Suicide Risk Assessment and Management Protocols

1 Framework for Suicide RiskAssessment and Management for NSW Health StaffNSW DEPARTMENT OF HEALTH73 Miller StreetNORTH SYDNEY NSW 2060 Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgementof the source. It may not be reproduced for commercial usage or for purposes other than those indicated above requires written permission from the NSW Department of Health. NSW Department of Health 2004 SHPN (MH) 040184 ISBN 0 7347 3721 1 For further copies of this document please contact:Better Health Centre Publications WarehouseLocked Mail Bag 5003 Gladesville NSW 2111 Tel. (02) 9816 0452 Fax. (02) 9816 0492 Further copies of the Framework for Suicide Risk Assessment and Management for NSW Health Staffcan be downloaded from the: NSW Health website: : 2004 ContentsNSW HealthFramework for Suicide Risk Assessment and Management for NSW Health StaffiExecutive summary.

2 For Suicide Risk Assessment and Management for NSW Health role of NSW Health clinicians ..4 Requirements for all Area Health Services ..6 Components of a comprehensive Suicide risk Assessment ..7 Engagement .. Suicide Risk Management ..10 Mental Health Assessment ..11 Assessment of Suicide Risk ..12 Corroborative Suicide Risk of Suicide Risk ..21Re- Assessment of Suicide Risk ..26 Discharge ..27 Appendix 1: Special needs groups ..28 Glossary ..31 References ..34 FiguresFigure 1: Framework for Suicide Risk Assessment and Management for NSW Health staff ..5 Figure 2: Assessment of Suicide risk (screening questions)..9 TablesTable 1: Examples of demographic, group andpersonal risk factors for dying from Risk Assessment Guide ..20 Table 2: Interventions to reduce Suicide documentsSuicide Risk Assessment and Management : Emergency Department SHPN (MH) 040186 Suicide Risk Assessment and Management Protocols : General Hospital Ward SHPN (MH) 040185 Suicide Risk Assessment and Management Protocols : General Community Health Service SHPN (MH) 040187 Suicide Risk Assessment and Management Protocols : Community Mental Health Service SHPN (MH) 040182 Suicide Risk Assessment and Management Protocols : Mental Health In-Patient Unit SHPN (MH) 040183 Suicide Risk Assessment and Management Protocols .

3 Justice Health Long Bay Hospital SHPN (MH) 040188 Framework for Suicide Risk Assessment and Management for NSW Health StaffPreliminary SuicideRisk AssessmentEngagementDetectionImmediate ManagementMental HealthAssessmentAssessment ofSuicide RiskCorroborative HistoryDetermining SuicideRisk LevelManagement ofSuicide RiskRe- Assessment ofSuicide RiskDischargeFramework for Suicide Risk Assessment and Management for NSW Health StaffNSW HealthiiExecutive summaryThe Framework for Suicide Risk Assessment andManagement for NSW Health Staffis a key componentof the NSW Health Circular, Policy guidelines for themanagement of patients with possible suicidalbehaviour for NSW Health staff and staff in privatehospital facilities1and is relevant to all health provides detailed information on conducting suiciderisk assessments and specific information on the rolesand responsibilities of generalist and mental healthservices to guide the Suicide risk Assessment andmanagement framework has been developed to link with theNSW Health Mental Health Outcomes and AssessmentTools (MH-OAT) comprehensive mental healthassessment and Management Protocols (only applicableto mental health services).

4 It is also linked to the NSWH ealth Discharge and Follow Up Protocols for NSWM ental Health Services and Postvention guidelinessurrounding a Suicide death for NSW Health staff andstaff in private hospital with possible suicidal behaviour must receivepreliminary Suicide risk Assessment and, whereappropriate, a referral for a comprehensive mentalhealth Assessment including a detailed Suicide riskassessment. The goal of a Suicide risk Assessment is todetermine the level of Suicide risk at a given time andto provide the appropriate clinical care and is a continuing process occurring along apathway of care from the person s first presentation toahealth service, through to the provision of treatmentleading to Assessment and Management of Suicide risk isconducted within a collaborative partnership betweenthe relevant health services, the person at risk of suicideand their risk Assessment generates a clinician ratingof the risk that the person will attempt Suicide in theimmediate period.

