title: Predicting inpatient violence using an extended version of the Brøset-Violence-Checklist: instrument development and clinical application Factors associated with the use of physical restraints for agitated patients in psychiatric emergency rooms. Psychiatric emergencies in prehospital emergency medical systems: a prospective comparison of two urban settings. Reliability of the Sedation-Agitation Scale between nurses and doctors. Prevalence and variation of physical restraint use in acute care settings in the US. Sedation assessment tool to score acute behavioural disturbance in the emergency department. Aggressive behaviors in the psychiatric emergency service The Psychiatric Emergency Research Collaboration-01: methods and results. Reliability of the Brazilian version of HCR-20 Assessing Risk for Violence. Rapid tranquilization for agitated patients in emergency psychiatric rooms: a randomized trial of olanzapine, ziprasidone, haloperidol plus promethazine, haloperidol plus midazolam and haloperidol alone. [Psychiatric emergency service in a university general hospital: a prospective study]. The Overt Agitation Severity Scale for the objective rating of agitation. [Are restraints used too frequently? Indications, incidence and conditions for restraint in a general psychiatric department. A prospective study]. Psychometric Testing of the Agitation Severity Scale for Acute Presentation Behavioral Management Patients in the Emergency Department Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting. Pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus promethazine. Validation of the behavioural activity rating scale (BARS): A novel measure of activity in agitated patients Physical restraints versus seclusion room for management of people with acute aggression or agitation due to psychotic illness (TREC-SAVE): a randomized trial. Effects of a psychiatric intensive care unit in an acute psychiatric department
abstract: Background Patient aggression is a common problem in acute psychiatric wards and calls for preventive measures . The timely use of preventive measures presupposes a preceded risk assessment . The Norwegian Brøset-Violence-Checklist ( BVC ) is one of the few instruments suited for short-time prediction of violence of psychiatric in patients in routine care . Aims of our study were to improve the accuracy of the short-term prediction of violence in acute inpatient setting s by combining the Brøset-Violence-Checklist ( BVC ) with an overall subjective clinical risk- assessment and to test the application of the combined measure in daily practice . Method We conducted a prospect i ve cohort study with two sample s of newly admitted psychiatric patients for instrument development ( 219 patients ) and clinical application ( 300 patients ) .  Risk of physical attacks was assessed by combining the 6-item BVC and a 6-point score derived from a  Visual Analog Scale . Incidents were registered with the Staff Observation of Aggression Scale-Revised SOAS-R. Test accuracy was described as the area under the receiver operating characteristic curve ( AUCROC ) . Results The AUCROC of the new VAS-complemented BVC-version ( BVC-VAS ) was 0.95 in and 0.89 in the derivation and validation study respectively . Conclusion The BVC-VAS is an easy to use and accurate instrument for systematic short-term prediction of violent attacks in acute psychiatric wards . The inclusion of the VAS-derived data did not change the accuracy of the original BVC OBJECTIVE To examine factors associated with physical restraint in psychiatric emergency rooms . METHOD We extracted variables likely to predict use of physical restraints from a large r and omised trial undertaken in three psychiatric emergency rooms in Rio de Janeiro . We fitted a Bayesian binary multivariate model using only variables clearly preceding the restraints . RESULTS Of 301 agitated , aggressive people admitted to emergency rooms , 73 ( 24 % ) were restrained during the first 2 h of admission . In Rio , younger people ( OR=1.03 for each year younger ) , exhibiting intense ( OR=2.53 ) or extreme agitation ( OR=7.71 ) , thought to result from substance misuse ( OR=1.75 ) or diagnoses other than psychosis ( OR=1.88 ) , arriving in the morning ( OR=1.64 ) were at greater risk of  physical restraints  than older , less severely aggressive or agitated people , arriving at the hospital during the afternoon or night . Hospital , gender , first admission to hospital and medication were not associated with risk of being restrained . CONCLUSION Restraint practice s in Rio are predictable and based on a limited clinical assessment . Predictive factors for physical restraint may vary worldwide , but should be monitored and studied to assist training , and to establish programs to evaluate and refine this controversial practice BACKGROUND Psychiatric emergency situations ( PES ) are of high importance to the German prehospital physician-based emergency medical system . So far , however , no prospect i ve studies regarding the incidence of PES have been performed , neither have effects of training programs on diagnostic and therapeutic accuracy been studied . METHOD The protocol s of two emergency medical services ( EMS ) were collected and analyzed prospect ively .  