The Imminent Risk Rating Scale (IRRS): An effective tool for identifying inpatients at increased risk for violence

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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_at_cdha.nshealth.ca

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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. Whats to like?
• 6. Where are we heading with the tool?

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Inpatient Violence

• Though there is abundant attention / procedure
  for addressing clinical issues (symptoms,
  treatment) on psychiatric units, not the same for
  aggression
• East Coast Forensics 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

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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

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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

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

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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

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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

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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

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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?

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IRRS A Case Example

• Gordon IRRS Scores / Behaviour

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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

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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.

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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

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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

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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.