1. A Comprehensive Approach to Suicide Risk Management in Behavioral Healthcare Settings Paul A. LeBuffe Devereux Center for Resilient Children

2. Suicide & Behavioral Health Providers  Suicidal ideation/behavior is the most common reason for adult psychiatric admissions  15-20% of completers die while in treatment  Of inpatient suicides, 1/3 occur in hospital, 1/3 on pass, 1/3 on AWOL status  High incidence of suicide at admission, near discharge and within the first 3 months post-discharge  Comprise 13% of sentinel events reviewed by JCAHO

3. Consequences of Patient Suicide  Worst possible outcome for the patient  Tragedy for family  Increased risk for family, other patients & staff  Suicide clusters  25% of psychologists; 50% of psychiatrists lose a patient to suicide  Possible career or agency ending event  Possible malpractice exposure  Negative public relations

4. Malpractice  Suicide malpractice is the #1 cause of suits against all mental health practitioners  Few graduate programs in behavioral health disciplines provide explicit training in suicide assessment & management  Duty to protect ensure that resources are used for treatment  Type III error

5. Goals of Suicide Risk Reduction Program (SRRP)  Reduce the incidence of patient suicides & life- threatening attempts  Manage suicidal crises in a way that reduces the risk of a suicide cluster  Protect agency against unnecessary lawsuits  In the event of a suicide - provide assurance to staff that they exceeded the community standard of care

6.  Train all staff in suicide prevention  Train all clinicians in suicide risk assessment  Assess all clients for suicide risk  Develop suicide-specific crisis response plans for each program Four Components of a SRRP

7. Component 1 –Train all Staff in Suicide Prevention  Gatekeeper training model  Endorsed by the Surgeon General  Train all staff  Selected the Question, Persuade, Refer (QPR) Program  Subject of an NIMH-funded randomized clinical trial  Recognized by Joint Commission as a best practice  Received the Negley Award  Developed by Paul Quinnett, QPR Institute, Spokane, WA

8.  60 to 90-minute training  Designed to:  raise awareness  dispel myths & misconceptions  teach warning signs  teach 3 skills to avert suicide  Goal is to have staff escort client to clinician for evaluation Component 1 –Train all Staff in Suicide Prevention

9. Component 1 - Evaluation Results  Many accompanied referrals  Most, but not all of the time, clinicians knew of elevated risk  Clinicians appreciate additional information  Clinicians report that it sensitizes staff  100% of Devereux centers recommended continuing QPR training

10. Component 2 - Train all Clinicians in Suicide Risk Assessment  Utilize the QPR Institute’s QPRT System  Mandated of all clinicians  8 hour training program  Competency based  Post-test of knowledge  Skill demonstration  In the classroom (role plays)  In vivo

11. Results: Component 2 (Cumulative)

12. Component 2 – The QPRT  Structured interview format  Essential components  Assess suicidal thoughts and plans  Assess risk and protective factors  Assess willingness to commit to a safety plan  Outcome – assign a risk level with associated treatment intents  Justify decision  Consult  Document

13. Component 2- Evaluation Results  General Satisfaction – 43% “very valuable”  Advantages  Systematic approach – useful especially with new clinicians  Provides good documentation  Requires justification for risk & monitoring  However, needed revisions and adaptations to Devereux populations and programs  100% recommended continuing with revised QPRT

14. Component 3 - Formally Assess all Clients for Suicide Risk  At admission  At discharge  Prior to leaves/home visits  At significant transitions during treatment  change in risk factors/protective factors  change in placement/caregivers  Documented in core clinical record

15. QPRT Flow Chart Can client participate in a structured interview? Review history, interview caregivers regarding suicide, etc. Are there self- injurious behaviors present? Conduct FBA- Specific function hypothesized/identified? QPRT-P Chart specific function, and level of suicide risk 2 and treat as indicated Default is to treat behavior as suicidal. Chart level of suicide risk 2 and treat as indicated Chart level of suicide risk 2 and treat as indicated Y N Y Y N N Y Y N Are 1 or more of the 3 indicators present? 1 Y AGE Ages 10-18 Age > 18? Age 10-18? Age <10? Y QPRT

16. Malpractice Issues and Errors Type 1 Error: Failure to detect risk. Type 2 Error: Substandard care or treatment Type 3 Error: Postvention failure

17. Component 4 - Crisis Response Plans  Procedural document that details staff responsibilities in the event of a completed suicide or a life threatening attempt  Rationale  Importance of an “affectively calm” environment  Reduce risk of suicide clusters  Help staff, clients and families cope  Avoid unnecessary litigation

18. Component 4 - Crisis Response Plans  Content  First responder duties  Safety of clients  Needs of unit  Needs of staff  Needs of families  Reporting and documentation requirements  Management of outside contacts  QI and periodic review  Staff must be trained!

19. Evaluation Results Feedback  88% expressed one or more positive statements about the SRRP  Only 37% expressed one or more concerns

20. Evaluation Results  QPR  Clinicians welcome staff monitoring patien  Clinicians welcome staff monitoring patients  High compliance rates  QPRT  Established an attainable, universal “basal level” of suicide risk assessment  Quality and completeness must be monitored  Needed significant modifications (now available from QPR Institute)  Crisis response plans  Have been very effective in crisis management  But staff must be trained

21. Evaluation Results - Concerns   Does not include environmental safety   Training is time consuming – challenges with taking staff out of ratio for training   Challenges with independent contractors   Program fidelity and maintenance   Major risk events monitoring   Peer review   Quality site visits   Needs adaptation for individuals with mental retardation and young children

22. Outcomes and Benefits   QPR heightened staff awareness and increased confidence   QPRT has helped identify clients at risk   Client with autism   Dispelled myths about individuals with MR   Established standard of care   Crisis response plans improved staff response

23. Outcomes and Benefits   Effects on suicide rate.   Had a low base rate to begin with   Significant reduction in completed suicides   Significant reduction in life-threatening attempts   Helped avert at least 5 staff suicides

24. To Reach Me:  Paul LeBuffe: plebuffe@Devereux.org 610-542-3090 plebuffe@Devereux.org Devereux Center for Resilient Children 444 Devereux Drive Villanova, PA 19085