Zero Suicide Pathway. Suicide Prevention Strategy The Gold Coast Mental Health and Specialist Service

Transcription

1 The Gold Coast Mental Health and Specialist Service Suicide Prevention Strategy Zero Suicide Pathway Dr Kathryn Turner Clinical Director GCMHSS Matt Welch CNC PM Conf July 2017 V1 template 1

2 Attempt and Loss survivors are active participants in the guidance of suicide care. Identify Systematically identify and assess suicide risk among people receiving care. Engage Ensure every individual has a pathway to care that is both timely and adequate to meet his or her needs. Include collaborative safety planning and restriction of lethal means. Treat Use effective, evidence-based treatments that directly target suicidal thoughts and behaviors. Transition Provide continuous contact and support, especially after acute care.

3 Suicide Prevention Pathway Commencement Criteria: 1. Presents with recent Suicide Attempt 2. Past History of Suicide Attempt and presents with Suicidality 3. At Clinicians Discretion

4 Mandatory Components The Suicide Prevention Pathway Definition Screening Identifies the best way we can engage our consumers and detect suicide risk. Assessment Risk Formulation Initial Intervention Identifies techniques and approaches that will enhance the identification of suicide risk. Synthesis the suicide risk information and articulates a consumers immediate distress and resources at a specific time and place. Safety Planning Counselling on Access to Lethal Means Brief Patient & Carer Education Rapid Referral Structured Follow Up Transition of care Identifies components of follow up which aims to address drivers of suicidality, resolve crisis and identify resolution Identifies a process for the safe transition of care between service providers. Suicide Prevention Pathway GCMHSS KT,MW,2016

