Evaluation of a violence risk assessment system (the Alert System) for reducing violence in an acute hospital: a before and after study

Objectives

To investigate the effectiveness of a risk assessment system in reducing the risk of violence in an acute care hospital in the Canadian province of British Columbia.

Methods

Hospital violence incident rates (number of incidents/100,000 work hours) were calculated and compared pre, during and post implementation of the Alert System, a violence risk assessment system, at one acute care hospital. Poisson regression models were used to examine the effect of the Alert System on hospital-level violent incident rates. Multivariable, conditional logistic regression was used to examine the effect of the Alert System on the individual-level risk of violent incidence using a case-control study.

Results

The violent incident rate decreased during the Alert System implementation period only, but subsequently returned to pre-implementation levels. In the case-control analyses, the Alert flag was associated with an increased risk for a patient violent incident (odds ratio = 7.74, 95% CI = 4.81-12.47).

Conclusions

Although useful at identifying violent patients, the Alert System even though offered in conjunction with violence prevention training, does not appear to provide the resources or procedures needed by healthcare workers to prevent a patient from progressing to a violent incident once flagged. Violence in healthcare should be studied and prevented using a multifaceted approach.     

An association between occupancy rates in the emergency department and rates of violence toward staff

Background

Studies have explored possible causes of violent acts in the emergency department (ED), however, the association of violence with ED crowding has not been studied. Although the total number of violent acts would be expected to increase, it is not clear if the rate of violent acts also increases as occupancy levels rise.

Objective

The purpose of this study was to determine if there is an association between occupancy rates in the ED and rates of violence toward staff.

Methods

This was a retrospective chart review study. Violent incidents in a community, Level I trauma center ED were identified from review of orders of emergency detainment, adverse event forms, physical restraint logs, and pharmacy records from January 1, 2005 to June 1, 2008. Occupancy rates for all days were calculated and violent vs. non-violent days were compared using a standard two-sample t-test. Logistic regression analysis was then used to investigate other factors associated with violent incidents.

Results

A rate of violence of 1.3 incidents per 1000 patients was found. When comparing the occupancy rates of violent days (mean 95%, SD 26%) with non-violent days (mean 86%, SD 24%), a statistically significant association was found (p < 0.0001). Multivariate logistic regression confirmed a significant association between crowding and violence toward staff (odds ratio 4.290, 95% confidence interval 2.137–8.612).

Conclusion

These results suggest another possible negative effect that crowding has on ED staff and physicians. Policies and recommendations regarding ED operating procedures and staff safety during times of higher occupancy levels should be discussed.     

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

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

An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: a pluralistic design

Following an initial springboard study, a further more extensive piece of research was conducted to identify and evaluate approaches used to manage patient aggression and violence on three acute mental health wards. Data were gathered using an incident form, a questionnaire and interviews. The views of patients (n = 80), nurses (n = 72) and medical staff (n = 10) were explored. Findings revealed a clear distinction between the way staff and patients view both the problem and the response. Patients' view present staff approaches as 'controlling' and believe that environmental and poor communication factors underpin aggressive behaviour. Staff, conversely, attribute aggressive behaviour to internal patient and external factors, which may explain the reason for approaches used. A strong correlation was found between type of patient aggression and response (r = 0.36, P < 0.000) and a high percentage of incidents reported were of an aggressive, as opposed to violent, nature. For example 70% of incidents involved verbal abuse or threat. Despite this, 47% (n = 103) of approaches incorporated the use of medication, restraint or seclusion. These are commonly referred to as traditional methods. Patients clearly view this controlling style as a part of the problem and an emphasis upon control and symptom reduction may be inappropriate given the type of aggression encountered. Key issues were further analysed using an internal, external and situational model, each of which endeavour to explain reasons for patient aggression from different perspectives. It is this emphasis upon sole perspectives that may both contribute to and result in the use of a limited number of management approaches adopted in practice. The integration of all three models to examine the complex nature of patient aggression and violence from a variety of perspectives may be the way forward. As a result, approaches to deal with this problem could be more meaningful and subsequently effective.     

