Violence Reduction in Neurology

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Violence Reduction in Neurology

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Grand Rounds, Kirby Forensic Psychiatric Center, Wards Island, New ... Avoid apparent wrongdoing. Misinterpretations. Misconstrued conclusions. Required in 2005 ... – PowerPoint PPT presentation

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Title: Violence Reduction in Neurology

1
Violence Reduction in Neurology

2

Clinician Safety References
Brasic JR. Clinician safety. Grand Rounds, Kirby
Forensic Psychiatric Center, Wards Island, New
York, May 23, 2002 videotape
Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005 Available at http//www.emedicine.
com/neuro/topic713.htm.
Brasic JR, Fogelman D Clinician safety.
Psychiatric Clinics of North America
199923(4)923-940

Victims of Patient Assault

Physicians
Nurses
Social workers
Allied health personnel
Emergency teams

Administrators
Law enforcement
Corrections
Other patients
Visitors

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005 . Available at http//www.emedicine
.com/neuro/topic713.htm. Crilly, et al. Violence
towards emergency department nurses by patients.
Accid Emerg Nurs 2004 12 67-73
4

Violence in Schizophrenia
Four times more common than in people without
mental illness
Psychotic symptoms
Alcohol abuse
Psychopathy
Antisocial personality disorder
Special education

Violence in Hospitalized Male Patients With
Paranoid Schizophrenia
Alcohol abuse
Drug abuse
Good ability to infer cognitive mental states
of others
High hostility
Poor empathy
Youth

Violence in First Episode Psychosis
Involuntary admission
Drug abuse
Poor insight
High psychopathology

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine
.com/neuro/topic713.htm Foley, et al. Incidence
and clinical correlates of aggression and
violence at presentation in patients with first
episode psychosis. Schizophrenia Res 2005 72
161-168
7

Research Review
Avoid apparent wrongdoing
Misinterpretations
Misconstrued conclusions
Required in 2005

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine
.com/neuro/topic713.htm. Foley, et al. Incidence
and clinical correlates of aggression and
violence at presentation in patients with first
episode psychosis. Schizophrenia Res 2005 72
161-168
8

Hypotheses
Violent patients have medical disorders (eg,
metabolic, toxic)
Violent patients have substance abuse
Violent patients have reduced empathy
Violent patients have learning disorders
Violent patients have paranoid schizophrenia

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine.
com/neuro/topic713.htm
9

Goals
To measure medical disorders
(eg, metabolic, toxic)
To measure substance use
To measure empathy
To measure learning disorders
To measure psychiatric disorders

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine.
com/neuro/topic713.htm.
10

Subjects
Probability sampling
Statistical theory applies
Can generalize to total population
Nonprobability sampling (Cochran, 1977)
Cannot generalize to total population

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine
.com/neuro/topic713.htm. Brašic, et al. Quality
assurance of the community placement of
institutional residents. German Journal of
Psychiatry 20025(4)95-114 http//www.gjpsy.uni-
goettingen.de/gjp-article-brasic-quality.pdf Brasi
c, et al., Psychoactive Medication Quality
Assurance Rating Survey (PQRS). Journal of
Developmental and Physical Disabilities
19979311-336 Cochran WG. Sampling Techniques,
3rd ed New York John Wiley Sons, 1977
11

Subjects
Probability sampling
Total population (Brasic et al, 2002)
Simple random sample of ten percent (Brasic et
al, 1997)
Need for probability sampling (Cochran, 1977)
Generalize to total population

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine.
com/neuro/topic713.htm. Brašic, et al. Quality
assurance of the community placement of
institutional residents. German Journal of
Psychiatry 20025(4)95-114 http//www.gjpsy.uni-
goettingen.de/gjp-article-brasic-quality.pdf Brasi
c, et al., Psychoactive Medication Quality
Assurance Rating Survey (PQRS). Journal of
Developmental and Physical Disabilities
19979311-336 Cochran WG. Sampling Techniques,
3rd ed New York John Wiley Sons, 1977
12

Subjects
Nonprobability sampling (Cochran, 1977)
Readily accessible (Cochran, 1977)
Haphazard selection (Cochran, 1977)
Typical units (Cochran, 1977)
Volunteers (Cochran, 1977)
Cannot generalize to total population

