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EBM Conference: Violence Risk Assessment

EBM Conference: Violence Risk Assessment. Joshua Bess MD House Officer Department of Psychiatry University of Michigan. The Problem. Healthcare workers at high risk for being victims of violence Risk (at least) twice as high as other professions Equivalent to police officers

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EBM Conference: Violence Risk Assessment

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  1. EBM Conference:Violence Risk Assessment Joshua Bess MD House Officer Department of Psychiatry University of Michigan

  2. The Problem • Healthcare workers at high risk for being victims of violence • Risk (at least) twice as high as other professions • Equivalent to police officers • Emergency Room and Psychiatric staff at highest risk

  3. The Problem: Example • In 2000, 40% of violence-related claims made to Workers’ Compensation Board of British Columbia were from healthcare workers • Healthcare workers made up less than 5% of the workforce in the province Kling R, Corbiere M, Milord R, Morrison JG, Craib K, Yassi A, Sidebottom C, Kidd C, Long V, Saunders S: Use of a violence risk assessment tool in an acute care hospital: Effectiveness in identifying violent patients. AAOHN J 2006; 54:481-487.

  4. The Problem: Example • Study of 242 ED employees in Cincinnati: • 319 physical assaults by patients • 67% percent of nurses, 63% of PCWs, and 51% of physicians had been physically assaulted by a patient at least once • Workers in the psychiatric ED had the highest percentage (11%) of being assaulted seven or more times by a patient Gates DM, Ross CS, McQueen L: Violence against emergency department workers. Journal of Emergency Medicine 2006/10; 31:331-337

  5. The Problem: Example • 2005 Resident Retreat: Walter Reuther Psychiatric Hospital • UM Resident: “How many assaults against staff are there?” • Medical Director: “Two or three.” • UM Resident: “Oh, two or three a year… that’s not bad.” • Medical Director: “That’s two or three a month.”

  6. The “Pre-EBM” Question • Is there a way to predict violence? • Who? • When (inpatient vs after d/c)? • Why?

  7. A “Pre-EBM” Answer • Yes, but with far less than 100% accuracy. • “Pre-EBM” = Clinical Approach • Study of Psychiatry Residents in Israel – predicted wrong 25-50% of the time Rabinowitz J, Garelik-Wyler R: Accuracy and confidence in clinical assessment of psychiatric inpatients risk of violence. International Journal of Law & Psychiatry 1999; 22:99-106

  8. The “Near-EBM” Question • What are the risk factors for violence?

  9. A “Near-EBM” Answer • Various (see following slides) • “Near EBM” = Actuarial approach • Meta-analysis of 136 studies that compared clinical vs. actuarial prediction: • Clinical more accurate = 8 • Actuarial more accurate = 64 • No difference = 64 Doyle M, Dolan M: Violence risk assessment: Combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk. Journal of Psychiatric & Mental Health Nursing 2002; 9:649-657

  10. Risk Factors … Doyle M, Dolan M: Violence risk assessment: Combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk. Journal of Psychiatric & Mental Health Nursing 2002; 9:649-657

  11. Risk Factors … Doyle M, Dolan M: Violence risk assessment: Combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk. Journal of Psychiatric & Mental Health Nursing 2002; 9:649-657

  12. The EBM Question • How can we perform a violence risk assessment?

  13. An EBM Answer • There are lots of different ways! (see below) • EBM = “structured clinical judgement” • Moves the process from prediction to risk management Doyle M, Dolan M: Violence risk assessment: Combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk. Journal of Psychiatric & Mental Health Nursing 2002; 9:649-657

  14. The Search • PICO Question • P: Acute Psychiatric Inpatients • I: Assessment Scale (that includes clinical and actuarial, i.e. dynamic and static factors) • C: Clinical Judgment alone • O: Accuracy of Risk Assessment

  15. The Search – 1st pass

  16. The Search – 1st pass

  17. The Search – Use PICO

  18. The Search – Use PICO

  19. The Search – Use PICO

  20. The Search – Use PICO

  21. The Search – Let’s Cheat

  22. The Search – Let’s Cheat

  23. The Search – Let’s Cheat

  24. The Search – Let’s Cheat

  25. The Search – Let’s Cheat

  26. The Answer (Maybe) Doyle M, Dolan M: Violence risk assessment: Combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk. Journal of Psychiatric & Mental Health Nursing 2002; 9:649-657

  27. The Answer (Maybe) Doyle M, Dolan M: Violence risk assessment: Combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk. Journal of Psychiatric & Mental Health Nursing 2002; 9:649-657

  28. Washtenaw CSTS

  29. Many Others Doyle M, Dolan M: Violence risk assessment: Combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk. Journal of Psychiatric & Mental Health Nursing 2002; 9:649-657

