Use of a Violence Risk Assessment Tool in an Acute Care Hospital

Effectiveness in Identifying Violent Patients

by Rakel Kling, BA, Marc Corbire, PhD, Rebecca Milord, Bcomm, Janet G. Morrison, RN, BHSc, COHN(C), MAdEd, Kevin Craib, PhD, Mmath, PStat, Annalee Yassi, MD, MSc, FRCPC, Claire Sidebottom, BA, Catherine Kidd, RN, MN, Victoria Long, RN, and Sharon Saunders, BA Research Abstract
This study examined the use and effectiveness of the Alert assessment form. The form is part of the Alert system, used by one large acute care hospital to identify patients with a propensity for violence. All reported incidents of patient violence from August 1, 2003, through December 31, 2004, were included in patient charts. One hundred seventeen violent patient charts were reviewed and compared with 161 non-violent patient charts, randomly chosen from the same time period. Overall use of the Alert assessment form for violent and non-violent patients was 75.7% and 35.4%, respectively. The assessment form was found to have moderate sensitivity (71%) and high specificity (94%). It is reasonably effective in identifying potentially violent or aggressive patients when it is used according to protocol. Efforts to improve the tool are warranted, as is evaluation of its benefit in settings with low prevalence of violence. Also, greater effort must be taken to prevent violence once an aggressive patient has been identified.

iolence and abuse are chronic within the health care setting. Studies conducted in the United States, Canada, Sweden, Britain, Australia, and elsewhere demonstrate that, internationally, health care workers are at high risk for violent incidents (Arnetz & Arnetz, 2000; Crilly, Chaboyer, & Creedy, 2004; Erickson & Williams-Evans, 2000; Fernandes et al., 1999; Lyneham,
About the Authors

Ms. Kling is a master of science candidate, School of Occupational and Environmental Hygiene, University of British Columbia, and research assistant, Occupational Health and Safety Agency for Healthcare, Vancouver, British Columbia, Canada. Dr. Corbire is Assistant Professor, Department of Rehabilitation, University of Sherbrooke, Sherbrooke, Canada. Ms. Milord is Project Specialist, Centre for Healthy Aging, Providence Health Care, Vancouver, British Columbia, Canada. Ms. Morrison is Program Head, Occupational Health Nursing, School of Health Science, British Columbia Institute of Technology, Burnaby; and a doctoral student, School of Communications, Simon Fraser University, Burnaby, British Columbia, Canada. Dr. Craib is a statistician, Occupational Health and Safety Agency for Healthcare, Vancouver, British Columbia, Canada. Dr. Yassi is Tier 1 Canada Research Chair; Professor, Department of Healthcare and Epidemiology and Department of Medicine, University of British Columbia; and Founding Executive Director, Occupational Health and Safety Agency for Healthcare, Vancouver, British Columbia, Canada. Ms. Sidebottom is a master of science candidate, Business Psychology Department, University of Westminster, London, United Kingdom. Ms. Kidd is Regional Director, Employee and Workplace Health and Safety, Vancouver Coastal Health, Vancouver, British Columbia, Canada. Ms. Long is Advisor, Workplace Violence Prevention, Employee and Workplace Health and Safety, Vancouver Coastal Health, Vancouver, British Columbia, Canada. Ms. Saunders is Coordinator of OHS Research, Pensions & Benefits, British Columbia Nurses Union, Burnaby, British Columbia, Canada.

2000; OConnell, Young, Brooks, Hutchings, & Lofthouse, 2000; Rippon, 2000; Schnieden & Marren-Bell, 1995; U.S. Department of Justice, 2001; Yassi, 1994; Yassi & McLeod, 2001; Yassi et al., 2004). Violence in health care differs from violence in other industries. Health care workers must interact closely with patients and families, often under difficult circumstances. Patients may act violently or aggressively due to their health condition or the medication they are taking. They may have a history of violence or aggression, or feel frustrated and angry as a result of their circumstances. In 2000 the Workers Compensation Board of British Columbia reported that approximately 40% of all violencerelated claims for compensation came from health care workers, although these workers made up less than 5% of the work force in the province. In fact, health care workers had more accepted claims and more lost days of work due to acts of violence than any other group (Workers Compensation Board, 2000). In a study of workplace violence across all occupations in British Columbia, Boyd (1995) found the risk for violence to health care workers was almost as high as the risk for violence to police officers, with risk for both occupations more than twice the risk for other occupations. The pervasive climate of violence in health care poses risks for both health care workers and health care organizations. Most hospital-based violence prevention programs