Consent From Patients
Institutional Review Board
Justify need to provide for the safety of
patients and staff
Admission protocol
Written informed consent (Brasic, 2003 Brasic
and Davis, 1998 )
Record (Audio Video tape, CD, DVD) the
consenting procedure (Brasic, 2003 Brasic and
Davis, 1998 )

Brasic JR Pervasive developmental disorder
autism. eMedicine Pediatric Journal serial
online. November 3, 2003. Available at
http//www.emedicine.com/ped/topic180.htm.
Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine
.com/neuro/topic713.htm. Brasic JR, Davis E
Obtaining informed consent for research from
persons with Parkinsons disease and movement
disorders. Movement Disorders 199813 (supplement
2)206 abstract
14

Consent From Staff
Institutional Review Board
Justify need to provide for the safety of
patients and staff
Employment application include study protocol
Written informed consent (Brasic, 2003 Brasic
and Davis, 1998 )
Record (Audio Video tape, CD, DVD) the
consenting procedure (Brasic, 2003 Brasic and
Davis, 1998 )

Subjects Baseline Assessment
On admission (for control nonviolent patients)
Research team independent of clinical and
administrative hierarchy
All patients
A simple random sample of 10 of all patients

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine.
com/neuro/topic713.htm.
16

Subjects Acute Assessment
Perpetrator patients
Immediately after violent episodes
Research team independent of clinical and
administrative hierarchy

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine.
com/neuro/topic713.htm.
17

Subjects Follow-up Assessment
Perpetrator patients
After intervention (eg, training, education,
behavior modification, medication) for violent
episodes
Research team independent of clinical and
administrative hierarchy

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine.
com/neuro/topic713.htm.
18

Tools to Measure Patient Characteristics
Substance abuse, current and past
Criminal record, current and past
Violence, current and past
Employment status
Demographic Coding Form (Brasic, 2003, 2004)

Abu-Akel A, Abushua'leh K 'Theory of mind' in
violent and nonviolent patients with paranoid
schizophrenia. Schizophrenia Res 2004 69
45-53 Brasic JR. Documentation of demographic
data. Psychological Reports 200393151-152 Brasic
JR. Documentation of ethnicity. Psychological
Reports 200495859-861 Brasic JR, Ainsworth J
Clinical safety in neurology. eMedicine Neurology
Journal serial online. 2005. Available at
http//www.emedicine.com/neuro/topic713.htm.
19

Tools to Assess Patients
Hostility Scale (hostility, suspiciousness, and
uncooperativeness items) of the Brief
Psychiatric Rating Scale (BPRS) (Overall and
Gorham, 1962)
Negative Symptom Scale (flat affect, emotional
withdrawal, and motor retardation items of the
BPRS) (Overall and Gorham, 1962)
Positive Symptom Scale (concept
disorganization, hallucinatory behavior, and
unusual thoughts items of the BPRS) (Overall and
Gorham, 1962)
Empathy tasks (Abu-Akel and Abushualeh, 2004)
Modified Overt Aggression Scale (Kay et al,
1988)
Maudsley Violence Questionnaire (Walker, 2005)

Abu-Akel A, Abushua'leh K 'Theory of mind' in
violent and nonviolent patients with paranoid
schizophrenia. Schizophrenia Res 2004 69
45-53 Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine.
com/neuro/topic713.htm. Foley, et al. Incidence
and clinical correlates of aggression and
violence at presentation in patients with first
episode psychosis. Schizophrenia Res 2005 72
161-168 Kay SR, et al., (1988) Profiles of
aggression among psychiatric patients. I. Nature
and prevalence. J Nervous Mental Disease,
1988176 539-546 Overall JE, Gorham DR. 1962.
The Brief Psychiatric Rating Scale. Psychol Rep
10799-812 Walker JS. The Maudsley Violence
Questionnaire initial validation and
reliability. Personality and Individual
Differences 200538187-201
20

Tools to Measure Staff Characteristics
Substance abuse, current and past
Criminal record, current and past
Violence, current and past
Employment status
Age
Gender
Length of employment
Training in management of violence
Demographic Coding Form (Brasic, 2003)