5 Staff Resource: Snapshot of the Suicide Prevention Pathway Step 1 Getting on the Pathway : a perosn can only be placed on the pathway following a face to face assessment and meets one or more of the following : Anyone who presents with or is revealed to have had a recent suicide attempt A perosn with a history of suicide attempt and now presenting in an acute state / crisis for assessment / treatment. Suicidal Ideation identified at face to face assessment (Note: In some circumstances, following comprehensive assessment including collateral, and consultation with a senior colleague, consumers in this group may not require a further face to face appointment, however should receive the Initial Interventions, good handover of information to the next service, and should be seen by the next service (e.g.. Private Psychiatrist, GP, Psychologist) prior to formal discharge from our service. A clinician may place someone on the Pathway at their own discretion Step 2 Assessment of Suicide Risk (CASE Method) Remember: Identify Intent: stated intent - Reflected Intent and Withheld Intent. Utilise CASE Structure: 1. Presenting suicide events over the last 48hrs Remember to utilise CASE Questioning Techniques: page 2. Recent suicide events the 2 months leading up to the suicide event 39 in your manual 3. Past suicide events prior to the 2 months leading up to the event (past Hx) 4. Immediate suicide events What do they feel now following the assessment / attempt Step 3 Completing Your Risk Formulation: Use this structure Instead of rating risk as L, M, H. Use this process to identify, treatment modality, and risk management. (see overleaf for examples of how to document your formulation) Identify Risk status static, enduring factors, past suicidal behaviour, substance use, strengths and protective factors relative to others in a stated population (general, community MH, inpatient higher than, lower than, similar to) Identify Risk State dynamic factors, relative to consumer s baseline risk, recent stressors, sx, changes, engagement and alliance, recent suicidal behaviour (compared to baseline, higher than, lower than, similar to) Identify Available Resources Supports, internal and social strengths Document formulation on under Clinical and Risk Formulation /assessment summary. Do not tick risk as L,M,H Identify Foreseeable Changes that could quickly increase/decrease risk stat and write see formulation below'. in the box Step 4: Before following up in the Community: Complete Safety Plan involve consumer, family, carers. check demographics, Scan the safety plan into CIMHA as attachment to Progress Provide counselling on access to lethal means Note. Enter in Alerts section under tab Other Special Mental Health, add date of safety plan. Provide everyone involved a copy of the safety plan. Rapid Referral before consumer leaves, ensure appointment with specific time, place and person/team within 24 48hrs. Document on back of Safety Plan Step 5 The first follow up appt: Ideally there should be a Face to face review within 24-48hrs and includes: MSE& Risk assessment Review and revise safety plan Create/update MH Care Plan. Use SBAR to document : Ensure communication with carers, family and other health professionals Identify likely ongoing service providers and initiate referral processes to expedite transition when indicated Agree plan and organise next appointment Document steps on progress note in SBAR format Step 6 Discharging off the Pathway & Transition Once the suicide pathway elements have been successfully enacted and transition processes have occurred then only an MDT decision can remove the consumer from the pathway. and address: The suicide precipitants have been addressed to the point where they are no longer influence suicide thoughts There is clear evidence of resolution to the problems driving the suicidality There is an improvement in mental state that is sustained and collaborated by consumer, family and or carers. All consumers on the pathway will receive a an appt with the ongoing service provider prior to discharge. Written handover should be sent to the new service provider a few days prior to first appointment which should occur prior to consumer s discharge from the service. A final face to face appointment, together with further collateral from carer/family prior to discharge Transition Resource/Literature Packs to be provided to consumers and carers on discharge and during transitions of care. Refer to Your Manual for more detailed information Staff Resource: Suicide Prevention Pathway Snapshot of Structured Follow Up Documentation using SBAR This is an example of how to document the suicide prevention pathway structured follow up using the SBAR format, taken from the SPP training scenario. 1. Situation: Example: Suicide prevention pathway, 1st review 1000hrs Scheduled appt. presents with brother 2. Background: Example: Brought into ED on Sunday 09/11/16. Expressing suicide ideation and plan (jumping in front of train), in context of recent relationship break up and loss of job. Hx of dep/self-harm (cutting/burning) Trauma hx parents died when pt 14yrs in car accident Nil formal tx to date, Nil psychiatric admissions, Hx of suicide ideation. 3. Assessment: check mood and mental state and risk assessment Since last review, Mood remained depressed and anxious at times, expresses distress re reduced contact with children Ruminating re lack of employment and finances, Nil self-harm or suicide ideation Remains residing with brother ADD MSE 4. Review the Safety plan - Did they use the plan, what worked well what needs to be changed, what was effective. Update and develop a new plan if required Check Means restriction actions are still in place: - Example: brother states removed access to ETOH and resides with brother (not near train station) 5. Develop a CARE PLAN Identify issues driving the persons suicidality and strategies to address these issues. Aim to address the top 2 or 3 issues driving the perosn suicidality. If you cannot come up with strategies discuss with a colleague for ideas. Identify the key Issue driving suicidality : Example: - Relationship break up grief and loss Identify the Goal: Example: Psychological support leading to acceptance and recovery: build resilience and strength Identify Strategies to address the issues: Example provide psycho education on grief and loss, (Kubler Ross), contact arrangements with EX, resilience and internal strength developing exercises. Identify roles and responsibilities for each action: Example Patient will do this and clinician will do that.. Identify likely ongoing service providers: Example if a psychologist is required then commence the process of referral now to GP etc. Identify a Timeframe: Example within 3 days 6. Communication & Engagement Ensure all plans are discussed with supports and involve family/carers Example: Discussed plan with brother, CM to make contact with GP today 7. Other Agencies: ensure details of other agencies are correct and update on the safety plan Example: GP - Dr John Smith contact details Southport medical centre ph , Family Mediation Ashmore mediation services ph , Centre link Labrador ph Plan 1. Next appointment: Example: Medical appointment confirmed for weds 12/11/16 review care plan 2. Confirmed current phone contact numbers and address 3. Care plan copy provided to Bryce and brother 4. Bryce and brother have 24hr contact numbers Refer to your SPP Manual for more information page 117 GCMHSS SPP, Staff Support resources MW,KT,SW V2 22/12/2016 GCMHSS SPP, Staff Support resources MW,KT V4 22/12/2016

6

7

8 Assessment Shea, 2009 Source: SRAM-ED Modules, Qld Centre for Mental Health Learning

9 How to get beyond Stated Intent Real Intent Stated Intent Reflected Intent Withheld Intent Shawn Shea: Chronological Assessment of Suicide Events ( CASE Approach ) Enhanced Training

