Using a Single-item Rating Scale as a Psychiatric Behavioral Management Triage Tool in the Emergency Department

A Systematic Review of Violence Risk Assessment Tools Currently Used in Emergency Care Settings

INTRODUCTION

Violence risk assessment is commonplace in mental health settings and is gradually being used in emergency care. The aim of this review was to explore the efficacy of undertaking violence risk assessment in reducing patient violence and to identify which tool(s), if any, are best placed to do so.

METHODS

CINAHL, Embase, Medline, and Web of Science database searches were supplemented with a search of Google Scholar. Risk of bias assessments were made for intervention studies, and the quality of tool development/testing studies was assessed against scale development criteria. Narrative synthesis was undertaken.

RESULTS

Eight studies were included. Three existing violence risk assessment tools featured across the studies, all of which were developed for use with mental health patients. Three newly developed tools were developed for emergency care, and 1 additional tool was an adaptation of an extant tool. Where tested, the tools demonstrated that they were able to predict patient violence, but did not reduce restraint use. The quality issues of the studies are a significant limitation and highlight the need for additional research in this area.

DISCUSSION

There is a paucity of high-quality evidence evaluating the psychometric properties of violence risk assessment tools currently used along the emergency care pathway. Multiple tools exist, and they could have a role in reducing violence in emergency care. However, the limited testing of their psychometric properties, acceptability, feasibility, and usability in emergency care means that it is not possible to favor one tool over another until further research is conducted.

A Quality Improvement Project on Agitation Management in the Emergency Department

INTRODUCTION

Agitation is common in the emergency department. When agitation is not detected early, patients can become aggressive and violent, potentially leading to restraint use and subsequent injury. The goals of the project were early detection and management of patient agitation, reduction of restraint use in the emergency department, and determination of the usability of the Behavioral Activity Rating Scale.

METHODS

This quality improvement project was assessed using a pre- and posttest single unit design, comparing 4 months of postimplementation data to historic controls at the same time of year in the previous year. The intervention was implementing the Behavioral Activity Rating Scale in the ED electronic medical record. Data were collected through retrospective chart review and nurse survey. From September through December of both 2017 and 2018, data were collected on restraint use. The 4-month 2018 data collection period included measures of Behavioral Activity Rating Scale documentation and the System Usability Scale survey for nurses to measure ease of usability of the Behavioral Activity Rating Scale.

RESULTS

The Behavioral Activity Rating Scale was documented frequently (n = 4 867 documentations) by emergency nurses to assess patients with behavioral health and medical complaints (n = 780). Nurses identified 18 episodes of violent behavior in behavioral health patients on the Behavioral Activity Rating Scale (2.31%) and applied restraints 18 times. The most common chief complaints for patients who were identified as violent was suicidal ideation (n = 6; 33.33%). In 2017, there were 20 episodes of restraint use during the same time period, a nonsignificant difference (χ² = 0.72; P = 0.40). However, only 2 patients were kept in restraints longer than 1 day in 2018 compared with 8 in 2017. Emergency nurses found the Behavioral Activity Rating Scale to be usable in the structured usability assessment (μ = 83.46; SD = 11.73).

DISCUSSION

The Behavioral Activity Rating Scale is a usable tool for emergency nurses to assess for patient agitation. With the incorporation of agitation management interventions, the ED team can potentially manage agitation before violence occurs. Further studies are needed on the use of agitation or aggression assessment tools for managing patient behavioral activity such as aggression in the emergency department.

Use of Intramuscular Chlorpromazine Versus Intramuscular Olanzapine for the Management of Acute Agitation and Aggression in Youth

OBJECTIVES

In the inpatient psychiatric setting, one treatment strategy used to manage acute agitation in youth includes administration of IM antipsychotics. The aim of this study was to compare the effectiveness and safety of IM chlorpromazine versus IM olanzapine in treating aggression in youth.

METHODS

We conducted a retrospective chart review of patients younger than 18 years hospitalized in the inpatient psychiatric unit who received either IM chlorpromazine or IM olanzapine for acute agitation. Demographic, efficacy, and tolerability data were collected using the electronic health record EPIC. The primary outcome was change from baseline to end point in the Behavioral Activity Rating Scale (BARS) score. BARS was applied retrospectively using nursing and physician documentation to evaluate for clinical response.

RESULTS

Among 145 patients who met the inclusion criteria, 72 received IM chlorpromazine, compared with 73 who received IM olanzapine. The mean change in BARS score (before and after IM antipsychotic) was greater with olanzapine (3.58 ± 0.99) than with chlorpromazine (3.07 ± 1.18, p = 0.006). The target BARS score of 4 was achieved more frequently with chlorpromazine (45.8%) than with olanzapine (24.7%, p < 0.008). Coadministration of IM diphenhydramine occurred significantly more often in the olanzapine group than in the chlorpromazine group (71.2% vs 36.1%, p < 0.001).