  30. Broset Violence Checklist ALMVIK R, WOODS P, RASMUSSEN K: The Broset Violence Checklist: Sensitivity, specificity, and interrater reliability. J Interpers Violence 2000; 15:1284-1296

  31. Alert Kling R, Corbiere M, Milord R, Morrison JG, Craib K, Yassi A, Sidebottom C, Kidd C, Long V, Saunders S: Use of a violence risk assessment tool in an acute care hospital: Effectiveness in identifying violent patients. AAOHN J 2006; 54:481-487

  32. HCR-20 Douglas KS, Ogloff JR, Nicholls TL, Grant I: Assessing risk for violence among psychiatric patients: The HCR-20 violence risk assessment scheme and the psychopathy checklist: Screening version. Journal of Consulting & Clinical Psychology 1999; 67:917-930

  33. HCR-20 Douglas KS, Ogloff JR, Nicholls TL, Grant I: Assessing risk for violence among psychiatric patients: The HCR-20 violence risk assessment scheme and the psychopathy checklist: Screening version. Journal of Consulting & Clinical Psychology 1999; 67:917-930

  34. HCR-20 Douglas KS, Ogloff JR, Nicholls TL, Grant I: Assessing risk for violence among psychiatric patients: The HCR-20 violence risk assessment scheme and the psychopathy checklist: Screening version. Journal of Consulting & Clinical Psychology 1999; 67:917-930

  35. HCR-20 Douglas KS, Ogloff JR, Nicholls TL, Grant I: Assessing risk for violence among psychiatric patients: The HCR-20 violence risk assessment scheme and the psychopathy checklist: Screening version. Journal of Consulting & Clinical Psychology 1999; 67:917-930

  36. DASA Ogloff JR, Daffern M: The dynamic appraisal of situational aggression: An instrument to assess risk for imminent aggression in psychiatric inpatients. Behav Sci Law 2006; 24:799-813

  37. A Great Review Daffern M: The predictive validity and practical utility of structured schemes used to assess risk for aggression in psychiatric inpatient settings. Aggression and Violent Behavior 2007/0; 12:116-130

  38. References 1. ALMVIK R, WOODS P, RASMUSSEN K: The broset violence checklist: Sensitivity, specificity, and interrater reliability. J Interpers Violence 2000; 15:1284-1296 2. Daffern M: The predictive validity and practical utility of structured schemes used to assess risk for aggression in psychiatric inpatient settings. Aggression and Violent Behavior 2007/0; 12:116-130 3. Douglas KS, Ogloff JR, Hart SD: Evaluation of a model of violence risk assessment among forensic psychiatric patients. Psychiatric Services 2003; 54:1372-1379 4. Douglas KS, Ogloff JR, Nicholls TL, Grant I: Assessing risk for violence among psychiatric patients: The HCR-20 violence risk assessment scheme and the psychopathy checklist: Screening version. Journal of Consulting & Clinical Psychology 1999; 67:917-930 5. Doyle M, Dolan M: Violence risk assessment: Combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk. Journal of Psychiatric & Mental Health Nursing 2002; 9:649-657 6. Gates DM, Ross CS, McQueen L: Violence against emergency department workers. Journal of Emergency Medicine 2006/10; 31:331-337 7. Hanson RK: Twenty years of progress in violence risk assessment. J Interpers Violence 2005; 20:212-217 8. Kling R, Corbiere M, Milord R, Morrison JG, Craib K, Yassi A, Sidebottom C, Kidd C, Long V, Saunders S: Use of a violence risk assessment tool in an acute care hospital: Effectiveness in identifying violent patients. AAOHN J 2006; 54:481-487 9. Monahan J, Steadman HJ, Robbins PC, Appelbaum P, Banks S, Grisso T, Heilbrun K, Mulvey EP, Roth L, Silver E: An actuarial model of violence risk assessment for persons with mental disorders.see comment. Psychiatric Services 2005; 56:810-815 10. Nijman H, Merckelbach H, Evers C, Palmstierna T, a Campo J: Prediction of aggression on a locked psychiatric admissions ward. Acta Psychiatr Scand 2002; 105:390-395 11. Ogloff JR, Daffern M: The dynamic appraisal of situational aggression: An instrument to assess risk for imminent aggression in psychiatric inpatients. Behav Sci Law 2006; 24:799-813 12. Rabinowitz J, Garelik-Wyler R: Accuracy and confidence in clinical assessment of psychiatric inpatients risk of violence. International Journal of Law & Psychiatry 1999; 22:99-106 13. Slovic P, Monahan J, MacGregor DG: Violence risk assessment and risk communication: The effects of using actual cases, providing instruction, and employing probability versus frequency formats. Law & Human Behavior 2000; 24:271-296

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