Patient violence in health care facilities occurs daily. Structured risk assessments, when regularly completed, have been effective in prompting interventions to reduce aggression in Behavioral Health (BH) settings.
This quasi-experimental study evaluated the effectiveness of the Dynamic Appraisal of Situational Aggression – Inpatient Version (DASA) validated screening tool to reduce aggressive outbursts in an emergency department (ED) setting with BH patients awaiting transfer to a psychiatric facility. The tool was used in 4 non-psychiatric EDs from a large health care system. Chart audits were completed to record initial patient DASA scores observed at triage and at subsequent intervals during the ED encounter. ED staff documented interventions used for patients. Inclusion criteria included adults 21 years and older following a telepsychiatry consultation with a recommendation for BH inpatient admission. Pre-/post-implementation aggressive events were collected to assess ED DASA use. DASA scores from BH ED patients were examined to increase understanding of patient utilization. Staff workplace safety was examined to compare staff safety perception pre- and post-DASA implementation.
Violent events were reported statistically significantly higher post-DASA implementation. There was an increased risk of elevated DASA scores for specific diagnoses and genders. An increased awareness of the importance of reporting workplace violence improved documentation.
Using an evidence-based screening tool helped identify BH patients with behaviors associated with aggressive ED events. Proactive use of interventions, including use of Comfort Cart items, de-escalation, and prescribed medications, can positively influence reduction of risk from aggressive behaviors within BH patient populations in EDs.
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- DOL Workplace Violence Program: level two (escalation of the situation). U.S. Department of Labor.https://www.dol.gov/agencies/oasam/centers-offices/human-resources-center/policies/workplace-violence-program#level2Date accessed: September 1, 2022
- Assaulted and unheard: violence against healthcare staff.New Solut. 2018; 27: 581-606https://doi.org/10.1177/1048291117732301
- Workplace violence against healthcare professionals: a systematic review.Aggress Violent Behav. 2020; 51101381https://doi.org/10.1016/j.avb.2020.101381
- Workplace violence against health care workers in the United States.N Engl J Med. 2016; 374: 1661-1669https://doi.org/10.1056/nejmra1501998
- Addressing risks of violence against healthcare staff in emergency departments: the effects of job satisfaction and attachment style.Biomed Res Int. 2019; 20195430870https://doi.org/10.1155/2019/5430870
- Prevalence of workplace violence against nurses working in hospitals: a literature review.Am J Nurs Sci. 2020; 9: 84-90https://doi.org/10.11648/j.ajns.20200902.19
- Impact and prevalence of physical and verbal violence toward healthcare workers.Psychosomatics. 2018; 59: 584-590https://doi.org/10.1016/j.psym.2018.04.007
- Emergency department length-of-stay for psychiatric visits was significantly longer than for nonpsychiatric visits, 2002-11.Health Aff (Millwood). 2016; 35: 1698-1706https://doi.org/10.1377/hlthaff.2016.0344
- Characteristics, clinical care, and disposition barriers for mental health patients boarding in the emergency department.Am J Emerg Med. 2021; 46: 550-555https://doi.org/10.1016/j.ajem.2020.11.021
- The impact of psychiatric patient boarding in emergency departments.Emerg Med Int. 2012; 2012360308https://doi.org/10.1155/2012/360308
- Determinants of boarding of patients with severe mental illness in hospital emergency departments.J Ment Health Policy Econ. 2020; 23: 61-75
- Boarding of mentally ill patients in emergency departments: American Psychiatric Association resource document.West J Emerg Med. 2019; 20: 690-695https://doi.org/10.5811/westjem.2019.6.42422
- Bedding, not boarding: psychiatric patients boarded in hospital.Mod Healthc. 2013; 43: 15-17
- Interventions following a high violence risk assessment score: a naturalistic study on a Finnish psychiatric admission ward.BMC Health Serv Res. 2017; 17: 26https://doi.org/10.1186/s12913-016-1942-0
- Preventing workplace violence against healthcare workers.J Korean Med Assoc. 2018; 61: 292-296https://doi.org/10.5124/jkma.2018.61.5.292
- Preventing emergency department violence through design.J Emerg Nurs. 2018; 44: 7-12https://doi.org/10.1016/j.jen.2017.06.012
- Sentinel Event Alert: physical and verbal violence against health care workers. The Joint Commission,
2018https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_59_workplace_violence_4_13_18_final.pdfDate accessed: May 1, 2020
- Diagnostic sensitivity of the dynamic appraisal of situational aggression to predict violence and aggression by behavioral health patients in the emergency department.J Emerg Nurs. 2020; 46: 302-309https://doi.org/10.1016/j.jen.2019.12.006
- Risk assessment and subsequent nursing interventions in a forensic mental health inpatient setting: associations and impact on aggressive behaviour.J Clin Nurs. 2018; 27: e971-e983https://doi.org/10.1111/jocn.14107
- The prediction of imminent aggression in patients with mental illness and/or intellectual disability using the dynamic appraisal of situational aggression instrument.Australas Psychiatry. 2009; 17: 493-496https://doi.org/10.1080/10398560903289975