Enhancing the capability of medical team to manage aggressive events in acute psychiatric wards

Incidences of violence in acute psychiatric ward can lead to not only facility destructions, but also mental, physical injuries and even medical disputes. As part of efforts to enhance medical team abilities to manage aggressive events, this study aimed to provide references for reducing both aggressive events and resultant damage. Over two-thirds (69%) of all unanticipated occurrences registered by our unit in 2003-2004 were classed as "aggressive events", i.e. there were 27 occurrences (0.09%) in which 0.04% resulted in staff injury. Events were mainly attributable to psychiatric symptoms, poor impulse control and interpersonal conflicts. For this study, we used several intervention methods, including categorizing patients by "risk of violence" rank, revising the hospital's standard operation processes for handling violence and revising the nursing rules to enhance nurse skills at managing violent events, countering patient violence, helping patients safely vent their anger and physical force, listening to relax music and conducting behavior modification. As a result, aggressive event prediction sensitivity increased from 56% to 100%, with successful prevention rates reaching 80%. The rate of aggressive event occurrence reduced from 0.09% to 0.06% and staff injuries decreased from 0.04% to 0.02%. Intervention methods employed were shown to be quite effective. If medical teams elsewhere enhanced their sensitivity and abilities to avoid aggressive events, injury and damages could be prevented and medical care quality enhanced.     

中文版暴力风险量表在住院精神疾病病人中的应用

[目的]探讨中文版暴力风险量表在住院精神疾病病人中的应用效果。[方法]观察组（2013年7月1日-12月31日入院）病人采用中文版Br？set 暴力核查清单（BVC）进行暴力风险评估,根据评分值采取相应的干预措施,并与2012年同期入院的对照组病人暴力攻击行为发生情况、约束情况、病人家属满意度进行比较。[结果]两组病人入院8周内暴力攻击行为发生率、约束率、约束时间、病人家属满意度比较,差异均有统计学意义（P〈0.05）。[结论]BVC评估精神疾病病人的暴力风险简便、准确,提高了暴力应急处理的预见性,降低了暴力攻击行为的发生率及约束率,提高了病人家属满意度,对规范及完善暴力风险的管理程序具有积极意义。     

Aggressive incidents on a psychiatric intensive care unit

AIM: Although factors related to inpatient aggression have been extensively studied, there is relatively little specific information about violence in intensive care, so the authors decided to conduct their own research into the subject. METHOD: The authors studied the behaviours of the small number of patients who are involved in most of the aggressive incidents in a psychiatric intensive care unit (PICU) over 15 months. RESULTS: The study found that female patients were significantly more likely to be involved in aggressive incidents, but that most of these incidents involved self-harm. Patients with a diagnosis of schizophrenia were more likely to display violent behaviour than those from other diagnostic categories. Patients with a personality disorder were more likely to inflict violence against themselves. CONCLUSION: The authors concluded that all the research on patient violence needs to be standardised to inform practice properly. Nurses need to be aware that relatively few patients are responsible for most of the violent incidents that occur.     

Preventing violence through primary care intervention.

Homicide was the United States' second leading cause of death among people aged 15 to 24 in 1988; non-fatal assaults occur 100 times more frequently. Yet as a society, we have ignored the problem. Risk factors for violent injuries comprise sociological, developmental/psychological and neurophysiological elements. Providers of primary care for children, young adults and their families can help parents develop healthy parenting techniques in child-rearing, help the grade-school-aged child develop non-violent conflict-resolution skills, and help young people learn to avoid violence and potentially violent activities and situations. Health care providers are able to reduce the incidence of violent injuries by addressing the issue of violence in periodic examination visits with both parents and children. Familiarity with risk indicators enables the health care provider to intervene early when needed. An anticipatory guidance outline and a violence-induced injury-visit form are included.     