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Applying Research to Practice

A simple risk assessment form, such as the one studied (M55), can be used to accurately assess a patients risk for violence in an acute care hospital. Despite the accuracy of these assessments, they do not take into account important environmental risk factors that are likely to influence a patients potential for violence or aggression. Therefore, even with the use of such assessment tools, not all atrisk patients are correctly identified. Assessment tools must be used as soon as possible (ideally on admission) to facilitate effective violence reduction interventions. Continual education on violence and aggression prevention and management is necessary so health care workers can appropriately manage at-risk patients after initial risk assessment has been completed.

Alert System Risk Indicators (M55 Form)

A flag is initiated with the presence of any of the following indicators:
History of violence or physical aggression Physically aggressive or threatening Verbally hostile or threatening

A flag is initiated with the presence of three or more of the following indicators:
Shouting or demanding Displaying signs of drug or alcohol intoxication (potential for withdrawal) Suffering auditory or visual hallucinations Threatening to leave Confused or cognitively impaired Suspicious Withdrawn

provide education and training that teach health care workers physical and verbal methods for interacting with violent or aggressive patients (Arnetz & Arnetz, 2000; Cowin et al., 2003; Ore, 2002). These interventions have generally been successful in reducing incidents or costs of violence and aggression. Other successful interventions that do not include education or training have also been implemented. For example, Rankins and Hendey (1999) evaluated the implementation of a security system in an emergency department and found a significant increase in weapons confiscated from patients, although there was no reduction in the number of assaults. Methods that assess and communicate a patients violence potential have also been developed. These methods include both clinical judgment and rating scales (McNiel & Binder, 1995; Needham et al., 2004; Woods & Almvik, 2002). For example, the Brset Violence Checklist (Linaker & Busch-Iversen, 1995) is a patient assessment system that has been widely studied in acute care psychiatric wards and psychiatric hospitals. This system evaluates patients on six behaviors: confusion, irritability, boisterousness, physical threats, verbal threats, and attacking objects. Almvik, Woods, and Rasmussen (2000) found that demonstration of two or more of these behaviors is predictive of a violent patient event within 24 hours. Drummond, Sparr, and Gordon (1989) implemented a system whereby files of patients identified as high risk for violence were flagged. The purpose of flagging was to give staff the opportunity to take proper precautions (e.g., security on standby, patient confinement to one area of the hospital, a show of force, or search for weapons). The flagging system in that study reduced violent incidents by 90%. Despite the promising nature of these assessment and prevention methods, little evaluation has been conducted in a wide variety of health care settings.

Agitated

A large acute care hospital in British Columbia developed and implemented the Alert system in 2003, in response to a Workers Compensation Board order. The Alert system is now a permanent component of this hospitals violence prevention program. The system includes a violent-behavior screening tool (form M55, Sidebar) to be used on all patients who are admitted to the hospital, a reassessment tool (form M55a) for use on patients who had positive results on the M55 screening, and a notification system (flagging) to inform health care workers about a patients risk for violence or aggression. Alert system protocol mandates initial assessment of all patients on admission to the hospital using the M55 form. If a patient displays certain risk factors for aggression or violence, a flagging system (an alert) is implemented. This process involves placing a V notation in the computerized Patient Care Information System and on the patients chart and wristband. Patients are periodically reassessed using the M55a form. If no risk factors are observed when the patient is reassessed with the M55a form, the flag is removed. Approximately 38% of patient care staff in the acute care hospital were educated on the Alert system prior to its implementation. Education sessions continued following implementation. All new patient care staff received an overview of the Alert system as part of their orientation. Although the Alert system has been in place for 2 years, its effectiveness has not been assessed. This study examined how the Alert system, a violence risk assessment tool and flagging system, was used in a general admission, acute care hospital; assessed the effec-

