The Imminent The Imminent Risk Rating Scale (IRRS):Risk Rating Scale (IRRS):

AAn effective tool for identifying n effective tool for identifying inpatients at increased risk for inpatients at increased risk for

violenceviolence

Dr. Andrew StarzomskiDr. Andrew Starzomski

PsychologistPsychologist

East Coast Forensic HospitalEast Coast Forensic Hospital

Capital Health, Halifax, Nova Capital Health, Halifax, Nova ScotiaScotia

andrew.starzomski@cdha.nshealth.caandrew.starzomski@cdha.nshealth.ca

Presentation Objectives:Presentation Objectives:

• 1. The problem of inpatient violence 1. The problem of inpatient violence • 2. The challenge of ‘short term’ risk 2. The challenge of ‘short term’ risk

assessmentassessment• 3. What is the IRRS, and what is ‘in’ it?3. What is the IRRS, and what is ‘in’ it?• 4. A quick case study 4. A quick case study • 5. What’s to like?5. What’s to like?• 6. Where are we heading with the tool?6. Where are we heading with the tool?

Inpatient ViolenceInpatient Violence

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

• East Coast Forensic’s Mentally Ill East Coast Forensic’s Mentally Ill Offender Unit (court-ordered Offender Unit (court-ordered assessments) in ‘01/’02: assessments) in ‘01/’02: – 55 violent incidents of 169 admissions; 55 violent incidents of 169 admissions;

staff victim 56% of time, co-patient staff victim 56% of time, co-patient victim 44% of timevictim 44% of time

Inpatient ViolenceInpatient Violence

• Consequences?Consequences?– Injury to co-clients/staff, related costsInjury to co-clients/staff, related costs– Staff focus: clinical/treatment vs ?Staff focus: clinical/treatment vs ?– Nature / quality / rates of recovery?Nature / quality / rates of recovery?– Public perception / unease about Public perception / unease about

seeking care for self / family?seeking care for self / family?– Shortage of trained heath care Shortage of trained heath care

professionals due to attritionprofessionals due to attrition

Why Create a New Tool?Why Create a New Tool?• Existing tools solely addressing individual-Existing tools solely addressing individual-

oriented variables (e.g., symptoms, mental oriented variables (e.g., symptoms, mental state) are missing a great deal… therefore state) are missing a great deal… therefore incomplete as an approach or orientation incomplete as an approach or orientation to the issueto the issue

• Steinert: necessity of evaluating person-Steinert: necessity of evaluating person-environment fit and interactionenvironment fit and interaction

• Need for a Need for a briefbrief measure capable of measure capable of detecting change in key variables that can detecting change in key variables that can occur occur quicklyquickly– Other existing measures are lengthier and Other existing measures are lengthier and

without a day-to-day focuswithout a day-to-day focus

7

Psychologists, and Psychologists, and others, love a good others, love a good

measure of bad measure of bad behaviourbehaviour

What is IN the IRRS?What is IN the IRRS?

• Seven domains are evaluated:Seven domains are evaluated:– History of ViolenceHistory of Violence– Subtypes (re: personality & psychosis)Subtypes (re: personality & psychosis)– Acuity of hostility / angerAcuity of hostility / anger– StressStress– Communication impairmentCommunication impairment– Social status / relationship problemsSocial status / relationship problems– Milieu strainMilieu strain

What is the IRRS?What is the IRRS?

• Checklist format/ info rated by Checklist format/ info rated by trained clinician based on file, trained clinician based on file, observation infoobservation info

• Quickly addresses a set of historical Quickly addresses a set of historical and dynamic variables associated and dynamic variables associated with short-term violence riskwith short-term violence risk

• Developed with breadth in mind: Developed with breadth in mind: there are MANY pathways / causes / there are MANY pathways / causes / forms of aggressionforms of aggression

• 7 items get rated on a 0-1-2 scale7 items get rated on a 0-1-2 scale

How is the IRRS used?How is the IRRS used?

