Wayte

twayte@bcmhs.bc.ca