5 The person s Suicide risk in theimmediate to short-term period can be assigned to oneof the four broad risk categories: high risk, medium risk,low risk, no (foreseeable) risk. The level of changeabilityof the person and the confidence of the clinician in theassessment rating are also taken into are circumstances where generalist health staffand services will conduct comprehensive Suicide riskassessments and be responsible for the ongoingmanagement of people at risk of Suicide . These servicesmay include Sexual Assault, Sexual Health, Drug andAlcohol and Generalist Counselling services. The typeand level of services provided will depend on the skilland competency of the health worker. NO (FORESEEABLE) RISKF ollowing comprehensive Suicide risk assessmentthere is no evidence of current risk to the are no thoughts of Suicide or history of attempts and they have a good social support RISKD efinite but low Suicide risk.

6 The clinician considersa person at this level of risk requires review atleast monthly. The timeframe for review shouldbe determined based on clinical judgment. Afterdischarge from an in-patient unit, the review isto be conducted within one week. The personat risk should be provided with written informationon 24-hour access to suitable clinical risks ignificant but moderate risk of Suicide . The clinician ensures that a person at this levelof risk receives a re- Assessment within one weekand contingency plans are in place for rapid re- Assessment if distress or symptoms RISK or HIGH CHANGEABILITY and/orLOW Assessment CONFIDENCEThe clinician ensures that the person is in anappropriately safe and secure environment. Theclinician organises re- Assessment within 24 hours,and ongoing Management and close monitoring areindicated. Contingency plans are in place for rapidre- Assessment if distress or symptoms HealthFramework for Suicide Risk Assessment and Management for NSW Health Staff1 Framework for Suicide Risk Assessment and Management for NSW Health StaffNSW Health2 ChangeabilityChangeability of risk status, especially in the immediateperiod, should be assessed and high changeabilityshould be identified.

7 When high changeability isidentified the clinician recognises the need for careful re- Assessment and gives consideration as to when the re- Assessment should occur, eg within 24 vigilant Management is adopted with respect to the safety of the person in the light of the identifiedrisk of high confidenceThe clinician should consider the confidence he/she has in this risk Assessment . A number of factors mayindicate low Assessment confidence: factors in the person at risk, such as impulsivity,likelihood of drug or alcohol abuse, presentintoxication, inability to engage factors in the social environment, such as impendingcourt case, divorce with child custody dispute factors in the clinician s Assessment , such asincomplete Assessment , inability to obtain collateral there is low Assessment confidence the clinicianrecognises the need for careful consideration of whenre- Assessment should occur, eg within 24 hours.

8 A more vigilant Management is adopted with respect to safety of the person in the light of the gaps ininformation or Framework for Suicide Risk Assessment andManagement for NSW Health Staffoutlines acomprehensive framework to guide the Suicide riskassessment and Management process. The frameworkcontains the standards of practice that must beimplemented in key treatment settings throughout allhealth services. This framework includes specificprotocols that describe the responsibilities andrequirements for health professionals in the generalisthealth and specialist mental health settings in the Assessment and Management of Suicide risk. Specific Protocols have been developed for the following settings or groups: Emergency Department General Hospital Ward General Community Health Service Community Mental Health Service Mental Health In-Patient Unit Justice Health Service Long Bay framework was developed following an extensivereview of the literature and consultation with recognisedexperts in the field.

9 It represents the essentialcomponents for best practice in the Assessment andmanagement of Suicide risk. The framework aims to assist clinicians to: cover specific components of Assessment of Suicide risk adopt a reflective practice style in which clinicians are encouraged to consider the quality of the Assessment in relation to: the likelihood of the person s Suicide riskchanging in the next 24 hours the clinician s Assessment of the quality of the alliance with the person the clinician s confidence that he/she has all the required information consider the most appropriate Management plangiven the current level of Suicide risk assessed plan when to review the Suicide risk with the summaryIntroductionSuicide prevention is the concern of all health workersand the whole community. Health workers play a keyrole in early detection and intervention with people who are at risk of behaviour is complex and despite the bestavailable expertise and exemplary care, some individualswill go on to Suicide .

10 There is no current rating scale or clinical algorithm that has proven predictive value in the clinical Assessment of , 4, 5A thoroughassessment of the individual remains the only validmethod of determining risk. Assessments are based on a combination of the background conditions and thecurrent factors in a person s life and the way in whichthey are interacting. The aim of this document is toassist health staff to make informed judgments aboutrisk by providing a framework and information ongood Management is central to effective managementof a person at risk of Suicide . In particular, transitionsin care can be highly vulnerable periods in themanagement of a person at risk. Clear, concisedocumentation of assessments, including observationsand clinical decisions, is the most helpful process toassist in good team Management . Where a clinicianremains uncertain after a clinical Assessment , it isimportant to consult with a senior Framework for Suicide Risk Assessment andManagement for NSW Health Staff outlines acomprehensive framework to guide the Suicide riskassessment and Management process.