Standard 5: Comprehensive Care

Predicting, preventing and managing self-harm and suicide

Action 5.31

The health service organisation has systems to support collaboration with patients, carers and families to:

a. Identify when a patient is at risk of self-harm

b. Identify when a patient is at risk of suicide

c. Safely and effectively respond to patients who are distressed, have thoughts of self-harm or suicide, or have self-harmed

Intent

The workforce has the skills and knowledge to engage collaboratively to identify and respond to patients at risk of self-harm or suicide.

Reflective questions

What processes are in place to ensure that the workforce can work collaboratively to identify patients at risk of self-harm or suicide?

How does the health service organisation ensure that clinicians know how to respond safely and effectively to patients who are distressed, have thoughts of self-harm or suicide, or have self-harmed?

How do members of the workforce gain access to specialist mental health expertise to provide care to patients who have thoughts of self-harm or suicide, or have self-harmed?

Key tasks

  • Implement screening for thoughts of self-harm or suicide for people who present with self-harm, mental illness or acute emotional distress.

  • Set up a tiered system for response according to the level of risk.

  • Ensure that the environment is safe.

  • Maintain a recovery-oriented approach throughout engagement.

Strategies for improvement

Hospitals

Identify risk of self-harm

When a person presents with self-harm or thoughts of self-harm, their physical safety is often the clinical priority. Triage can be supported by use of a validated tool such as the Mental Health Triage Tool.1

Maintain an empathic, non-judgemental approach while implementing clinical actions. Engage therapeutically with the person to understand what the act or thought of self-harm means for the person. Self-harm can be related to suicidal thoughts, or can be independent of these. The person may or may not be clear about their intent. Some self-harm may be enacted without suicidal ideation, but still present a risk to the person’s life. Always consider self-harm seriously.

Processes of respectful and effective therapeutic engagement create safety for people who have thoughts of self-harm or suicide. Avoid making presumptions about the person’s intent, including whether the person’s self-harm does or does not indicate suicidal thoughts or is ‘attention-seeking’. Communicate with the person, their carers and family, and other clinicians in non-judgemental language.

The Royal Australian and New Zealand College of Psychiatrists endorses the national guidelines developed in the United Kingdom by the National Institute for Health and Care Excellence on the clinical management of self-harm.2

Some people have recurrent episodes of self-harm, including people who have been diagnosed with borderline personality disorder. Members of the workforce may experience conflicting feelings about treating people for recurrent self-harm. Clinical guidelines have been developed to support health service organisations.3

Identify risk of suicide

When a person presents with suicidal thoughts, or has attempted suicide, their immediate physical safety is a priority. Use the environment, formal observation, and engagement with the person and any accompanying support people to ensure that the person remains safe until comprehensive assessment is conducted and a collaborative care plan is initiated. Steps taken to implement this action align with the Clinical Governance Standard, the Partnering with Consumers Standard, and the Recognising and Responding to Acute Deterioration Standard.

Ensure that the organisation has a system in place for frontline members of the workforce to gain access to specialist mental health expertise to assess and manage a person with suicidal thoughts. This process should be developed locally, and reflect available resources and partnership agreements. Ensure that members of the workforce are aware of the local process and how to escalate care. Review the effectiveness of the local process regularly, and in response to critical incidents.

Ensure implementation of national, state or territory, or local policies, such as the NSW Health policy Clinical Care of People Who May Be Suicidal.4

Many people who attempt suicide have contacted a member of the workforce before the attempt. Train all members of the workforce to recognise signs of potential risk for suicide and engage therapeutically to develop trust so that people can discuss these thoughts. People who have been treated after a suicide attempt report that the attitudes of members of the healthcare workforce were an important factor determining whether they would disclose suicidal thoughts in the future.5

For some people, treatment after a suicide attempt may be the first time that the clinical or social stressors leading to the attempt have come to light.

