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Dr. Andrew Starzomski Psychologist East Coast Forensic Hospital

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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  1. 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

  2. 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?

  3. 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

  4. 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

  5. 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

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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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?

  12. IRRS: A Case Example • Gordon: IRRS Scores / Behaviour

  13. 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

  14. 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.

  15. 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

  16. 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

  17. 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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