Violence prediction in the Emergency Department

The purpose of this study was to examine whether the SAGE assessment survey could predict, within the Emergency Department setting, those youth at risk for engaging in violent behavior. It also examined whether those who test positive for engaging in high-risk violent behavior during the initial baseline SAGE survey were prone to continue this behavior 1 month later. This was an observation, convenience sample of young male and female patients, half of whom had injuries related to violence and half of whom had injuries unrelated to violence, who presented when a research fellow was available. They were given the SAGE aggression assessment survey and questioned about their risk behavior in the past 6 months to 1 year. Those youths were contacted 1 month after enrollment to determine the incidence of continued at-risk behavior. Demographic information was used to contact the patient on follow-up but not for identification purposes. The study was IRB-approved. The setting was a Level I pediatric and adult trauma center in an inner city with 45,000 annual visits. The inclusion criteria were: age 10-24 years, consenting patient or guardian, medically stable, and able to communicate. The exclusion criteria were: those youths who were uncooperative or refused to participate. The comparison between the SAGE overall scores of the 182 subjects with 46% who had injuries related to violence vs. 54% who presented with injuries not related to violence did not show a significant difference. Those who presented with non-violent injuries had an overall score range of 7-8 with a mean of 7.4 and those who presented with violent injuries had an overall scale of 10-11 with a mean of 10.1 out of a possible 12 total. There were, however, significant differences at the .05 or less level when looking at specific questions asking about certain behaviors such as physical fighting, shoving, needing medical attention, and kicking, in the initial survey. At the 1-month follow-up, with 118 subjects, the SAGE tool also showed differences in the areas of physical fighting, shoving, and kicking between the 56% who had injuries not related to violence vs. the 44% who did have violence-related injuries. It identified 18-50% of those who presented with violence-related injuries and who continued to engage in high-risk behavior at the 1-month follow-up. These results indicate that the SAGE survey scores based on the responses to all 12 questions is not effective in identifying those youths at risk for general violent behavior, especially with a high-risk population. A set of four questions from the 12-question SAGE survey, however, was successful at tracking specific types of at-risk behaviors. This indicates that certain questions within the SAGE survey may be effective at tracking those who engage in high-risk violent behavior. These same questions were able to track those who continued to engage in high-risk violent behaviors 1 month later.     

Understanding inpatient violence in a New Zealand child and adolescent psychiatric setting

This paper describes the rate of violent episodes at a youth psychiatric unit, identifies significant clinical and demographic differences between service users who had admissions with violent episodes and those who did not, and describes characteristics of violent incidents, including antecedents, consequences, victim type, and severity of violence. A retrospective file audit over a 2-year period reviewed 303 admissions. Characteristics of violent incidents (n = 242) and service users (violent/non-violent) were recorded. Of 263 service users, 21.7% exhibited violent behaviour. Significant differences between admissions with and without violent episodes were found in terms of ethnicity, legal status, length of admission, and diagnosis. Staff were the most frequent victims and less severe incidents were most common. The most frequent antecedents to violence were positive symptoms of psychosis, hostility, and agitation, while the most common consequences were seclusion, physical restraint and 'as-required' medication. This study has identified that violent incidents are a common and significant issue. The findings might help staff in reviewing current management approaches. Future areas of study have been identified.     

A Quality Improvement Project on Agitation Management in the Emergency Department

IntroductionAgitation 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.MethodsThis 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.ResultsThe 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).DiscussionThe 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.     

