Bedside Risk Assessments, Part 3

The next tool I want to review, in our tour of violence risk assessments in healthcare, is the Aggressive Behavior Risk Assessment Tool (ABRAT). The ABRAT is a slight departure from the two tools we have already looked at. To review, the STAMP tool and the Bröset Violence Checklist (BVC) both base their prediction of risk solely on present observable behaviors. Each tool asks the assessor to identify 5-6 observable behaviors and then predicts the potential for violence based on the presence of those behaviors. Please refer back to parts 1 & 2 if you have any questions about the STAMP or BVC.  

The ABRAT adds to what is observable with other indicators as well. Using the ABRAT involves a 17 point checklist of mostly observable behaviors like staring, agitation, tone of voice, but the unique change is that the ABRAT also adds in indicators like the present medical condition, history of physical aggression or history of mania. We know that disease progression can be a significant indicator for violence, and it is this combination of present state behaviors, present medical concerns and known history that makes the ABRAT a leap forward in predictive value.

The 17 key points covered by the ABRAT are as follows:

1) History of Physical Aggression; 2) Physically Aggressive/ Threatening; 3) Verbally Hostile/ Threatening; 4) Shouting/ Demanding; 5) Confusion/ Cognitive Impairment; 6) Drug/ Alcohol Intoxication; 7) Auditory/ Visual Hallucination; 8) Threatening to Leave; 9) Agitation; 10) Staring; 11) Tone of Voice demeaning/ sarcastic; 12) History or signs/ symptoms of mania; 13) Suspicious; 14) Withdrawn; 15) Anxiety; 16) Mumbling; 17) Pacing

The ABRAT has been studied in both long term care facilities as well as in hospital based medical-surgical units. In each study the tool has demonstrated significant predictive value. In one study, published in the Journal of Advanced Nursing, the authors stated that the tool presented a 95% confidence interval in predicting violent behavior (Kim, SC, Ideker, K, & Todicheeney-Mannes, D., 2012). Other studies have demonstrated similar results and continue to show the tool has both high inter-rater reliability as well as sensitivity. That means we continue to see similar results no matter who is assessing the patient as well as reliable risk values no matter the combination of issues presented by the patient.

In some cases, researchers have reduced the number of assessment points from 17 to 10 for a modified ABRAT, but with similar results. In all cases, the tool has been easily adopted by frontline practitioners, and has proven to be simple to use. The ease in adoption and deployment help significantly add to the value of the tool.

The ABRAT presents a promising leap forward in bedside violence risk assessment, and when combined with proactive response by the staff can significantly reduce the risk of a workplace assault.

What are your thoughts? What would happen if your organization built the ABRAT into the normal care for each patient? What value could be added by building it directly into the medical record as a recurring nursing assessment? Could it be used to alert all staff to the risk of violence presented by any patient they may encounter? How might that add value to your workplace violence prevention program? I’m eager to know your thoughts.

References:

Berry, B., Young, L., Kim, SC. (2017). Utility of the Aggressive Behavior Risk Assessment Tool in long-term care homes. Geriatric Nursing 38(5), 417-422.

Kim S.C., Ideker K. & Todicheeney‐Mannes D. (2012) Usefulness of Aggressive Behaviour Risk Assessment Tool for prospectively identifying violent patients in medical and surgical units. Journal of Advanced Nursing 68(2), 349–357.

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