Abu-Akel A, Abushua'leh K 'Theory of mind' in
violent and nonviolent patients with paranoid
schizophrenia. Schizophrenia Res 2004 69
45-53 Brasic JR. Documentation of demographic
data. Psychological Reports 200393151-152 Brasic
JR, Ainsworth J Clinical safety in neurology.
eMedicine Neurology Journal serial online.
2005. Available at http//www.emedicine.com/neuro
/topic713.htm. Crilly, et al Violence towards
emergency department nurses by patients. Accid
Emerg Nurs 2004 12 67-73
21

Debriefing of Patient
Immediately after violent incident
Interviewer unfamiliar with patient
Interviewer from outside team for study only
Do not blame patient
Maintain polite, neutral, calm demeanor
Record (Audio Video tape, CD, DVD) interview
for blind rating by outside colleagues
unfamiliar with patient
Ask open-ended questions
Elicit detailed description of incident
Precipitating events
Cognitive awareness of injury
Intent to perpetrate violence

Treatment of Patient
Immediately after violent incident
Physical examination of patient
Therapy for acute injuries
Do not blame patient
Maintain polite, neutral, calm demeanor
Record (Audio Video tape, CD, DVD) examination
of patient for blind rating by outside
colleagues unfamiliar with patient
Immediate toxicology
Immediate basic metabolic profile
Immediate hematological profile
Treatment plan for posttraumatic stress disorder
and other anxiety disorders
Observe closely to prevent further violence

Debriefing of Staff
Immediately after violent incident
Interviewer unfamiliar with staff
Interviewer from outside team for study only
Do not blame staff
Maintain polite, neutral, calm demeanor
Record (Audio Video tape, CD, DVD) interview
for blind rating by outside colleagues
unfamiliar with patient
Ask open-ended questions
Elicit detailed description of incident
Precipitating events
Cognitive awareness of injury
Intent to perpetrate violence

Treatment of Staff
Immediately after violent incident
Physical examination of staff
Therapy for acute injuries
Do not blame staff
Maintain polite, neutral, calm demeanor
Record (Audio Video tape, CD, DVD) examination
of patient for blind rating by outside
colleagues unfamiliar with staff
Treatment plan for posttraumatic stress disorder
and other anxiety disorders
Observe closely to prevent further violence

Debriefing of Unit
Immediately after violent incident
Mental health clinicians (consultation-liaison
psychiatrist, psychologist, nurse, social
worker) unfamiliar with unit
Do not blame staff
Maintain polite, neutral, calm demeanor
Ask open-ended questions
Elicit detailed description of incident
Precipitating events
Cognitive awareness of injury
Intent to perpetrate violence

Treatment of Unit
Immediately after violent incident
Mental health clinicians (consultation-liaison
psychiatrist, psychologist, nurse, social
worker) unfamiliar with unit
Do not blame staff
Maintain polite, neutral, calm demeanor
Express concern for welfare of members of unit
Identify posttraumatic stress disorder (PTSD)
and other sequelae of incident
Institute group counseling
Institute individual treatments for staff with
PTSD
Protect unit from future violence

Mathematical Modeling
Poisson distribution, a mathematical model for
rare events
Models of airplane crashes, automobile accidents
Clustering of events in time and space
Seasonal variation
Temporal variation, eg, evenings, nights,
weekends
Nursing unit variation, eg, admission, maximal
security, violent patients
Staff variation, eg, students, new staff

Statistical Analysis
Nonparametric tests for categorical data
(clinical data, demographic data, empathy
scores) between violent and nonviolent patients
using baseline assessments
Logistic regression models to predict violence
on clinical data, demographic data, empathy
scores, involuntary admission status,
employment status, insight

Clinical Trials For Patient Assault on Staff
Baseline assessment
Intervention
Staff training
Patient training
Follow-up assessment

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine.
com/neuro/topic713.htm.
30

Program to Reduce
Violence in Neurology
Prepare manual to detail procedures to minimize
violence
Present nationally and internationally
Publish results

Brasic JR, Ainsworth J Clinical safety in
neurology. eMedicine Neurology Journal serial
online. 2005. Available at http//www.emedicine
.com/neuro/topic713.htm.

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