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tiveness of this system by determining if it correctly identified patients at risk for violence or aggression; and provided insight into worker perceptions of the Alert system and how it was used in a clinical setting. For the purpose of this study, violence is defined as the attempted or actual exercise by a person, other than a worker, of any physical force so as to cause injury to a worker including any threatening statement or behavior which gives a worker reasonable cause to believe that he or she is at risk of injury (Workers Compensation Board, 2000, Occupational Health and Safety Regulation 4.27). Methodology The study had two phases. A retrospective chart review was conducted to quantify use of the Alert system. The chart review was followed by focus group appraisal to qualitatively assess staff perspectives on the use and effectiveness of the Alert system.
Chart Review

Focus Group Questions

1: Are you familiar with the Alert system aggressive behavior forms (M55 and M55a)? 2 a: How do you identify potentially violent patients? b: Do you find the forms easy to use? 3: Do you understand how the Alert system works? 4: Do the Alert assessment (M55) and the Alert review (M55a) forms provide you with sufficient information to effectively assess a patient for the potential for aggression, initiate a flag, and review the flag status later? 5: What, if anything, would you change on the Alert assessment (M55) or Alert review (M55a) forms to make them more effective and/or useful? 6: In what way(s) is the Alert system useful? 7: Is the Alert system effective in identifying potential risks for aggression? 8: Are there any reasons or situations where you might not always use the Alert system or forms?

A retrospective casecontrol methodology was used with a total of 268 patients involved. Case-patients (n = 107) were defined as all patients with recorded violent or aggressive behaviors toward health care workers, identified by aggression incident reports from hospital records during August 1, 2003, through December 31, 2004. Case-patients charts were reviewed to determine if the patients had been identified and flagged for potential violence. It was established that a patient was flagged for violence if a health care worker completed the M55 form and the patient was deemed, as per the M55 protocol, to be at risk for violence. Hospital records staff randomly selected control-patients (n = 161) from the charts of all patients admitted during the same time period (August 1, 2003, to December 31, 2004). Charts were selected to ensure that the distribution of control-patient charts represented the entire analysis period. These charts were assessed in the same manner as the case-patient charts.
Calculation Procedure

Focus Group Methods

Sensitivity, specificity, and likelihood ratios were calculated. Sensitivity was defined as the probability the Alert system correctly yielded positive results (i.e., the patient was flagged, then violent). Specificity was defined as the probability the Alert system correctly yielded negative results (i.e., the patient was not flagged and did not become violent). The likelihood ratio for a positive result (LR+) is an indication, in the case of the Alert system, of how much more likely a violent individual (case-patient) is to have a positive test result compared with a non-violent individual (control-patient). The likelihood ratio for a negative result (LR-) is an indication of how much less likely a violent individual is to have a negative test result compared with a non-violent individual. Likelihood ratios above 10 and below 0.1 are considered strong evidence to rule in or rule out diagnoses (risk factors) in most circumstances. High likelihood ratios (e.g., LR > 10) indicate that the test, sign, or symptom can be used to rule in the risk factor, whereas low likelihood ratios (e.g., LR < 0.1) can rule out the risk factor (Deeks & Altman, 2004).

Three focus groups, lasting approximately 1 hour each, were held. The six participants per group represented the following hospital units: Emergency, Psychiatric Assessment, Neurology, Burns and Plastics, Acute Medical, and Orthopaedics/Trauma. Although the participants from each unit were selected based on convenience, these units were representative of hospital units ranging from high to low risk for violence and aggression. Each focus group was lead by a different facilitator, and all facilitators followed the same set of previously determined questions and prompts (Sidebar). Ethics approvals for this study were obtained from both the University of British Columbias Behavioural Ethics Board and the Ethics Committee of Vancouver Coastal Health Authority. Results
Alert System Use and Effectiveness

Table 1 details M55 use for case- and control-patients. It indicates that overall use varied between case- and control-patients (75.7% and 35.4%, respectively). It also indicates the use of the M55 within the appropriate time frame. For the purpose of this study, appropriate time frame was defined as: l Case-patients screened with the M55 prior to the occurrence of a violent event (i.e., date and time noted on the M55 form preceded date and time noted on aggression incident report). l Control-patients screened with the M55 on admission (noted on their chart). Violent or aggressive patients were more likely to be assessed using the M55 at some stage during their stay.

