Dr andrew starzomski psychologist east coast forensic hospital
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The Imminent Risk Rating Scale (IRRS): A n effective tool for identifying inpatients at increased risk for violence. Dr. Andrew Starzomski Psychologist East Coast Forensic Hospital Capital Health, Halifax, Nova Scotia andrew.starzomski@cdha.nshealth.ca. Presentation Objectives:.

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Dr. Andrew Starzomski Psychologist East Coast Forensic Hospital

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The Imminent Risk Rating Scale (IRRS):An effective tool for identifying inpatients at increased risk for violence

  • Dr. Andrew Starzomski

  • Psychologist

  • East Coast Forensic Hospital

  • Capital Health, Halifax, Nova Scotia

  • andrew.starzomski@cdha.nshealth.ca


Presentation Objectives:

  • 1. The problem of inpatient violence

  • 2. The challenge of ‘short term’ risk assessment

  • 3. What is the IRRS, and what is ‘in’ it?

  • 4. A quick case study

  • 5. What’s to like?

  • 6. Where are we heading with the tool?


Inpatient Violence

  • Though there is abundant attention / procedure for addressing clinical issues (symptoms, treatment) on psychiatric units, not the same for aggression

  • East Coast Forensic’s Mentally Ill Offender Unit (court-ordered assessments) in ‘01/’02:

    • 55 violent incidents of 169 admissions; staff victim 56% of time, co-patient victim 44% of time


Inpatient Violence

  • Consequences?

    • Injury to co-clients/staff, related costs

    • Staff focus: clinical/treatment vs ?

    • Nature / quality / rates of recovery?

    • Public perception / unease about seeking care for self / family?

    • Shortage of trained heath care professionals due to attrition


Why Create a New Tool?

  • Existing tools solely addressing individual-oriented variables (e.g., symptoms, mental state) are missing a great deal… therefore incomplete as an approach or orientation to the issue

  • Steinert: necessity of evaluating person-environment fit and interaction

  • Need for a brief measure capable of detecting change in key variables that can occur quickly

    • Other existing measures are lengthier and without a day-to-day focus


Psychologists, and others, love a good measure of bad behaviour


What is IN the IRRS?

  • Seven domains are evaluated:

    • History of Violence

    • Subtypes (re: personality & psychosis)

    • Acuity of hostility / anger

    • Stress

    • Communication impairment

    • Social status / relationship problems

    • Milieu strain


What is the IRRS?

  • Checklist format/ info rated by trained clinician based on file, observation info

  • Quickly addresses a set of historical and dynamic variables associated with short-term violence risk

  • Developed with breadth in mind: there are MANY pathways / causes / forms of aggression

  • 7 items get rated on a 0-1-2 scale


How is the IRRS used?

  • Typically:

    • After training, nurses rate new inpatients based on file review, info emerging from observations / interview… inter-rating evaluation

    • Information is shared with staff, areas of uncertainty flagged / more info needed, intervention strategies considered

    • Ratings every 4-7 days as-needed…

    • Focus on inpatient environment


IRRS: A Case Example

  • Gordon:

    • 41 year old single male from rural NS

    • NCR on charges Mischief, Assault Peace Officer

    • Dx: features of psychosis, mania, OCD, behavioural / personality issues...

    • Tx: atypicals, mood stabilizers, anxiolytics, ECT

      • some lengthy periods of stability and decent community functioning over last several years

    • Aggression as tactic for attention, confinement

    • Back at ECFH since summer 08 / group home aggression


IRRS: A Case Example

  • Gordon:

    • As of late winter 2009:

      • Ongoing uncertainty about discharge

      • Implementation of a new rehabilitation agenda via the “Treatment Mall”: social / lifestyle stress

      • Uncertainty that maintenance ECT doing much

      • Recurrence of aggressive thoughts, tangentiality, communication impairments, lability

      • Aggression – numerous times, toward pts & staff

      • How does this translate to IRRS ratings?


IRRS: A Case Example

  • Gordon: IRRS Scores / Behaviour


IT WORKS!

  • 60 patients at MIOU tracked through 2006-2007

  • Never-violent patients score sig lower on average during admission than those who were aggressive once or more

  • Scores vary meaningfully over course of admission for those who are violent (IRRS reductions linked to better adjustment on the unit)

  • IRRS scores hold up for predicting verbal and physical aggression for about 10 days (not just 24-72 hours), after which time ratings are no longer able to predict aggressive behaviour


Other Evidence of Utility: Staff Perspectives

  • From the beginning I thought it was an interesting idea.

  • Easy to do

  • Anticipate it becoming a helpful tool to help predict possible violence.

  • Helps with awareness for aggression

  • Has been quite accurate in some cases

  • Should be used in all mental health facilities.


Benefits of the IRRS

  • Common language

  • Staff know their patients better and as a result are able to recognize / identify risk

  • Early recognition and appropriate response (interventions)

  • Interdisciplinary work


Potential Benefits of the IRRS… pending evaluation

  • Hopefully: decreased incidents of aggression… needs evaluation

  • Hopefully: Increased staff satisfaction and retention… needs more formal evaluation

  • Hopefully: Increased quality of patient care… needs evaluation


Where do we go from here?

  • More data, more evaluation

  • Other settings: short term / crisis unit, mainstream Emergency suites, youth, correctional health units

  • A tool to help create safer health settings: building awareness, promotion, etc.


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