Comprehensive psychosocial assessment may reveal mental illness or substance use conditions that can respond to clinical treatment, or social factors such as domestic violence that increase the risk of suicide. Ensure that the organisation has the capacity to deal with the issues, or has established links with partner organisations.

Adopt a recovery-oriented approach, focused on restoring hope, throughout clinical engagement with a person after a suicide attempt. The specific treatment immediately after a suicide attempt is likely to be a brief episode in the person’s experience. They and their families will be dealing with the long-term effects, and interventions need to:

  • Align with the patient’s and family’s existing skills, values and preferences
  • Identify the supports that may be needed to achieve these
  • Link to these services.

Currently, less than half of the people who have attempted suicide report being involved in treatment decisions.5

Carers and family members often need extra support to cope with a person’s suicide attempt. Provide these services, or arrange for a partner organisation to do so. These supports are also needed for family members if a person has completed suicide. A range of organisations can provide this support, including:

Use tools and resources

Population screening is recommended for certain groups when higher risk has been identified for members of the group who have no previous history of mental illness or self-harm. For instance, women accessing prenatal services are screened using the Edinburgh Postnatal Depression Scale.

The national framework for suicide prevention sets out the roles of health service and other organisations. Called Living is for Everyone, the framework is supported by a regularly updated website. The website also contains a series of fact sheets, which include guidance about suicide prevention strategies and how to implement them.

Reflecting the specific issues facing Aboriginal and Torres Strait Islander Australians, there is also a National Aboriginal and Torres Strait Islander Suicide Prevention Strategy.6 Ensure that members of the workforce are familiar with this strategy, and review processes to ensure that they cover the issues for the local Aboriginal and Torres Strait Islander communities. Support this approach with workforce training in culturally competent care, and the employment of, or partnerships with, experts in Aboriginal and Torres Strait Islander mental health, and social and emotional wellbeing.

Day Procedure Services

Day procedure services conduct pre-admission screening to determine whether it is currently safe to undertake a procedure in this setting.

Members of the workforce may become aware that a person is experiencing thoughts of self-harm or suicide. Day procedure services typically do not have resources on site to conduct comprehensive psychosocial and risk assessments. It is therefore critical that the organisation has referral mechanisms for this information to be provided to the referring clinician and, where possible, to establish links with relevant local agencies that can provide these services.

Make the workforce aware of the local referral processes and how to use them when they have identified a person who is at risk of self-harm or suicide.

Refer to the hospitals tab for detailed implementation strategies for this action.

Examples of evidence

Select only examples currently in use:

  • Policy documents that outline collaborative processes for identifying and treating patients at risk of self-harm or suicide, or who have self-harmed, including pre-admission screening
  • Risk assessment tools for patients at risk of self-harm or suicide
  • Training documents about identifying and treating patients at risk of self-harm or suicide, or who have self-harmed
  • Consumer and carer information packages or resources about strategies for managing self-harm, or risks of self-harm or suicide, and escalation protocols
  • Clinical incident monitoring system that includes information on self-harm and suicide
  • Resources for the workforce to help identify patients who require close monitoring
  • Audit results of healthcare records for identifying carers and engaging them in shared decision making when a person is identified as at risk of self-harm
  • Patient and carer experience surveys, a complaints management system and a consumer participation policy for patients at risk of self-harm or suicide
  • Observation that information about referring patients to specialist mental health services is accessible to clinicians.
MPS & Small Hospitals

Identify risk of self-harm

When a person presents with self-harm or thoughts of self-harm, their physical safety is often the clinical priority. Triage can be supported by use of a validated tool such as the Mental Health Triage Tool.1

Maintain an empathic, non-judgemental approach while implementing clinical actions. Engage therapeutically with the person to understand what the act or thought of self-harm means for the person. Self-harm can be related to suicidal thoughts, or can be independent of these. The person may or may not be clear about their intent. Some self-harm may be enacted without suicidal ideation, but still present a risk to the person’s life. Always consider self-harm seriously.