Emergency physicians ( EPs ) in Kaiserslautern ( KL ) attended a st and ardized educational program and underwent daily supervision .  EPs in Homburg ( HOM ) had not been informed about the study . In KL , sociodemographic variables were collected . An investigator who was not involved in the individual EMS mission assessed the correct classification of PES . RESULTS Among all calls for an EP , 11.8 % were classified as PES . There was no difference between the two centers . Correct classification of PES in KL was significantly higher than that in HOM ( 94.3 % vs. 80.6 % ) . Documentation of suicidal behavior was deficient in both centers . EPs in KL gave verbal crisis intervention significantly more often , administered less medication overall , and dispensed more specific drugs in psychotic disorders and significantly less drugs in substance abuse disorders . Patients were more often treated at the scene and were less often transported to a hospital . Some sociodemographic variables were associated with psychiatric morbidity of treatment . CONCLUSION Accounting for 12 % of all missions , psychiatric emergencies are a frequent reason for calls for EPs , equaling trauma-related and neurological emergencies . The most frequent reasons for calls were alcohol intoxication , states of agitation and suicidal behavior . The diagnostic and therapeutic accuracy of EPs may be improved with a concise st and ardized teaching program This study determined the inter-rater reliability of the  Sedation-Agitation Scale ( SAS ) when used by staff in a tertiary level general intensive care unit ( ICU ) . The study was design ed to answer the question in the ' real world ' , with minimum patient exclusion criteria , do nurses and doctors rate ICU patient 's sedation levels using the SAS similarly ? A convenient sample of 35 nursing and seven medical staff and a r and omly selected sample of 69 patients were used . A nurse and a doctor rated each patient simultaneously using the SAS , with a systematic five-stage arousal process . The results showed that there was exact agreement between the nurses ' and doctors ' scores in 74 % of assessment s. The weighted kappa finding of 0.82 indicates very good agreement ( reliability ) . The mean SAS scores recorded for nurses ( 2.33+/-1.21 ) and doctors ( 2.36+/-1.35 ) were similar . Intraclass correlations for single measures ( r=.921 , p<.001 ) and average measures ( r=.959 , p<.001 ) indicated individuals who completed multiple ratings did not introduce bias . Where there was a difference between the paired ratings , these were only one level of the SAS away from each other . This research indicates nurses and doctors rate patients ' levels of sedation similarly using the SAS . It also provides support for the use of the instrument in general ICUs outside the USA . Research is now needed to determine the value of the SAS in guiding clinical decision-making related to sedation management PURPOSE To describe  physical restraint ( PR ) rates and context s in U.S. hospitals . DESIGN This 2003 - 2005 descriptive study was done to measure PR prevalence and context s ( census , gender , age , ventilation status , PR type , and rationale ) at 40 r and omly selected acute care hospitals in six U.S. metropolitan areas . All units except psychiatric , emergency , operative , obstetric , and long-term care were included . METHODS On 18 r and omly selected days between 0500 and 0700 ( 5:00 am and 7:00 am ) , data collectors determined PR use and context s via observation and nurse report . FINDINGS PR prevalence was 50 per 1,000 patient days ( based on 155,412 patient days ) . Preventing disruption of therapy was the chief reason cited . PR rates varied by unit type , with adult ICU rates the highest obtained . Intra- and interinstitutional variation was as high as 10-fold . Ventilator use was strongly associated with PR use . Elderly patients were over-represented among the physically restrained on some units ( e.g. , medical ) but on many unit types ( including most ICUs ) their PR use was consistent with those of other adults . CONCLUSIONS Wide rate variation indicates the need to examine administratively mediated variables and the promotion of unit-based improvement efforts . Anesthetic and sedation practice s have contributed to high variation in ICU PR rates . Determining the types of units to target to achieve improvements in care of older adults requires