Evaluation of a risk assessment tool to predict violent behaviour by patients detained in a psychiatric intensive care unit

Development and Implementation of an Emergent Documentation Aggression Rating Tool: Quality Improvement

INTRODUCTION

Workplace violence is prevalent in the emergency department, putting patients and staff at risk for harm. An ED-specific standardized tool is needed to promote a consistent assessment process to strengthen documentation of escalating patient behaviors, give justification for de-escalating interventions, and reduce restraints. The purpose of this project was to design, implement, and evaluate feasibility of an ED-specific tool to help nurses proactively identify and intervene with patients' escalating behaviors, capture better documentation of aggressive/violent patient events, and reduce restraint usage.

METHODS

A quality improvement design was used. The Emergent Documentation Aggression Rating Tool was constructed by combining evidence-based behavioral cues for potential aggression/violence with observed behaviors and successfully implemented interventions in patients. Nurses were trained on how to use the tool to rate patients' behaviors and take necessary action. Chart data were collected from August 2018 to December 2019 at a Midwestern Suburban Hospital Emergency Department. Chart audits and just-in-time education were conducted after implementation. Survey data were collected to evaluate nurses' perception of the tool's usefulness.

RESULTS

Use of the novel Emergent Documentation Aggression Rating Tool increased over time (67.36% in Quarter 3 2018 to 97.55% in Quarter 4 2019). After Emergent Documentation Aggression Rating Tool implementation, visual inspection of the time series indicated a decrease in percent restraints, and there was an overall increase in documented escalations de-escalations over time. The patients that escalated most frequently had diagnoses of alcohol use, suicidal ideations, pain-related complaints, or mental health issues.

CONCLUSION

The Emergent Documentation Aggression Rating Tool was feasible for emergency nurses to proactively identify and intervene with patients at risk for aggression/violence.

Screening for risk of violence using service users' self-perceptions: A prospective study from an acute mental health unit

Service users' self-perception of risk has rarely been emphasized in violence risk assessments. A recent review pointed to the importance of a multidisciplinary approach, because different perspectives may provide a deeper and improved understanding of risk assessment. The aim of this study was to investigate service users' perceptions of their own risk of committing violence, using a self-report risk scale, to determine the feasibility and efficacy of this potential violence risk marker during acute mental health hospitalization. All service users admitted to a psychiatric emergency hospital in Norway during one calendar year were included (N = 512). Nearly 80% self-reported no risk or low risk; only seven (1.4%) reported moderate risk or high risk. Service users who reported moderate risk, high risk, don't know, or won't answer were more likely to be violent (OR = 4.65, 95% CI = 2.79-7.74) compared with those who reported no risk or low risk. There was a significant gender interaction with higher OR for women on both univariate and multivariate analyses. Although the OR was higher for women, women's violence rate (11.0%) was almost half that of men (21.8%). For women, sensitivity and specificity were 0.55 and 0.88, respectively; corresponding values for men were 0.40 and 0.80. Inclusion of self-perception of violence risk is the first step towards service users' collaborative involvement in violence prediction; these results indicate that self-perception can contribute to violence risk assessments in acute mental health settings. Findings also indicate that there are gender differences in these assessments.

Predictive validity and gender differences in a biopsychosocial model of violence risk assessment in acute psychiatry

Current violence risk assessment methods seem to have reached an upper limit of accuracy. More comprehensive biopsychosocial models may improve on existing methods. Research on gender differences concerning risk factors of violence is scarce and inconclusive. In this prospective study from an acute psychiatric ward, all patients admitted from March 2012 to March 2013 were included. Predictive validity and potential gender differences in a biopsychosocial model of violence risk assessment consisting of a psychosocial checklist (Violence risk screening-10, V-RISK-10), a patient's self-report risk scale (SRS), total cholesterol (TC) and high-density lipoprotein cholesterol (HDL) were examined in an inpatient (N = 348) and a 3-months follow-up (N = 101) sample. Overall increases in explained variances and predictive values were small and non-significant compared to V-RISK-10 alone. In the inpatient sample, HDL contributed significantly to the model for men but not for women. In the follow-up sample, SRS contributed significantly for the whole sample. Results indicated that the biopsychosocial model we tested partially improved accuracy of violence risk assessments in acute psychiatry and that gender differences may exist.