Processes of respectful and effective therapeutic engagement create safety for people who have thoughts of self-harm or suicide. Avoid making presumptions about the person’s intent, including whether the person’s self-harm does or does not indicate suicidal thoughts or is ‘attention-seeking’. Communicate with the person, their carers and family, and other clinicians in non-judgemental language.

The Royal Australian and New Zealand College of Psychiatrists endorses the national guidelines developed in the United Kingdom by the National Institute for Health and Care Excellence on the clinical management of self-harm.2

Some people have recurrent episodes of self-harm, including people who have been diagnosed with borderline personality disorder. Members of the workforce may experience conflicting feelings about treating people for recurrent self-harm. Clinical guidelines have been developed to support health service organisations.7

Identify risk of suicide

When a person presents with suicidal thoughts, or has attempted suicide, their immediate physical safety is a priority. Use the environment, formal observation, and engagement with the person and any accompanying support people to ensure that the person remains safe until comprehensive assessment is conducted and a collaborative care plan is initiated. Steps taken to implement this action align with the Clinical Governance Standard, the Partnering with Consumers Standard, and the Recognising and Responding to Acute Deterioration Standard.

Ensure that the organisation has a system in place for frontline members of the workforce to gain access to specialist mental health expertise to assess and manage a person with suicidal thoughts. This process should be developed locally, and reflect available resources and partnership agreements. Ensure that members of the workforce are aware of the local process and how to escalate care. Review the effectiveness of the local process regularly, and in response to critical incidents.

Ensure implementation of national, state or territory, or local policies, such as the NSW Health policy Clinical Care of People Who May Be Suicidal.4

Many people who attempt suicide have contacted a member of the workforce before the attempt. Train all members of the workforce to recognise signs of potential risk for suicide and engage therapeutically to develop trust so that people can discuss these thoughts. People who have been treated after a suicide attempt report that the attitudes of members of the healthcare workforce were an important factor determining whether they would disclose suicidal thoughts in the future.5

Stigma following self-harm or a suicide attempt can present particular challenges in a small hospital or MPS because members of the community are often treated in the same setting. In these circumstances, strategies to maintain privacy for the person include using carers or companions rather than security guards.

For some people, treatment after a suicide attempt may be the first time that the clinical or social stressors leading to the attempt have come to light.

Comprehensive psychosocial assessment may reveal mental illness or substance use conditions that can respond to clinical treatment, or social factors such as domestic violence that increase the risk of suicide. Ensure that the organisation has the capacity to deal with the issues, or has established links with partner organisations.

Adopt a recovery-oriented approach, focused on restoring hope, throughout clinical engagement with a person after a suicide attempt. The specific treatment immediately after a suicide attempt is likely to be a brief episode in the person’s experience. They and their families will be dealing with the long-term effects, and interventions need to:

  • Align with the patient’s and family’s existing skills, values and preferences
  • Identify the supports that may be needed to achieve these
  • Link to these services.

Currently, less than half of the people who have attempted suicide report being involved in treatment decisions.5

Carers and family members often need extra support to cope with a person’s suicide attempt. Provide these services, or arrange for a partner organisation to do so. These supports are also needed for family members if a person has completed suicide. Several organisations can provide this support, including:

Use tools and resources

Population screening is recommended for certain groups when higher risk has been identified for members of the group who have no previous history of mental illness or self-harm. For instance, women accessing prenatal services are screened using the Edinburgh Postnatal Depression Scale.

The national framework for suicide prevention sets out the roles of health service and other organisations. Called Living is For Everyone, the framework is supported by a regularly updated website. The website also contains a series of fact sheets, which include guidance about suicide prevention strategies and how to implement them.

Reflecting the specific issues facing Aboriginal and Torres Strait Islander Australians, there is also a National Aboriginal and Torres Strait Islander Suicide Prevention Strategy.6 Ensure that members of the workforce are familiar with this strategy, and review processes to ensure that they cover the issues for the local Aboriginal and Torres Strait Islander communities. Support this approach with workforce training in culturally competent care, and the employment of, or partnerships with, experts in Aboriginal and Torres Strait Islander mental health, and social and emotional wellbeing.