study of PR sequelae rate by unit type OBJECTIVE The objective of the study was to evaluate the effectiveness of the  sedation assessment tool ( SAT ) in assessing patient response to treatment for acute behavioural disturbance ( ABD ) . METHODS The SAT is a simplified version of the altered mental status score ( AMSS ) and is a 7-point scale assessing levels of agitation and sedation using only two descriptors . To assess the SAT we firstly compared plots of the SAT and the  AMSS  versus time in patients with ABD recruited to a clinical trial . AMSS were converted to the SAT for this comparison . Second , the sensitivity and specificity were calculated for an increase in the SAT to + 2 or + 3 as a predictor of whether additional sedation was required in a prospect i ve cohort of 138 patients . Third , interrater reliability was assessed using two individuals to score the same patient at two different time points and finally the time to record the score was measured . RESULTS Plots of AMSS and  SAT  for 91 patients in the clinical trial illustrated similar trends in agitation/sedation . Seventeen of 138 patients in the second cohort had an increase in the SAT .  Fifteen of 17 ( 88 % ) received additional sedation . The sensitivity and specificity of the SAT for additional sedation was 100 % ( 95 % CI 75 - 100 % ) and 98 % ( 95 % CI 94 - 100 % ) , respectively . The median time for staff to assign the SAT was 10 s ( range 3 - 15 s ) . Interrater reliability was high with a kappa of 0.87 . CONCLUSION The SAT is a simple , rapid and useful measure of the level of agitation/sedation in patients with ABD . Increases in the score reliably indicated the need for further sedation Introduction : Studies of aggressive behaviors in a nonforensic mental health setting have focused primarily on the inpatient ward and , on event prediction , using behavior-based clinical rating scales . Few studies have specifically targeted aggressive behaviors in the psychiatric emergency service or determined whether assessing the demographic and clinical characteristics of such patients might prove useful for their more rapid identification . Methods : We used a prospect ively acquired data base of over 20,900 visits to four services in the province of Quebec , Canada , over a two-year period from September 2002 onwards . A maximum of 72 variables could be acquired per visit . Visits with aggression ( any verbally or physically intimidating behavior ) , both present and past , were tagged . Binary logistic regressions and cross-tabulations were used to determine whether the profile of a variable differed in visits with aggression from those without aggression . Results : About 7 % of visits were marked by current aggression ( verbal 49 % , physical 12 % , verbal and physical 39 % ) . Including visits with a “ past only ” history of aggression increased this number to 20 % . Variables associated with aggression were gender ( male ) , marital status ( single/separated ) , education ( high school or less ) , employment ( none ) , judicial history ( any type ) , substance abuse ( prior or active ) , medication compliance ( poor ) , type of arrival to psychiatric emergency services ( involuntary , police , judiciary , l and lord ) , reason for referral ( behavioral dyscontrol ) , diagnosis ( less frequent in anxiety disorders ) , and outcome ( more frequently placed under observation or admitted ) . Conclusion : Our results suggest that many state-independent variables are associated with aggressive behaviors in the psychiatric emergency service . Although their sum may not add up to a specific patient profile , they can nevertheless be useful in service planning , being easily integrated alongside state-dependent rating scales in a triage and /or observation instrument for daily use in the psychiatric emergency service OBJECTIVE To describe the Psychiatric Emergency Research Collaboration ( PERC ) , the methods used to create a structured chart review tool and the results of our multicenter study . METHOD Members of the PERC Steering Committee created a structured chart review tool design ed to provide a comprehensive picture of the assessment and management of psychiatric emergency patients . Ten primary indicators were chosen based on the Steering Committee 's professional experience , the published literature and existing consensus panel guidelines . Eight emergency departments completed data abstract ion of 50 r and omly selected emergency psychiatric patients , with seven providing data from two independent raters . Inter-rater reliability ( Kappas ) and descriptive statistics were computed . RESULTS Four hundred patient charts were abstract ed . Initial concordance between raters was variable , with some sites achieving high agreement and others not . Reconciliation of discordant ratings through re- review of