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Table 1

Table 2

Use of the Alert System*

CasePatients (n = 107)
M55 completed M55 completed in time frame Flagged Not flagged 81/107 (75.7%) 48/81 (59.3%)

ControlPatients (n = 161)
57/161 (35.4%) 33/57 (57.9%)

Cross-Classification of Alert System Results and Occurrence of Aggressive Behavior for 80* Patients
Alert System Result
Positive (flag) Negative (no flag) Total

Patient Was Aggressive

34 14 48

Patient Was Not Aggressive

2 30 32

Total
36 44 80

34/48 (71%) 14/48 (29%)

2/33 (6%) 30/32 (94%)

*Total number of patients was 268. It was not recorded on one patients chart whether the patient had been flagged for violence.

*It was not recorded on one patients chart whether the patient had been flagged for violence.

Table 1 indicates that if the Alert system was used, it was used in the appropriate time frame approximately 60% of the time for both study populations. The effectiveness of the M55 form in flagging patients at risk of aggression is also detailed in Table 1. It was determined that the Alert system effectively flagged staff to the risk of aggression if: l Case-patients were screened for risk of aggression using the Alert system in the appropriate time frame (before the violent event) and flagged. l Control-patients were screened for risk of aggression using the Alert system in the appropriate time frame (admission) and not flagged. Seventy-one percent of case-patients (recorded violent incident) who were flagged in the appropriate time frame eventually became violent. Twenty-nine percent were not flagged. Only 6% of control-patients were flagged. Eighty-one of the original 268 patients were assessed using the Alert system within the proper time frame, therefore only the results from these patients were used for further calculations. The results of the Alert system for these patients are summarized in Table 2. Regarding the sensitivity and specificity of the Alert system, results showed a sensitivity of 0.708 (34 of 48), meaning that the tool correctly assessed and flagged 71% of violent patients, and a specificity of 0.938 (30 of 32), meaning that the tool correctly assessed 94% of non-violent patients. An LR+ of 11.3 was found, indicating a positive Alert system result is 11 times as likely to come from a violent patient as a non-violent patient. An LR- of 0.31 was found, meaning a violent patient is one-third as likely to have a negative test result as a non-violent patient.
Focus Group Feedback on the Alert System

Before recommendations can be made on how to improve the use and outcome of this tool, it is necessary to ascertain why there is inconsistent use of the M55 and why violent events continue to occur with the proper use

of the Alert system assessment forms. Focus groups were conducted to provide a qualitative assessment of the Alert system and to support and supplement the findings of the casecontrol quantitative evaluation of the Alert system, specifically to determine why such a high proportion of violent incidents occurred even after patients had been flagged. The focus group sessions resulted in three themes: usability of the Alert system, utility and effectiveness of the system, and suggestions for improving the Alert system. Usability of the Alert System. The participants in all focus groups indicated they were familiar with the entire Alert system, particularly the M55 form (the assessment tool), although several participants in one of the focus groups indicated they were not familiar with the M55a form. The participants indicated that they used the M55 form to identify potentially violent patients. Some participants indicated that they might flag a patient based on clinical judgment, rather than the Alert system. Although staff members were familiar with the M55 forms, they disagreed on ease of use. Two of the focus groups felt the forms were easy to use and the third felt they were difficult. All agreed that the Alert system process was difficult and procedures were inconsistently followed. Feedback from the groups indicated that night shift and newer workers were unsure of how to use the forms; too many workers were responsible for completing the forms, resulting in error or omission (e.g., nurse fills out the form, unit clerk enters the information in the computerized record); and flags were not consistently transferred when patients moved to another unit. Participants expressed concern that if a patient was not reviewed on discharge, a flag could carry over to the next hospital admission, thus retaining a potentially violent label when it was not warranted. Feedback for the M55a form suggested it is not often completed. Participants reasons for not completing the M55a form included being too busy, limited patient accessibility, or patient admitted and discharged on the