10 Assessment Shea, 2009 Source: SRAM-ED Modules, Qld Centre for Mental Health Learning

11 Pisani et al Formulation model

12 Risk Formulation using a Narrative Format: Enhanced Training 42y male with history of intermittent self-harm, suicide ideation and depression. Self-managed, denies any past or current formal professional treatment. Raised by grandparents. Grandfather passed away 2 years ago, anniversary in 3 weeks. Presented to ED with ex-partner, expressing suicide ideation in the context of recent relationship break up and loss of employment. Risk status is higher than general population (hx of selfharm, hx of trauma), similar to other depressed patients in the outpatient clinic (hx of depressed mood, hx of self-harm, hx of suicide ideation ) and lower than patients typically admitted (not psychotic, not intoxicated, co-operating with plan). Risk state is higher than base line, due to; recent loss of job, separation from family, increased suicide ideation, increased use of ETOH, self-harm and recent abuse of seroqual (obtained from housemate). Immediate available resources are his grandmother and brother. Foreseeable changes are increased suicide risk if less contact with children (court case pending), potential conflict with ex-partner and anniversary of grandfather s death in 3 weeks. Contingency plans have been made to mitigate foreseeable changes (see safety plan). Has engaged well with assessment process and good therapeutic alliance formed. At the time of interview, expresses ambivalence about desire for suicide and brother has agreed to care for him over the next few days. Is willing to engage in outpatient assessment and psychological treatment. F/U appt made for with ACT team at Ashmore outpatient mental health. Patient placed on suicide prevention pathway. Risk Formulation using a Headings Style Format: Bryce risk status: Higher than General Population (Hx of trauma, hx of self harm) Similar to outpatient mental health patients (hx of depression, hx of suicide ideation, hx of self-harm) Lower than inpatient population (nil psychosis, nil intoxication, nil hx of suicide attempts, co-operating with plan, good TA) Hx of self-harm cutting burning since adolescent Hx of suicide ideation Hx of depression (nil formal treatment received) Hx of Trauma - lost parents aged 14yrs in car accident Bryce risk state: Higher than baseline state Current suicide ideation with plan Loss of job Break up of relationship Reduced contact with chn Temporary accommodation Increased ETOH abuse Abuse of seroqual (obtained from friend) Bryce available resources: Children protective factor but not immediate resources Grandmother supportive relationship lives in NSW but speaks on phone often Brother lives locally and strong supportive relationship Wants to engage in treatment planning Resilience as evident by dealing with challenging situations in the past without professional help. Foreseeable changes: Court case and loss of contact with chn (increase) Conflict with ex-partner (Increase) Grandfather s anniversary of death (increase) Court case and access to chn (decrease) Family mediation conflict resolution with ex-partner (decrease) Employment opportunities (decrease) Plan: Safety plan completed (see attached) Copy provided to Bryce and brother (John) Contact numbers confirmed and verified during ax Counselling on access to lethal means completed Carer support package provided to brother Engaged well with assessment process Good alliance formed Brother agrees to take Bryce home with him tonight and agrees to b supportive person Brother does not reside near train station Follow up appt booked for 1000 hrs with ACT at Ashmo Patient placed on suicide prevention pathway

13

14

15

16

17 Previous training to 256 staff medical and community staff; Expanded to all staff intensive training over past month. Need for increased focus on inpatient units in terms of pathway all inpatient units now trained. (184 staff in past month)

18

19 Follow up and Transitions Structured Follow Up increased focus on Care Plan development. Transitions of Care NGO transition is just commencing. Well received Education session with over 100 Private practitioners (Psychiatrists, Psychologists, Social Workers, etc) on the Gold Coast to familiarize them with the Zero Suicide Framework, and our Pathway.

20 Two Month Data Comparison, March and April 2015 and 2017 (Process and Outcomes) Data only from EDIS (Emergency Department Presentations) subset of total data Other entry points for the SPP: Community MH services ACTT CCT HHOT Data only from those presenting with a suicide attempt Other criteria for referral to the SPP

21 Demographic Data March and April, 2015 March and April, 2017 Number of Clients in Database Age range Min Age range Max Mean Age Std Dev Age Men Women %Men %Women Number of clients on SPP 0 95 Number of clients not on SPP 0 72 % Clients on SPP

22 2017 On SPP 2015% 2017 On SPP % Questions 2015 What is the proportion of consumers who received a suicide screening or assessment during Received the reporting period? Screening No screening Was risk stratified in the 2015 data (was it divided into low, medium or high risk)? Not stratified Stratified Low Medium High

23 On SPP 2015% 2017 On SPP % What is the proportion of consumers with any safety plan developed during the reporting period? Yes No Partial Was access to lethal means addressed? (Were consumers who were assessed positive for suicide risk counselled about lethal means?) Yes No

24 Future Continue working towards goal of high reliability healthcare increase fidelity to the pathway. Addressing issue of Inpatient pathway. Issue of specific interventions for subpopulations (eg. Borderline Personality Disorder patients)