Risk Prediction Models for Hospital Mortality in General Medical Patients: A Systematic Review.

Objective: To systematically review contemporary prediction models for hospital mortality developed or validated in general medical patients. Methods: We screened articles in five databases, from January 1, 2010, through April 7, 2022, and the bibliography of articles selected for final inclusion. We assessed the quality for risk of bias and applicability using the Prediction Model Risk of Bias Assessment Tool (PROBAST) and extracted data using the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) checklist. Two investigators independently screened each article, assessed quality, and extracted data. Results: From 20,424 unique articles, we identified 15 models in 8 studies across 10 countries. The studies included 280,793 general medical patients and 19,923 hospital deaths. Models included 7 early warning scores, 2 comorbidities indices, and 6 combination models. Ten models were studied in all general medical patients (general models) and 7 in general medical patients with infection (infection models). Of the 15 models, 13 were developed using logistic or Poisson regression and 2 using machine learning methods. Also, 4 of 15 models reported on handling of missing values. None of the infection models had high discrimination, whereas 4 of 10 general models had high discrimination (area under curve >0.8). Only 1 model appropriately assessed calibration. All models had high risk of bias; 4 of 10 general models and 5 of 7 infection models had low concern for applicability for general medical patients. Conclusion: Mortality prediction models for general medical patients were sparse and differed in quality, applicability, and discrimination. These models require hospital-level validation and/or recalibration in general medical patients to guide mortality reduction interventions.

The violence triad and common single precipitants to psychiatric patient assaults on staff: 16-year analysis of the Assaulted Staff Action Program.

Psychiatric patient assaults are a serious community health hazard. Risk management strategies to identify common single precipitants have had limited value and this limitation has resulted in the emergence of multiple determinant studies. This 16-year retrospective study of assault precipitants in one, public sector mental health-care system assessed single common, immediate precipitants; the multiple clinical precipitants of history of violence, personal victimization, and substance use disorder (the violence triad); and both combined. Denial of services, acute psychoses, and excess sensory stimulation were the most common single precipitants. The multicomponent violence triad yielded greater association with subsequent assault than single precipitants. The combination of the violence triad and single precipitants did not yield statistically significant greater associations. Discussion of the clinical risk management implication, and methodological issues are presented.

Characteristics of staff victims of psychiatric patient assaults: 20-year analysis of the Assaulted Staff Action Program.

Psychiatric patient assaults on healthcare staff are a worldwide occupational hazard. This present 20-year, retrospective study examined the characteristics of these staff victims in one public-sector, health care system and assessed the psychological support provided to these victims by the post-incident Assaulted Staff Action Program (ASAP). An additional analysis compared the victim characteristics in this same health care system at 10-, 15-, and 20-year intervals. The findings were consistent with earlier, worldwide studies. Staff victims tend to be younger, less formally educated, less experienced, and less trained mental health workers, residential house counselors, and trainees of differing disciplines. ASAP provided needed support to staff victims. Risk management strategies for safety, methodological issues, and the problem of denial in fielding a post-incident crisis intervention program for staff victims were discussed.

Characteristics of assaultive psychiatric patients: 20-year analysis of the Assaultive Staff Action Program (ASAP).

Empirical research demonstrates that patient assaults on staff are a worldwide occupational hazard. This study examined patient assailant characteristics in a 20-year longitudinal, retrospective study in one public health care system. Older male patients with schizophrenic illness and histories of violence toward others and substance use disorder and younger male/female patients with personality disorders and histories of violence toward others, personal victimization, and substance use disorder were the more frequent assailants. This was true at 10-, 15-, and 20-year periods. Specific clinical findings with regard to forensic patients, the violence triad, and victimization of women as well as methodological issues were discussed and the implications noted.

Time of psychiatric patient assaults: twenty-year analysis of the Assaulted Staff Action Program (ASAP).

Apparent random acts of violence viewed in the aggregate appear to occur in fairly exacting temporal patterns. This is true of rape, street assaults, and domestic violence, among other acts of violence. Patient assaults on staff as acts of violence should also follow a temporal pattern. This twenty-year retrospective study of assaultive psychiatric patients in one public sector examined the temporal pattern of such assaults. Inpatient assaults were more likely to occur in the summer in the middle ten days of the month, during the first shift at mealtimes. In community settings, assaults were more likely in winter during the first ten days of the month, and on the first shift at noon time. The possible reasons for these time patterns, their possible biological roots, and their implications for emergency services personnel and health care providers were discussed.

Characteristics of four types of patient assaults: fifteen-year analysis of the Assaulted Staff Action Program (ASAP) with EMS implications.

Thirty years of empirical research have documented the recurring risk of assault by psychiatric patients on emergency services and health care providers. Most studies have reported all patient assaults in the aggregate. However six studies that have reported physical assault, sexual assault, nonverbal intimidation, and verbal threats as separate categories have reported significant patient/staff victim differences in characteristics by category. This 15-year retrospective study examined patient assaults and their impact by four standard assault categories. Similarities and differences across assault categories are presented Methodological issues and the safety implications for emergency services are discussed.