• Typically:Typically:– After training, nurses rate new inpatients After training, nurses rate new inpatients

based on file review, info emerging from based on file review, info emerging from observations / interview… inter-rating observations / interview… inter-rating evaluationevaluation

– Information is shared with staff, areas of Information is shared with staff, areas of uncertainty flagged / more info needed, uncertainty flagged / more info needed, intervention strategies consideredintervention strategies considered

– Ratings every 4-7 days as-needed…Ratings every 4-7 days as-needed…– Focus on inpatient environmentFocus on inpatient environment

IRRS: A Case ExampleIRRS: A Case Example

• Gordon:Gordon: – 41 year old single male from rural NS41 year old single male from rural NS– NCR on charges Mischief, Assault Peace OfficerNCR on charges Mischief, Assault Peace Officer– Dx: features of psychosis, mania, OCD, Dx: features of psychosis, mania, OCD,

behavioural / personality issues...behavioural / personality issues...– Tx: atypicals, mood stabilizers, anxiolytics, ECTTx: atypicals, mood stabilizers, anxiolytics, ECT

• some lengthy periods of stability and decent some lengthy periods of stability and decent community functioning over last several yearscommunity functioning over last several years

– Aggression as tactic for attention, confinementAggression as tactic for attention, confinement– Back at ECFH since summer 08 / group home Back at ECFH since summer 08 / group home

aggressionaggression

IRRS: A Case ExampleIRRS: A Case Example

• Gordon: Gordon: – As of late winter 2009:As of late winter 2009:

• Ongoing uncertainty about dischargeOngoing uncertainty about discharge• Implementation of a new rehabilitation agenda Implementation of a new rehabilitation agenda

via the “Treatment Mall”: social / lifestyle via the “Treatment Mall”: social / lifestyle stressstress

• Uncertainty that maintenance ECT doing muchUncertainty that maintenance ECT doing much• Recurrence of aggressive thoughts, Recurrence of aggressive thoughts,

tangentiality, communication impairments, tangentiality, communication impairments, labilitylability

• Aggression – numerous times, toward pts & Aggression – numerous times, toward pts & staffstaff

• How does this translate to IRRS ratings?How does this translate to IRRS ratings?

IRRS: A Case ExampleIRRS: A Case Example

• Gordon: IRRS Scores / BehaviourGordon: IRRS Scores / Behaviour

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2.00

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8.00

10.00

12.00

14.00

1/15 3/11 3/23 3/27 3/30 4/8 4/13 4/25 5/7 5/11

IRRS Aggression

IT WORKS!IT WORKS!

- 60 patients at MIOU tracked through 2006-60 patients at MIOU tracked through 2006-20072007

- Never-violent patients score sig lower on Never-violent patients score sig lower on average during admission than those who average during admission than those who were aggressive once or morewere aggressive once or more

- Scores vary meaningfully over course of Scores vary meaningfully over course of admission for those who are violent (IRRS admission for those who are violent (IRRS reductions linked to better adjustment on the reductions linked to better adjustment on the unit)unit)

- IRRS scores hold up for predicting verbal IRRS scores hold up for predicting verbal and physical aggression for about 10 days and physical aggression for about 10 days (not just 24-72 hours), after which time (not just 24-72 hours), after which time ratings are no longer able to predict ratings are no longer able to predict aggressive behaviouraggressive behaviour

Other Evidence of Utility: Other Evidence of Utility: Staff PerspectivesStaff Perspectives

• From the beginning I thought it was an interesting From the beginning I thought it was an interesting idea.idea.

• Easy to doEasy to do

• Anticipate it becoming a helpful tool to help Anticipate it becoming a helpful tool to help predict possible violence.predict possible violence.

• Helps with awareness for aggressionHelps with awareness for aggression

• Has been quite accurate in some casesHas been quite accurate in some cases

• Should be used in all mental health facilities.Should be used in all mental health facilities.

Benefits of the IRRSBenefits of the IRRS

• Common languageCommon language• Staff know their patients better and Staff know their patients better and

as a result are able to recognize / as a result are able to recognize / identify riskidentify risk

• Early recognition and appropriate Early recognition and appropriate response (interventions) response (interventions)

• Interdisciplinary workInterdisciplinary work

Potential Benefits Potential Benefits of the IRRS… pending of the IRRS… pending

evaluationevaluation• Hopefully: decreased incidents of Hopefully: decreased incidents of

aggression… needs evaluationaggression… needs evaluation• Hopefully: Increased staff satisfaction and Hopefully: Increased staff satisfaction and

retention… needs more formal evaluationretention… needs more formal evaluation• Hopefully: Increased quality of patient Hopefully: Increased quality of patient

care… needs evaluation care… needs evaluation

Where do we go from Where do we go from here?here?

• More data, more evaluationMore data, more evaluation• Other settings: short term / crisis Other settings: short term / crisis

unit, mainstream Emergency suites, unit, mainstream Emergency suites, youth, correctional health unitsyouth, correctional health units

• A tool to help create safer health A tool to help create safer health settings: building awareness, settings: building awareness, promotion, etc.promotion, etc.