精神科护士遭受工作场所身体暴力事件的现况调查

目的 探讨精神科护士遭受工作场所暴力的形式及心理情况的现状,为临床护士及管理者提供研究依据.方法 采取整群抽样的调查方法,对该院一年内遭受工作场所身体暴力的精神科护士的遭受暴力形式和心理状态调查,采用χ2以及单因素方差分析进行统计分析.结果 仅有9.9%的精神科护士掌握暴力防范技巧.精神科女护士较精神科男护士更易遭受暴力行为在身体性袭击(χ2=9.611)、遭遇患者或家属打砸(χ2=4.085)、和被威胁(χ2=5.172)等三方面,差异均有统计学意义(均P<0.05).71.8%的人认同医院暴力事件越来越多;83.0%的人认为不信任家属,对家属感到恐惧;74.6%的人认为经常失眠、伴有焦虑,但男女比较,差异无统计学意义(P>0.05).结论 精神科护士缺乏掌握工作场所暴力攻击的知识,大部分护士遭受过工作场所暴力,并且出现不良的心理状态(尤其是女护士),为管理者提供一定依据,以制定相应对策,降低工作场所暴力.     

Assault experiences: Lessons learned from mental health nurses in Taiwan

Mental health nurse are frequently subjected to patients' violent and aggressive behaviour. These assault experiences have given rise to mental health nurses' physical and psychological trauma, and negatively impact the quality of patient care. The purpose of the present qualitative study was to understand mental health nurses' experiences of being assaulted, the influences on their patient care, and their perspectives of the effectiveness of in‐service, violence‐prevention education. Ten mental health nurses from two different inpatient mental health facilities were interviewed using a semistructured interview guide. Thematic analysis of interview data found six themes: (i) violence is unpredictable; (ii) violence is normal; (iii) lasting psychological trauma; (iv) limited support from peers and the administrator; (v) violence prevention requires team cooperation; and (vi) doubting the effectiveness of in‐service education on violence prevention. Psychiatric ward administrators should assess nurses' learning and skill needs to determine whether these needs are met by existing in‐service training programmes. A culture of safety should also be promoted by building a warm and supportive ward climate for both staff and patients, which would include team cooperation and support for colleagues who suffer a violent incident.     

Strategies for nurse leaders to address aggressive and violent events

According to a 2010 report from the Bureau of Labor Statistics, 48% of all nonfatal injuries from occupational assaults and violent acts occur in healthcare and social service settings. A recent increase in workplace violence has been noted causing a heightened awareness among nurses. Information is scarce both in the literature and in healthcare settings regarding the proper steps to take in the event that violence occurs and de-escalation techniques for aggressive behavior do not work. Nurse leaders should prioritize time to become involved in developing and implementing workplace violence policies including offering education for nurses to deal with aggressive behaviors and violent acts and, learn de-escalation techniques.     

The effectiveness of two interventions in the management of patient violence in acute mental inpatient settings: report on a pilot study

Systematic risk assessment and training courses have been suggested as interventions to deal with patient violence in psychiatric institutions. A dual centre prospective feasibility study was conducted on two Swiss psychiatric admission wards to test the hypothesis that such interventions will reduce the frequency and severity of violent events and coercion. A systematic aggression risk assessment, in combination with a standardized training course in aggression management was administered and the frequency and severity of aggressive incidents and the frequency of coercive measures were registered. The incidence rates of aggressive incidents and attacks showed no significant reduction from the baseline through risk prediction and staff training, but the drop in coercive measures was highly significant. A 'ward effect' was detected with one ward showing a decline in attacks with unchanged incidence rates of coercion and the other ward showing the opposite. The severity of the incidents remained unchanged whilst the subjective severity declined after the training course. We conclude that a systematic risk assessment and a training course may assist in reducing the incidence rate of coercive measures on psychiatric acute admission wards. Further testing of the interventions is necessary to measure the effect of the training alone and to counteract 'ward effects'.     