CONCLUSIONS

Management of acute agitation with IM olanzapine resulted in a greater change in BARS score, despite more youth requiring coadministration with diphenhydramine. In comparison, IM chlorpromazine demonstrated a higher likelihood of returning patients to baseline. Study results suggest tolerability of IM chlorpromazine and olanzapine.

A Review of Various Methods of Management of Risk in the Field of Emergency Medicine

BACKGROUND:

The main concept of risk management in the emergency department (ED) contains a broader meaning, so that; it’s known as a sudden event or situation which would happen at an uncertain future that has some negative or positive impacts which could be called threat or opportunity respectively. However, the knowledge of risk management could cover the overall procedures involved with administering the planning of risk management, identification, investigation, monitoring and also step by step clinical examination. One of the main tools for preventing adversities is evaluating and management of possible risks.

AIM:

One of the main objectives of the present study is recognising the most frequent types of the risk happening in the EDs. Moreover, the present study is trying to evaluate the possible risks which could happen among various ED sections.

METHODS:

Six databases of EMBASE, HubMed, Cochrane Library, MEDLINE, PubMed, CHBD and Goggle scholar were chosen for discovering much-related articles from the year 2005 to 2019. A total number of 68 were chosen finally to be reviewed more precisely based on the main objective of the present study.

RESULTS:

Precise planning, preparing sufficiently and conducting the process of continuous monitoring are needed for ensuring the fact that any possible risks could be managed through these planned strategies. On the other hand, by modifying the patients’ beliefs, anticipations and the available social culture about the importance of risk management issue, the overall objective of the present study could be achieved at higher rates.

CONCLUSION:

Moreover, because the potential of occurrence of risk in EDs is high and approximately more than half of them are fatal, more precise adequate systematic plans for management of them should result.

Mental health triage tools for medically cleared disaster survivors: an evaluation by MRC volunteers and public health workers

OBJECTIVE

Psychological assessment after disasters determines which survivors are acutely distressed or medically compromised and what kind of assistance is needed (whether practical or psychological). A mental health triage tool can help direct more people to the appropriate type of help. The purpose of this study was to determine the effectiveness of the Fast Mental Health Triage Tool (FMHT) and the Alsept-Price Mental Health Scale (APMHS) among public health workers and Medical Reserve Corps (MRC) volunteers in conducting mental health triage. Both tools screen for ability to follow simple commands, chronic medical conditions, mental health conditions and services, occult injuries, and traumatic events in the past year. Both were designed for use in disasters where mental health resources are scarce and survivors are already medically triaged.

METHODS

Volunteers (n = 204) and workers (n = 66) were randomized into 3 groups, with 79 participating. Fifty-nine raters completed 20 each of 1180 mental health clinical vignettes of disaster survivors.

RESULTS

The survey presenting the vignettes was highly reliable at 0.771; the study model was parallel between baseline and treatment; and the interclass correlation among the raters was high at 0.852. Each rater triaged the same cases, but the rater was randomly assigned to use FMHT, APMHS, or no tool or scale. Between-subject effect for the tools used was significant (P = .039). The FMHT was significantly better than no tool in correct mental health triage, 67.3% to 51.5% (P = .028).

CONCLUSION

The incorporation of a temporal component should be evaluated for potential inclusion in existing mental health triage systems.

What is the best measure of daytime sleepiness in adults with heart failure?

PURPOSE

To identify the best screening measure of daytime sleepiness in adults with heart failure (HF).

DATA SOURCES

A total of 280 adults with HF completed the Epworth Sleepiness Scale, the Stanford Sleepiness Scale, and a single Likert item measuring daytime sleepiness. The sensitivity and specificity of these self-report measures were assessed in relation to a measure of daytime dysfunction from poor sleep quality.

CONCLUSIONS

Only 16% of the sample reported significant daytime dysfunction because of poor sleep quality. Those reporting daytime dysfunction were likely to be younger (p < .001), to be unmarried (p = .002), to have New York Heart Association (NYHA) functional class IV HF (p = .015), and to report low income (p = .006) and fewer hours of sleep (p = .015). The measure of daytime sleepiness that was most sensitive to daytime dysfunction was a single Likert item measured on a 10-point (1-10) scale. Patients with a score ≥4 were 2.4 times more likely to have daytime dysfunction than those with a score <4.

IMPLICATIONS FOR PRACTICE

Complaints of daytime dysfunction because of poor sleep are not common in adults with HF. Routine use of a single question about daytime sleepiness can help nurse practitioners to identify those HF patients with significant sleep issues that may require further screening.