An ED-Friendly Screening Tool to Identify Potentially Violent Patients
Considering violence is a continuing concern in the emergency setting, there is high interest in new mechanisms that can identify potentially violent patients at the front end of their care encounters. This way, safeguards or preventive measures can be activated to keep providers and other patients safe. However, any such tool needs to be brief and easily integrated into the workflow of a busy ED.
New research suggests adapting the Aggressive Behavior Risk Assessment Tool (ABRAT), a screening instrument that was originally developed to identify potentially violent patients in medical-surgical units, may provide a solution. Son Chae Kim, PhD, RN, a professor of nursing at Point Loma Nazarene University in San Diego and the original developer of the ABRAT, says she has spent years looking into patient violence. This focus has prompted her most recent work looking specifically at the ED.
“Although healthcare workers in EDs are experiencing an alarming frequency of violence perpetrated against them, there is a dearth of validated tools for identifying patients at high risk of violence [in this setting],” she explains.
Consequently, Kim and colleagues conducted a multisite study to see if a version of the ABRAT developed for the ED could deliver a tool with both the sensitivity and specificity to be useful for identifying potentially violent patients. They began with an instrument consisting of several items from the original ABRAT that includes indicators of violence in hospitalized patients. These include a history of aggression, aggressive or threatening behavior, agitation, anxiety, confusion, shouting, mumbling, staring, and signs or symptoms of mania.
Additionally, the instrument included six ED-specific violent behavior indicators: a history of drug or alcohol abuse, history of mental illness, hallucination, police custody, pacing, and signs of intoxication or drug use.
All indicators were loaded into the electronic medical records (EMR) of three EDs so triage nurses could complete the expanded ABRAT as part of their assessment of incoming patients. Patients arriving by ambulance underwent the screening during their initial nursing assessment.1
Any violent incidents that occurred over the course of the ED care encounter also were recorded and classified as physical assault, physical threat, harassment, sexual assault, verbal abuse, verbal threat, or aggression not otherwise specified. All patients older than age 10 years who visited any participating ED between May 1, 2021, and June 20, 2021, were included in the study. Researchers also noted reasons for visits.
Ultimately, out of 10,554 eligible patients with completed ABRAT scores, 127 were involved in one or more violent incidents. Analyzing all the data, including the reasons for a patient’s arrival in the ED, investigators concluded six items from the expanded ABRAT and four reasons for the visit were the best predictors of violence. Since only one chief complaint is given, the researchers concluded a seven-item screener can be used to identify patients who pose a risk for violent behavior.
The resulting ABRAT for EDs includes items pertaining to a history of aggression, history of mental illness, the reason for the patient’s ED visit, and four behavior indicators: aggressive or threatening behavior, agitation, staring, and confusion. The researchers concluded these seven items would correctly identify 84.3% of violent patients and 95.3% of non-violent patients.
“We are in the process of automating the collection of data from the [EMR] to make the tool more user-friendly to speed up the process of completing the ABRAT,” Kim reports. “Although the current ABRAT for EDs is simple and easy to administer, automation would make the tool even more useful. We hope to make the user-friendly tool available for use as quickly as possible.”
Kim acknowledges EDs need insight on what to do with the information the tool delivers. “Some possible strategies would include notification of staff regarding potentially violent patients, activation of BERT [behavioral emergency response teams], paying special attention to high-risk patients, [and] training ED staff on managing potentially violent patients,” she says. “We are in the process of planning for an interventional study to demonstrate the effectiveness of a focused intervention based on the ABRAT scores.”
REFERENCE
- Kim SC, Kaiser J, Bulson J, et al. Multisite study of Aggressive Behavior Risk Assessment Tool in emergency departments. J Am Coll Emerg Physicians Open 2022;3:e12693.
Considering violence is a continuing concern in the emergency setting, there is high interest in new mechanisms that can identify potentially violent patients at the front end of their care encounters. This way, safeguards or preventive measures can be activated to keep providers and other patients safe. However, any such tool needs to be brief and easily integrated into the workflow of a busy ED.
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