Action 5.32

The health service organisation ensures that follow-up arrangements are developed, communicated and implemented for people who have harmed themselves or reported suicidal thoughts

Intent

Adequate follow-up support is arranged and agreed by the nominated participants for when people who have self-harmed or reported suicidal thoughts leave the health service organisation.

Reflective questions

What procedures and processes are in place to ensure rigorous follow-up for people who have harmed themselves or reported suicidal ideation?

What partnerships have been developed with key agencies when responsibility for follow-up is transferred between agencies?

How does the health service organisation identify gaps in referral processes?

Key tasks

  • Develop a collaborative post-discharge treatment plan involving the person, their carers and family, and key service providers before the person leaves the health service organisation.

  • Communicate this plan verbally and in writing to all people who have a role in implementing the plan.

  • Ensure that plan is implemented.

Strategies for improvement

Hospitals

People who have recently attempted suicide are at increased risk of a subsequent attempt in the days and weeks following discharge from healthcare settings.5 People who have recently started antidepressant medicines are at increased risk of suicide. However, there is considerable variation in follow-up arrangements when people leave a health service organisation after a suicide attempt, with up to 30% of people leaving without any formal arrangements in place.

It is therefore essential that health service organisations ensure adequate follow-up for people who have harmed themselves or reported suicidal ideation. The Living is for Everyone framework underlines that ‘it is critical that the chain not be broken, as levels of risk can change rapidly’.8

Develop the post-discharge treatment plan

Ensure that development of the plan is collaborative and recovery oriented, using the principles of shared decision making outlined in the Partnering with Consumers Standard. Engage the person, their carers and family, and any other person involved in implementing the plan, and give them the opportunity to advise whether actions within the plan are feasible.

Post-discharge care may require cooperation across a number of different health and other service organisations in the community. Ensure that the roles and contact details are available to all key participants. If there is a person coordinating services, or if care is shared between different clinicians and services, include this information in the plan.

Communicate the post-discharge treatment plan

Ensure that communication of the plan is multimodal, using verbal, written and electronic means (where available). Confirm receipt of communication about the plan from key participants before discharge. Conduct all communications in respectful, non-judgemental language.

Implement the post-discharge treatment plan

Confirming implementation of the plan can present a challenge. For specialist mental health services, the rate of post-discharge community care within seven days is a nationally agreed performance indicator9, and follow-up can be confirmed internally within the organisation.

In situations in which clinical accountability is being transferred between services, support this process by establishing partnerships. For instance, when a person is being discharged from a private hospital, and they have an appointment with a private psychiatrist who has seen them in hospital and is sharing care with a general practitioner, processes can be implemented that specify when each clinician is reviewing the person, and how communication is being shared. Negotiate these arrangements such that they do not breach privacy legislation, but also such that privacy cannot be invoked and leave key participants uninformed of critical information.

The National Institute for Health and Care Excellence in the United Kingdom has developed guidelines for the longer-term clinical management of self-harm10 that align with the guidelines for short-term clinical response. These guidelines have been endorsed for use in Australia by the Royal Australian and New Zealand College of Psychiatrists.

Ensure that health service organisations working with recovery-oriented practice balance risk management with people’s stated preferences for care, particularly when a person has recently been identified as at high risk of self-harm or suicide.

Day procedure service

Day procedure services do not generally provide health care for treatment of self-harm or suicidal thoughts. In the rare event that a person discloses thoughts of self-harm or suicide in the day procedure setting, ensure that members of the workforce have access to local processes for notifying the referring doctor or referring the patient to specialist mental health services.

As identified in the endorsed national Living is for Everyone (LIFE) framework, suicide prevention requires a whole-of-community approach. If a workforce member at a day procedure service recognises that a person has thoughts of self-harm or suicide, ensure that follow-up is arranged. Do not assume that someone else or another agency has responsibility for this.