Characteristics of patients in restraint: fifteen-year analysis of the Assaulted Staff Action Program (ASAP) with EMS implications.

Research on the demographic and precipitant characteristics of restrained patients has documented that younger male/female patients diagnosed with schizophrenia, affective disorder, or personality disorder are at risk of being restrained when acutely psychotic or confronted with excess sensory stimulation or denial of services. However many patients with these same characteristics are not restrained Thus, these variables have yielded little predictive power. This study compared restrained/nonrestrained subjects on the demographic, precipitant variables and added three clinical variables (past violence to others, personal victimization, and substance use disorder) to assess the possible predictive power of clinical variables. Demographic and precipitant variables were similar to previous research findings. Violence toward others in combination with personal victimization was associated with higher restraint usage. The implications of the findings for emergency services are outlined.

Repetitively assaultive psychiatric patients: fifteen-year analysis of the Assaulted Staff Action Program (ASAP) with implications for emergency services.

Research has demonstrated that psychiatric patient's assaults on emergency services personnel providing onsite, prehospital care represent a serious and ongoing nationwide concern. Embedded within these patient assailants is a small group of repeat offenders who present a serious increased risk for assault. This study examined the demographic and clinical variables of repeat offenders over a 15-year period. Included in the sample were patients who were transferred from correctional facilities to mental health facilities and then to the community. The results indicated that older male patients with schizophrenia and younger patients with personality disorders were the more likely to re-offend. The risk of assault was greatly increased if these patients had histories of violence toward others, personal victimization, and substance use disorder. Correction patients did not appear to present any additional risk per se. The significance of the findings and the implications for emergency services personnel are presented.

Time of psychiatric patient assaults: fifteen-year analysis of the Assaulted Staff Action Program (ASAP).

An emerging literature on human-perpetrated violence suggests that seemingly apparent random acts of violence may indeed have important embedded temporal patterns. This study reviews this literature and presents the temporal findings of a fifteen-year study of patient assaults on staff in health care settings. Temporal patterns were observed for the variables of season, days of month, and shift. The reasons for these findings and their implications for health care providers are presented. A brief review of patient assaults on emergency services personnel (EMS) is outlined and this study 's findings and their implications for EMS personnel are discussed.

Psychiatric patient assault and staff victim gender: fifteen-year analysis of the Assaulted Staff Action Program (ASAP).

Extensive, largely cross-sectional research has documented the continued occurrence of patient assaults on male and female staff. Different studies report either male or female staff to be at highest risk. Studies of same/different gender assaults which might more fully answer this question have been few. In these latter studies both male and female staff were at high risk for same gender assaults. In community settings males were at risk from same gender assaults but females were at risk from assaults by both patient genders. The present 15-year longitudinal retrospective study examined same/different gender assaults over time. Since the health care system under study experienced several major policy changes during these years, data were also examined at 5-year intervals to assess the stability of findings across time. Male and female staff were at increased risk from same gender assaults over time in both inpatient and community settings. The findings and their implications are discussed. In addition, a cost-effective, comprehensive risk management strategy for containing assaults is outlined.

Characteristics of staff victims of pschiatric patient assaults: 15-year analysis of the Assaulted Staff Action Program (ASAP).

Psychiatric patient assaults on staff victims are a worldwide occupational hazard. This paper reports on a 15-year study of the characteristics of staff victims of patient assaults and a crisis intervention procedure to ameliorate the aftermath of theses incidents. The debate on the efficacy of early interventions is outlined and the present 15-year findings are presented, findings demonstrating remarkable consistency in victim characteristics over time. The crisis intervention procedures were associated with sharp declines in disrupted victim functioning. The validity of the study's findings are noted and the implications for enhanced risk management training and staff victim crisis intervention procedures are discussed.

Elderly patient assaults: empirical data from the Assaulted Staff Action Program (ASAP) with risk management implications for EMS personnel.

Some elderly patients may become violent in the course of receiving health care services. This paper reviews the largely cross-sectional research on elder assaultive patients in health care settings and patient assaults, including those by the elderly, in EMS services. Data on the assault characteristics of elderly patients are presented from a 15-year, retrospective, longitudinal study of the Assaulted Staff Action Program (ASAP). The findings and their implications for the delivery of health care services are discussed and a detailed series of risk management strategies to reduce assaults in EMS services are presented.

Past violence, substance use, and precipitants to psychiatric patient assaults: eleven-year analysis of the Assaulted Staff Action Program (ASAP).

Thirty-five years of empirical research on assaultive psychiatric patients has documented the presence of consistent patient assailant characteristics. However, these characteristics studies have yielded little in the way of predictor variables. This study examined three commonly present, patient clinical variables (past violence toward others, personal victimization, and substance use disorder) singly and in combinations as potential predictor variables. An additional subset analysis of patient precipitants was added to ascertain whether precipitant data would add further predictive power The combinations of past violence toward others and personal victimization with and without substances use disorder during an eleven-year period were associated with 61% of the subsequent assaults. A trend for denial of services to female patients during a three-year period was also associated with subsequent assaults. The predictive implications of these findings and their relevance for emergency services personnel are examined.