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same day. It was apparent from participant comments that patient assessment, both initial and ongoing, is often dependent on perception of the patient and personal tolerance for violence. Utility and Effectiveness of the Alert System. A mixed response existed regarding whether the M55 and M55a forms provide sufficient information to assess and flag a patient. One focus group felt there was enough information when the forms were completed (although it was noted there were often blank forms on charts). Another group commented that the system does not always flag patients properly. This group also disagreed with some of the criteria. For example, some participants did not feel comfortable flagging based on the history of violence criterion. Other problems were noted, including flags not being captured in the computer, V stickers falling off charts, new stickers not being initiated when a flag is initiated, and old forms without the V being used in patients charts. There was consensus among participants that the system is useful. Before the Alert system was implemented, word of mouth was the only method of warning workers about patient violence. Focus group participants felt that the Alert system provided better awareness of the risks and that flags changed the way they interacted with patients. For example, participants mentioned several actions they would take in response to a flag, including notifying security to standby or removing sharp objects or other hazards from a patients room. Although the Alert system was generally helpful, the participants identified problems. Some felt that the system was too basic. Some thought it was more helpful in identifying patients who had a history of violence. Some were concerned that a patients behavior during the short time the M55 was being completed (on admission) was the only indicator used to determine potential violence. This was of particular concern in the Emergency Department, where patients are often assessed as no risk in triage but are frequently required to wait before they are treated. Long wait times, pain, hunger, and anxiety are factors known to precipitate violence. Suggestions to Improve the Alert System. The focus groups made several suggestions to improve the Alert system. Two of the focus groups felt the system worked well and that any other information should be noted in an other section to capture all potential risk factors. Several participants suggested including sedation and dementia as part of the flagging criteria, although the focus groups recognized that the forms may not be completed if they contain too many items. Participants felt that the reason a patient is transferred in restraints should be noted on the M55 form; a patient restrained due to aggression from anesthetic effects differs from a combative patient. It was suggested that security should be made aware of a flagged patient. One focus group felt strongly that there was a difference between transient violence (e.g., a patient recovering from anesthesia) and intentional violence because a patient who is intentionally violent is an ongoing risk for all workers, whereas transient violence is usually a one-time episode. This group felt there should be criteria that distinguish between these two forms of violence. All

groups felt there should be a visual way of flagging a patient, such as placing a symbol on the patients bed. Overall, the focus group participants reported that the Alert system was effective at identifying patients at risk for becoming violent, although they considered assessment skills and clinical judgment equally as important. Discussion This study assessed the overall use and effectiveness of the Alert system. The overall use rates for the M55 form varied greatly (case-patients: 76%; control-patients: 35%). The higher use rate for case-patients suggests that staff also used clinical judgment when deciding whether to assess a patient, rather than evaluating all patients on admission, as per the Alert system protocol. Focus group results indicate that workers did not always assess a patient due to high workload, health status of the patient, or ethical objections regarding flagging. Despite this, many felt they were using the Alert system correctly. Based on these findings, this assessment tool could be simplified to make it easier for health care workers to use. Perhaps further education on the proper use of this tool is also required. Although the Alert system was used moderately overall for violent or aggressive patients (case-patients, 76%), health care workers assessed only a subset of patients in the proper time frame. This is a problem because if the tool is used only after violent or aggressive behavior has occurred, it loses its ability to caution staff. The percentage of control-patients assessed with the M55 in the correct time frame and found not to be at risk for aggression (not flagged, 94%) indicates that the Alert system can correctly identify patients who are not likely to be violent. Thus, this tool is likely to correctly flag a patient (only 6% of control-patients were flagged). This accuracy also suggests that M55 risk factors are appropriately used in screening for aggression. For hospital administrators, knowing that patients are not being incorrectly flagged for aggression means that resources can be allocated to addressing flagged (potentially violent) patients, staff training, environmental assessments, and interventions to reduce violent-incident triggers. The positive predictive value, defined by Oleckno (2002) as the percent of those who are positive for a disease (or risk factor) on a screening test and who actually have the disease, of the M55 form was 94%. This represents the probability that a patient with a positive result on the M55 form is actually violent. The positive likelihood ratio (LR+) further supports this percentage. The high LR+ (11.3) indicates that a positive result on an M55 form is approximately 11 times more likely to come from a violent patient than a non-violent patient. Health care professionals using this system can be confident that a flagged patient is likely to present a violence risk. They should, therefore, be trained to use these flags to mitigate the risk of violence or aggression by examining the environment, clinical factors, and their own responses. The Alert system is not as accurate in identifying non-violent patients as it is in positively identifying violent patients. Seventy percent of reported patient violence or aggression was expected (i.e., occurred in patients who

