Prediction and prevention of aggression and seclusion by early screening and comprehensive seclusion documentation

Objective: Identification and skilled management of aggressive patients are a continued safety concern for inpatient psychiatric settings. We studied aggression reduction and the use of seclusion and restraints on our inpatient unit by developing aggression management tools. Our objectives were to systematically identify potential aggressors among admitted patients within 24 to 48 hours of admission and develop a seclusion documentation form that simultaneously trains staff to use less restrictive interventions while collecting data on its use. Methods: Prior to patient assessment and data collection, we systematically trained all medical staff on interviewing patients using the Phipps Aggression Screening Tool. We prospectively screened 229 consecutive admissions using the Phipps Aggression Screening Tool and determined its inter-rater reliability and predictive validity. We systematically recorded the use of a variety of interventions, including seclusion, when applicable. We also documented details of acts of aggression on a comprehensive form and collected demographics, casemix severity, and outcomes. Results: Twenty-two acutely ill patients were responsible for 68 violent acts, all identified by the Phipps Aggression Screening Tool. There were highly significant differences between aggressive and nonaggressive groups for length-ofstay, cost of hospitalization, and illness complexity. With the use of the new form, seclusion decreased from 32 percent to 22.4 percent in 2007. Our current use of seclusion is 0.1/1000 patient hours in 2011. Conclusion: The seclusion documentation form appropriately guides aggression management with less restrictive alternatives to seclusion, once potentially aggressive patients have been identified by screening.