Screening for Behavioral Health Patient Aggression in Emergency Departments to Reduce Workplace Violence

IntroductionPatient violence in health care facilities occurs daily. Structured risk assessments, when regularly completed, have been effective in prompting interventions to reduce aggression in Behavioral Health (BH) settings.MethodsThis quasi-experimental study evaluated the effectiveness of the Dynamic Appraisal of Situational Aggression – Inpatient Version (DASA) validated screening tool to reduce aggressive outbursts in an emergency department (ED) setting with BH patients awaiting transfer to a psychiatric facility. The tool was used in 4 non-psychiatric EDs from a large health care system. Chart audits were completed to record initial patient DASA scores observed at triage and at subsequent intervals during the ED encounter. ED staff documented interventions used for patients. Inclusion criteria included adults 21 years and older following a telepsychiatry consultation with a recommendation for BH inpatient admission. Pre-/post-implementation aggressive events were collected to assess ED DASA use. DASA scores from BH ED patients were examined to increase understanding of patient utilization. Staff workplace safety was examined to compare staff safety perception pre- and post-DASA implementation.ResultsViolent events were reported statistically significantly higher post-DASA implementation. There was an increased risk of elevated DASA scores for specific diagnoses and genders. An increased awareness of the importance of reporting workplace violence improved documentation.DiscussionUsing an evidence-based screening tool helped identify BH patients with behaviors associated with aggressive ED events. Proactive use of interventions, including use of Comfort Cart items, de-escalation, and prescribed medications, can positively influence reduction of risk from aggressive behaviors within BH patient populations in EDs.     

Modifiable factors affecting inpatient violence in an acute child and adolescent psychiatric unit: A 16‐year retrospective study

Violent incidents in acute inpatient units for children and adolescents are a major and persistent problem. The demographic, clinical, and modifiable (environmental–organizational) risk factors that affect inpatient violence in an Acute Child and Adolescent Psychiatric Unit were investigated via a retrospective study. Data were collected from nursing and medical reports and the unit's census and included 100 days per year for 16 years. Incidents of violence and assault types were recorded, and variables such as the diagnostic category of assailants, total number of patients, and staffing factors during the incident were examined. Of the 2390 violent incidents recorded, 50% were attributed to cases of physical violence towards another patient, 17% to physical violence towards nursing staff, 19% to physical violence towards self and 14% to destruction of property. According to the final multivariable model, for each additional patient in the unit, the risk of a violent event increased by 9.51%; for each additional offender patient, the risk increased by 14.06%; the number of assistant nurses was associated with a 25.03% increased risk; and, after 2006, the risk increased by 68.99%. The most significant factor associated with a 59.98% decreased risk was the total number of nursing staff. All variables significantly and independently contributed to the model. Acute inpatient psychiatric units with a small number of hospitalized patients, adequate, well‐trained and specialized nursing staff, and the hospitalization of different types of patients in separate wards or units are expected to facilitate a reduction in the frequency of violent incidents.     

National directives on managing 'violent' patients: a critique

The incidence and nature of patient aggression and violence in health care has been a neglected area of investigation. However, since the 1980s there has been an increase in the amount of research examining the problem of patients who are aggressive and violent in a multitude of health care settings. A critique of three initiatives highlights the problems associated with aggression and violence in healthcare. They fail, however, to make the distinction between aggression and violence, and as aggression is more common, inappropriate, restrictive care for patients will continue at the expense of developing therapeutic relationships.     

Risk assessment of violence to others: time for action

Possible expansion in the scope of practice of mental health nurses, together with the prevalence of nurses being assaulted by patients, accentuates the need for nurses to be more skilled in risk assessment. A literature search was undertaken on the topics of risk assessment, dangerousness, aggression, and violence in the data bases of CINAHL, MEDLINE and PSYCHLIT, in order to determine an evidence based approach to risk assessment of patient violence towards others. In the absence of reliable and valid nursing risk assessment measures, the approach suggested here focuses on the use of observation skills to detect behaviour antecedent to physical assault, and the ability to systematically assess evidence-based risk factors of violent action. Given this rudimentary framework, there is the need to adapt it to specific clinical settings. Failure to proceed rapidly with such developments may jeopardize the safety of both patients and staff.