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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.
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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?
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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.
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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
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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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