Characteristics of assaultive psychiatric patients: fifteen-year analysis of the Assaulted Staff Action Program (ASAP).

This study reports on a fifteen-year longitudinal analysis of the characteristics of assaultive patients in one public-sector mental health care system. The data were gathered within the context of the Assaulted Staff Action Program (ASAP), a crisis intervention service for staff victims. The fifteen-year findings were consistent with previous worldwide research on assaultive patients and included both older male patients with schizophrenia and younger personality-disordered patients as high-risk assailants. Both groups had appreciable histories of violence toward others, personal victimization, and substance use disorders. The role of these three clinical variables in association with subsequent assaults, the role of trauma in female assailants, and the consistency of the fundamental characteristics of assaultive patients during several service system initiatives were examined. Implications for research and intervention are discussed.

Precipitants of psychiatric patient assaults on staff: three-year empirical inquiry of the Assaulted Staff Action Program (ASAP).

Patient violence toward health care staff is a complex function of person x event x environment model. Thirty-five years of research on the characteristics of patient assailants and staff victims has yielded no predictive markers and researchers are examining other possible components of the model. The precipitants, or motivation, for assaults is one area of inquiry. Although research to date has been sparse, acute psychosis, excessive sensory stimulation, and staff restrictions on patient behaviors (denial of services, privileges, etc.) appear to be common precipitants. This paper continued this inquiry over a three-year period. The most common precipitants were denial of services, acute psychosis, and excessive stimulation. No statistically significant interactions were obtained for patient / staff victim variables and these precipitants.

Precipitants of elderly psychiatric patient assaults on staff: preliminary empirical inquiry.

Although there have been several studies of the characteristics of psychiatric patient assailants, there have been only six comprehensive, empirical assessments of precipitants to these assaults and no precipitant study has focused solely on elderly psychiatric patient assailants. This one and one-half year, retrospective study continued the inquiry into the nature of patient assault precipitants and focused only on elderly assailants. Older, male patients with a diagnosis of schizophrenia and histories of violence toward others and substance use disorder physically assaulted primarily male, mental health workers. These staff victims experienced disruptions in the domains of mastery, attachment, and meaning as well as the symptomatology associated with psychological trauma. The most common precipitants to these assaults were denial of services and acute psychosis. The findings and implications for health care providers in long-term care settings where elderly psychiatric patients reside are discussed.

Precipitants of psychiatric patient assaults on staff: preliminary empirical inquiry of the Assaulted Staff Action Program (ASAP).

Although there has been extensive empirical research on the characteristics of psychiatric patient assailants and their staff victims, there has been a dearth of empirical research on the nature of the precipitants of these patient/staff interactions. Building on the few earlier studies, this year-long, retrospective, empirical study of patient precipitants was conducted within the context of the Assaulted Staff Action Program (ASAP) in ten public sector health care facilities. Excessive sensory stimulation, staff restrictions on patient behaviors (restraints), and acute psychosis were the most frequently occurring precipitants. There were no specific patterns to patient assailant and staff victim characteristics by assault precipitant. The implications of this study and future research needs are addressed.

Safety skills of mental health workers: empirical evidence of a risk management strategy.

To reduce violence in the workplace, health care facilities invest time and resources in risk management strategies such as photo identification and controlled access and surveillance. Studies of assaultive psychiatric patients continue to document that mental health workers (MHWs) are the most frequent targets of the patient violence. Unexamined in these findings is the role skilled MHWs contribute in restoring safety and order in the aftermath of these assaults. This six-year, empirical retrospective study examined the safety skills of MHWs in containing violence. Although they were 28% of the workforce, MHWs restored order in the majority of single assault incidents and restraint procedures. Their skills appear to be a risk management strategy in their own right. The implications are discussed.

Characteristics of assaultive patients with schizophrenia versus personality disorder: six year analysis of the Assaulted Staff Action Program (ASAP).

Literature reviews of individual assaultive patients, repetitively violent patients, and restrained assaultive patients document that persons diagnosed with schizophrenia or personality disorder are at the highest risk to become assaultive. While there has been some initial research of possible predictor variables across diagnostic groups, this six-year retrospective study is the first to compare only persons with schizophrenia or personality disorder on basic demographic and the selected clinical variables of history of violence, personal victimization, and substance use disorder. In this study, the variance suggested that persons with schizophrenia and personality disorder were both likely to be assaultive. Assaults by persons with schizophrenia were somewhat proportional to their presence in the population studied. However, personality disordered patients represented a disproportional increase from the population studied. Younger females with a diagnosis of personality disorder and with histories of violence toward others and personal victimization appeared at increased risk to be assaultive and to require restraints. The findings and their implications for safety and clinical care are discussed.