the original source documentation was necessary for four of the sites . Two hundred eighty-five ( 71 % ) subjects had some form of laboratory test performed , including 212 ( 53 % ) who had urine toxicology screening and 163 ( 41 % ) who had blood alcohol levels drawn . Agitation was present in 220 ( 52 % ) , with 98 ( 25 % ) receiving a medication to reduce agitation and 22 ( 6 % ) being physically restrained . Self-harm ideation was present in 226 ( 55 % ) , while other-harm ideation was present in 82 ( 20 % ) . One hundred seventy-nine ( 45 % ) were admitted to an inpatient or observation unit . CONCLUSION Creating a common st and ard for documenting , abstract ing and reporting on the nature and management of psychiatric emergencies is feasible across a wide range of health care institutions OBJECTIVE Assessing risk for violence is a complex task often based on not objective or structured clinical evaluations . HCR-20 Assessing Risk for Violence has been used in several countries to increase the accuracy of this exam . The purpose of this study was to inform on central aspects of this instrument , as well as the results of the reliability assessment of the HCR-20 Assessing Risk for Violence in a Brazilian inpatient criminal population . METHOD Two examiners independently assessed a r and om sample of 30 patients that were under criminal commitment at the Mauricio Cardoso Forensic Psychiatric Institute RESULTS Mean consensus values means were as follows : Historical = 13.1 ; Clinical = 4.8 and Risk management = 5.8 . The value of the Intraclass Correlation Coefficient for the score of subscale Historical was 0.97 , for subscale Clinical it was 0.94 , and for subscale Risk management , 0.96 . As to the individual items of the HCR-20 Assessing Risk for Violence , the result of the Intraclass Correlation Coefficient was good to excellent ( mean = 0.97 ; interval , from 0.60 to 0.99 ) . CONCLUSION The interrater reliability of the Brazilian version of the  HCR-20 Assessing Risk for Violence scale was similar to the results of studies in other countries OBJECTIVE To compare the effectiveness of intramuscular olanzapine , ziprasidone , haloperidol plus promethazine , haloperidol plus midazolam and haloperidol alone as the first medication(s ) used to treat patients with agitation and aggressive behavior . METHOD One hundred fifty patients with agitation caused by psychotic or bipolar disorder were r and omly assigned under double-blind conditions to receive olanzapine , ziprasidone , haloperidol plus midazolam , haloperidol plus promethazine or haloperidol alone . The Overt Agitation Severity Scale , Overt Aggression Scale and Ramsay Sedation Scale were applied within 12 hours after the first dosage . RESULTS All medications produced a calming effect within one hour of administration , but only olanzapine and haloperidol reduced agitation by less than 10 points , and only olanzapine reduced aggression by less than four points in the first hour . After twelve hours , only patients treated with haloperidol plus midazolam had high levels of agitation and aggression and also more side effects . Ziprasidone , olanzapine and haloperidol alone had more stable results for agitation control , while ziprasidone , haloperidol plus promethazine and olanzapine had stable results for aggression control . CONCLUSION Olanzapine , ziprasidone , haloperidol plus promethazine , haloperidol plus midazolam and haloperidol were effective in controlling agitation and aggression caused by mental illness over 12 hours . Although all the drugs had advantages and disadvantages , haloperidol plus midazolam was associated with the worst results in all the observed parameters OBJECTIVES The aim was to carry out a prospect i ve study about the characteristics of the public seen at a psychiatric emergency room  and of its service . METHODS The data were acquired though a protocol developed for this study and applied to all the patients seen during two months . RESULTS 600 protocol s were filled out , corresponding to 96.5 % ( 487 patients ) of the attendance during the study period . Most of the patients seen were males , single , with a low educational level , professionally inactive and living with their families . The most frequent diagnoses were psychoactive substance use disorders ( 26.3 % ) , schizophrenia ( 15.5 % ) , manic episode ( 11.8 % ) , major depression ( 10.9 % ) and non-psychotic disorders ( 10.9 % ) . There were differences between gender in some diagnostic categories . After initial evaluation , 2/3 were medicated , ( 1/2 ) stayed under observation , and ( 1/4 ) stayed more than 10 hours in the service unit . About 20 % of the attendance result ed in hospitalization and 60 % in referrals to outpatient services . Discharges due to evasion represented only 2.0 % of the total . Returning service users did