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were flagged). However, even with proper use of the M55 form, 29% of case-patients were not accurately identified. There are several possible reasons why the Alert system is not flagging as many violent or aggressive patients as exist. For example, key risk factors for aggression might be overlooked, or the timing of screening may not be optimal (e.g., before the patient has been exposed to triggers of aggression, such as extended waiting periods). Focus group participants suggested additional risk factor criteria for the M55 form, including dementia and sedation. Adding these characteristics may improve the sensitivity of this assessment tool. Further research should examine why almost one-third of violent patients assessed with the M55 form within the appropriate time frame are not correctly identified by the Alert system. Although the sensitivity of this tool was lower than expected, the sensitivity and specificity of the Alert system are similar to those found in previous studies. For example, Almvik et al. (2000) found a sensitivity of 63% and a specificity of 92% in their study of the Brset Violence Checklist. McNiel and Binder (1995) evaluated a violence assessment tool that incorporated both clinical judgment and scores on the Brief Psychiatric Rating Scale and the Overt Aggression Scale and found a sensitivity of 67% and specificity of 69%. Both studies concluded that the psychometric properties of their tools were satisfactory, although, as pointed out by Almvik et al. (2000), it is difficult to determine acceptable levels of sensitivity and specificity. More importantly, the predictive value of a tool depends not only on its sensitivity and specificity but also on the prevalence of outcome the tool is measuring. Thus, the use of this diagnostic tool in areas with lower prevalence of patient aggression than observed in this study merits careful consideration. Another issue raised in the Almvik et al. (2000), McNiel and Binder (1995), and current studies is, if these tools are accurately assessing a patients risk for future violence, how effective are they in aiding violence prevention? Seventy-one percent of case-patients in this study were properly assessed with the M55 form, yet went on to have a violent event, despite the flag. Use of a flagging system should result in a decrease in overall violent events. Preliminary results from the Alert system indicate it is effective in correctly identifying patients who present a potential risk for violence. However, a firm conclusion regarding the effectiveness of the Alert system in terms of overall violence prevention requires further study. Implications for Occupational Health Nurses The role of occupational health nurses in preventing violence in health care should include elements of risk identification and education. Occupational health nurses should identify all risk factors in their workplaces that could contribute to violence or aggression. They should continually assess the workplace for new or previously unrecognized risk factors. Using the most salient risk factors, occupational health nurses can create and promote the use of violence risk assessment tools to identify patients or workers at high risk for violence or aggression.

In addition to identifying risks, occupational health nurses can facilitate education about violence and aggression. Workers must be educated on current policies and procedures, risk factors, and strategies for preventing workplace violence and aggression. Occupational health nurses must continually review and update education programs, policies and procedures, and prevention strategies to ensure effectiveness. Conclusion Caution must be taken when interpreting the results of this study. To be identified as a case-patient, an individual had to be identified as the source of violent or aggressive patient behavior on a formal incident report. Due to underreporting of violent or aggressive incidents (Yassi, 1994), the study cases may represent only a small fraction of all incidents. M55 use rates may also be higher than indicated; it is possible that, on some units, an M55 assessment that did not result in a flag was not retained in the patients chart and therefore was not available for this study. Also, during the chart review process, inter-rater reliability was not assessed. Further research into the predictors of violent and aggressive behavior would be useful in establishing effective prevention measures. These measures should be incorporated into the Alert system to ensure violence or aggression does not occur after patients have been flagged. Future studies should examine environmental, policy, organizational, and worker-based interventions aimed at mitigating the risk of violent behaviors. These may include education on defusing violent situations, an environmental risk assessment, or introduction of new policies regarding violent or aggressive behaviors at this hospital. This work was funded by a Canadian Institutes for Health Research (CIHR)/Michael Smith Foundation for Health Research (MSFHR) Strategic Training Program Grant in Partnering in Community Health Research (PCHR). References

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