Refer to the hospitals tab for detailed implementation strategies and examples of evidence for this action.

MPS & Small Hospitals

People who have recently attempted suicide are at increased risk of a subsequent attempt in the days and weeks following discharge from healthcare settings.5 People who have recently started antidepressant medicines are at increased risk of suicide. However, there is considerable variation in follow-up arrangements when people leave a health service organisation after a suicide attempt, with up to 30% of people leaving without any formal arrangements in place.

It is therefore essential that health service organisations ensure adequate follow-up for people who have harmed themselves or reported suicidal ideation. The Living is For Everyone framework underlines that ‘it is critical that the chain not be broken, as levels of risk can change rapidly’.8

Develop the post-discharge treatment plan

Ensure that development of the plan is collaborative and recovery oriented, using the principles of shared decision making outlined in the Partnering with Consumers Standard. Engage the person, their carers and family, and any other person involved in implementing the plan, and give them the opportunity to advise whether actions within the plan are feasible.

Post-discharge care may require cooperation across a number of different health and other service organisations in the community. Ensure that the roles and contact details are available to all key participants. If there is a person coordinating services, or if care is shared between different clinicians and services, include this information in the plan.

Communicate the post-discharge treatment plan

Ensure that communication of the plan is multimodal, using verbal, written and electronic means (if available). Confirm receipt of communication about the plan from key participants before discharge. Conduct all communications in respectful, non-judgemental language.

Implement the post-discharge treatment plan

Confirming implementation of the plan can present a challenge. For specialist mental health services, the rate of post-discharge community care within seven days is a nationally agreed performance indicator10, and follow-up can be confirmed internally within the organisation.

In situations in which clinical accountability is being transferred between services, support this process by establishing partnerships. The health service organisation must be sure that, after a person has been treated for suicidal ideation, responsibility for engagement with the person has been effectively transferred. Negotiate these arrangements such that they do not breach privacy legislation, but also such that privacy cannot be invoked and leave key participants uninformed of critical information.

The National Institute for Health and Care Excellence in the United Kingdom has developed guidelines for the longer-term clinical management of self-harm9 that align with the guideline for short-term clinical response. These guidelines have been endorsed for use in Australia by the Royal Australian and New Zealand College of Psychiatrists.

Ensure that health service organisations working with recovery-oriented practice balance risk management with people’s stated preferences for care, especially when a person has recently been identified as at high risk of self-harm or suicide.

Last updated 5th July, 2018 at 10:49pm
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References

Australian Government Department of Health. Mental health triage tool. Canberra: DoH; 2013.

National Institute for Clinical Excellence (UK). Self-harm in over 8s: short-term management and prevention of recurrence. London: NICE; 2004.

National Health and Medical Research Council. Australian clinical practice guidelines. Canberra: NHMRC; 2017 [cited 2017 Mar 22].

NSW Ministry of Health. Clinical care of people who may be suicidal: Policy directive PD2016-007. Sydney: NSW Ministry of Health; 2016.

National Health and Medical Research Council Centre of Research Excellence in Suicide Prevention. Care after a suicide attempt. Sydney: National Mental Health Commission; 2015.

Australian Government Department of Health and Ageing. National Aboriginal and Torres Strait Islander suicide prevention strategy. Canberra: DoHA; 2013.

National Health and Medical Research Council. Clinical practice guideline for the management of borderline personality disorder. Melbourne: NHMRC; 2012.

Australian Government Department of Health and Ageing. Living is for everyone. Fact sheet 12: working together for suicide prevention. Canberra: DoHA; 2007.

National Institute for Clinical Excellence (UK). Self-harm: longer-term management. London: NICE; 2011.

National Mental Health Performance Subcommittee. Fourth national mental health plan: measurement strategy. Canberra: Australian Government Department of Health; 2011.