not differ from those seen only once to what concern marital status , professional situation and household conditions . However , returning users presented a higher frequency of previous hospitalization and psychotic disorders . CONCLUSIONS Individuals with severe psychiatric disorders were seen in an actual emergency situation . The psychiatric emergency service has been exp and ing its actions and has been an effective part of the mental health service network Two studies tested the reliability and validity of the  Overt Agitation Severity Scale ( OASS )  , a new instrument developed to define and objective ly rate the severity of  agitated behavior . The authors postulate that agitation should be conceptualized as vocal and motor behaviors on a continuum of expressions that extends from anxiety to aggression . Content validity through expert agreement was achieved in the development of test construction over a 2-year period . Results of two pilot studies ( n = 25 and n = 14 subjects ) established the reliability and validity of the OASS  to measure agitation severity . The OASS differs from other agitation scales in that it confines its rating exclusively to observable behavioral manifestations of agitation A 10-month prospect i ve study of 148 restraints on the acute psychiatric wards of a general hospital aim ed to describe the institutional context of restraints .  Nursing and medical staff were inquired according to a st and ardised procedure about ward atmosphere , staffing , medication and other factors . 81 % of restraints lasted up to 2 hours , danger of harm to others was found the principal indication criterion ( 70 % ) . 41 % restraints occurred during the first 3 days after admission , mainly within the late shift of nursing staff and outside the regular office hours of the doctors . Ward atmosphere was rated rather relaxed , whereas nursing staff twice as often as doctors rated medication as insufficient . Implication s for indication on the use of restraints and for future research are discussed Agitation is a vexing problem frequently observed in emergency department acute psychiatric patients , yet no instruments to measure agitation in this setting and population were found upon review of the literature . Previously developed agitation rating scales are limited by the length of observation they require , their need for participation by the patient , complexity in scoring , and a lack of validity in this setting and population . The purpose of this study was to psychometrically evaluate and refine an observation-based agitation scale for use with emergency department acute psychiatric patients . Using a method ological design , the 21-item Agitation Severity Scale was utilized to assess 270 adult psychiatric patients in the emergency setting in a prospect i ve , observational fashion . Reliability analysis , item analysis , exploratory factor analysis , and validity assessment s were completed . The relationship between Agitation Severity Scale scores and scores on the previously established Overt Agitation Severity Scale was evaluated . The instrument was reduced to 17 items representing four factors ( Aggressive Behaviors , Interpersonal Behaviors , Involuntary Motor Behaviors , and Physical Stance ) that accounted for nearly 70 % of observed variance , Cronbach 's & agr ; = 0.91 . Evidence of internal consistency reliability , equivalence reliability , construct validity , and convergent validity was established . Through this study , the 17-item Agitation Severity Scale demonstrated acceptable levels of reliability and validity when used with acute psychiatric patients in the emergency setting . This instrument holds promise as a method of enhancing clinical communication about agitation , evaluating the efficacy of interventions aim ed at decreasing agitation , and as a research tool BACKGROUND The pharmacological management of violence in people with psychiatric disorders is under- research ed . AIMS To compare interventions commonly used for controlling agitation or violence in people with serious psychiatric disorders . METHOD We r and omised 200 people to receive intramuscular lorazepam ( 4 mg ) or intramuscular haloperidol  ( 10 mg ) plus promethazine ( 25 - 50 mg mix ) . RESULTS At blinded assessment s 4 h later ( 99.5 % follow-up ) , equal numbers in both groups ( 96 % ) were tranquil or asleep . However , 76 % given the haloperidol-promethazine mix were asleep compared with 45 % of those allocated lorazepam ( RR=2.29,95 % CI 1.59 - 3.39 ; NNT=3.2,95 % CI 2.3 - 5.4 ) . The haloperidol-promethazine mix produced a faster onset of tranquillisation/sedation and more clinical improvement over the first 2 h. Neither intervention differed significantly in the need for additional intervention or physical restraints , numbers absconding , or adverse effects . CONCLUSIONS