- Verbal de-escalation of the agitated patient: consensus statement of the American Association for emergency psychiatry project BETA de-escalation workgroup.West J Emerg Med. 2012; 13: 17-25https://doi.org/10.5811/westjem.2011.9.6864
- A quality improvement project on agitation management in the emergency department.J Emerg Nurs. 2021; 47 (e3): 390-399https://doi.org/10.1016/j.jen.2021.01.005
- The dynamic appraisal of situational aggression: an instrument to assess risk for imminent aggression in psychiatric inpatients.Behav Sci Law. 2006; 24: 799-813https://doi.org/10.1002/bsl.741
- The DASA, accuracy and risk assessment.Australas Psychiatry. 2010; 18: 586-587https://doi.org/10.3109/10398562.2010.526215
- Using the Dynamic Appraisal of Situational Aggression with mental health inpatients: a feasibility study.Patient Preference Adherence. 2016; 10: 691-701https://doi.org/10.2147/ppa.s103840
- Implementation of a violence risk assessment tool on a safety-net inpatient psychiatry unit.Gen Hosp Psychiatry. 2017; 47: 114-115https://doi.org/10.1016/j.genhosppsych.2017.03.003
- Predictive power of the DASA-IV: variations in rating method and timescales.Int J Ment Health Nurs. 2018; 27: 1661-1672https://doi.org/10.1111/inm.12464
- Implementation of the dynamic appraisal of situational aggression in inpatient mental health.Perspect Psychiatr Care. 2022; 58: 1153-1159https://doi.org/10.1111/ppc.12915
- Unreported workplace violence in nursing.Int Nurs Rev. 2014; 61: 344-351https://doi.org/10.1111/inr.12106
- A systematic review of the literature: workplace violence in the emergency department.J Clin Nurs. 2011; 20: 1072-1085https://doi.org/10.1111/j.1365-2702.2010.03342.x
- The Joint Commission’s new and revised workplace violence prevention standards for hospitals: a major step forward toward improved quality and safety.Jt Comm J Qual Patient Saf. 2022; 48: 241-245https://doi.org/10.1016/j.jcjq.2022.02.001
- Nurses’ attitudes towards the reporting of violence in the emergency department.Australas Emerg Nurs J. 2016; 19: 75-81https://doi.org/10.1016/j.aenj.2015.03.006
- Frequency and barriers of reporting workplace violence in nurses: an online survey in China.Int J Nurs Sci. 2020; 8: 65-70https://doi.org/10.1016/j.ijnss.2020.11.006
- Literature synthesis: patient aggression risk assessment tools in the emergency department.J Emerg Nurs. 2016; 42: 19-24https://doi.org/10.1016/j.jen.2015.01.023
- Using dynamic risk and protective factors to predict inpatient aggression: reliability and validity of START assessments.Psychol Assess. 2012; 24: 685-700https://doi.org/10.1037/a0026668
- Brief psychiatric rating scale–excited component (BPRS-EC) and neuropsychological dysfunction predict aggression, suicidality, and involuntary treatment in first-episode psychosis.Schizophr Res. 2012; 134: 273-278https://doi.org/10.1016/j.schres.2011.12.002
- Violence risk–assessment screening tools for acute care mental health settings: literature review.Arch Psychiatr Nurs. 2019; 33: 112-119https://doi.org/10.1016/j.apnu.2018.08.012
- Predictive validity and psychiatric nursing Staff’s perception of the clinical usefulness of the French version of the dynamic appraisal of situational aggression.Issues Ment Health Nurs. 2012; 33: 670-675https://doi.org/10.3109/01612840.2012.697254
- Evaluating the impact of an electronic application of the dynamic appraisal of situational aggression with an embedded aggression prevention protocol on aggression and restrictive interventions on a forensic mental health unit.Int J Ment Health Nurs. 2019; 28: 1186-1197https://doi.org/10.1111/inm.12630
- Examination of the predictive validity of the dynamic appraisal of situational aggression in two mental health units.Int J Ment Health Nurs. 2013; 22: 485-492https://doi.org/10.1111/inm.12011
- Structured assessments for imminent aggression in mental health and correctional settings: systematic review and meta-analysis.Int J Nurs Stud. 2020; 104103526https://doi.org/10.1016/j.ijnurstu.2020.103526
- Nonviolent crisis intervention training. Crisis Prevention Institute,
2020https://www.crisisprevention.com/Our-Programs/Nonviolent-Crisis-InterventionDate accessed: May 1, 2020
- The REDCap consortium: building an international community of software partners.J Biomed Inform. 2019; 95103208https://doi.org/10.1016/j.jbi.2019.103208
- Nurses and midwives reporting of workplace violence and aggression: an integrative review.Contemp Nurse. 2022; : 1-12https://doi.org/10.1080/10376178.2022.2070519
- emergency department visit rates related to mental health disorders, by age group and sex—National Hospital ambulatory medical care survey, United States, 2016-2018.MMWR Morb Mortal Wkly Rep. 2020; 69: 1838https://doi.org/10.15585/mmwr.mm6948a13
Bonnie Hamrick is a Nurse Manager, Atrium Health, Charlotte, NC. ORCID identifier: https://orcid.org/0000-0002-4402-2725.
Tracy Van Hassel is the Director of Informatics, South Carolina Department of Mental Health, Columbia, SC. ORCID identifier: https://orcid.org/0000-0001-9554-6388.
Dorinda Snyder is a Service Line Nurse Educator, Atrium Health, Charlotte, NC. ORCID identifier: https://orcid.org/0000-0003-2092-4262.
Casey Stephens is an Associate Health Services Researcher, Atrium Health, Charlotte, NC. ORCID identifier: https://orcid.org/0000-0003-0792-5092.
Published online: October 19, 2022
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