Both interventions are effective for controlling violent/agitated behaviour . If speed of sedation is required , the haloperidol-promethazine combination has advantages over lorazepam We report psychometric results of the  Behavioural Activity Rating Scale ( BARS ) using data from three Phase III clinical trials of intramuscular ziprasidone in acutely agitated patients with psychosis ( Studies 1 and 2 ) or in stable psychotic patients ( Study 3 ) . Convergent validity and divergent validity were assessed with baseline data from Studies 1 and 2 in subjects with acute agitation . To investigate convergent validity , we sought Pearson and Spearman correlation of BARS scores with scores on the Clinical Global Impression of Severity ( CGI-S ) Scale and a predefined cluster of agitation-related items from the Positive and Negative Syndrome Scale ( PANSS ) . For divergent validity , we sought Pearson and Spearman correlation between BARS scores and a predefined cluster of PANSS items measuring negative symptoms . Discriminant validity was investigated with the help of subjects with moderate psychopathology ( Study 3 ) . Wilcoxon rank-sum and two- sample t tests determined whether mean ( or median ) BARS scores differed between subjects with acute agitation ( Studies 1 and 2 ) and moderate psychopathology ( Study 3 ) . Responsiveness to treatment effect and rater reliability were also evaluated . In Study 2 , Pearson correlation coefficients of BARS scores with PANSS agitation items and CGI-S were moderate ( convergent validity ) and statistically significant ( P<0.005 ) . The correlation between BARS scores and PANSS negative component scores was low ( divergent validity ) . Treatment effect size was larger for BARS than for PANSS agitation items and CGI-S ( responsive to treatment differences ) . Virtually perfect inter- and intra-rater reliability was achieved . Study 1 produced similar results . BARS showed psychometrically valid properties for measurement of behavioral activity in acutely agitated patients with psychosis BACKGROUND After de-escalation techniques have failed , restraints , seclusion and /or rapid tranquillization may be used for people whose aggression is due to psychosis . Most coercive acts of health care have not been evaluated in trials . METHOD People admitted to the emergency room of Instituto Philippe Pinel , Rio de Janeiro , Brazil , whose aggression/agitation was thought due to psychosis and for whom staff were unsure if best to restrict using physical restraints or a seclusion room  , were r and omly allocated to one or the other and followed up to 14 days . The primary outcomes were ' no need to change intervention early - within 1 h ' and ' not restricted by 4 h ' . RESULTS A total of 105 people were r and omized . Two-thirds of the people secluded were able to be fully managed in this way . Even taking into account the move out of seclusion into restraints , this study provides evidence that embarking on the less restrictive care pathway ( seclusion ) does not increase overall time in restriction of some sort [ not restricted by 4 h : relative risk 1.09 , 95 % confidence interval 0.75 - 1.58 ; mean time to release : restraints 337.6 ( s.d.=298.2 ) min , seclusion room 316.3 ( s.d.=264.5 ) min , p=0.48 ] . Participants tended to be more satisfied with their care in the seclusion group ( 17.0 % v. 11.1 % ) but this did not reach conventional levels of statistical significance ( p=0.42 ) . CONCLUSIONS This study should be replicated , but suggests that opting for the least restrictive option in circumstances where there is clinical doubt does not harm or prolong coercion Psychiatric acute units use different levels of segregation to satisfy needs for containment and decrease in sensory input for behaviourally disturbed patients . Controlled studies evaluating the effects of the procedure are lacking . The aim of the present study was to compare effects in acutely admitted patients with the use of a psychiatric intensive care unit ( PICU ) and not in a psychiatric acute department .  In a naturalistic study , one group of consecutively referred patients had access only to the PICU , the other group to the whole acute unit . Data were obtained for 56 and 62 patients using several scales . There were significant differences in reduction of behaviour associated with imminent , threatening incidents ( Broset Violence Checklist ) , and actual number of such incidents ( Staff Observation Aggression Scale-Revised ) in favour of the group that was treated in a PICU . The principles of patient segregation in PICUs have favourable effects on behaviours associated with and the actual numbers of violent and threatening incidents
target: Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting .
background: OBJECTIVE To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil .