Risk stratification for violent behavior in critically ill patients: Current assessment tools

Abstract

Background

Workplace violence (WPV) presents challenges in intensive care units (ICUs) calling for reliable prediction of violence. This narrative review aimed to identify and evaluate risk assessment tools from acute care settings which are or might be used to predict violent behavior in adult ICU patients focusing on their performance and clinical utility.

Methods

A screening of PubMed, Scopus and Google Scholar was conducted to identify risk scores used in the acute care setting such as emergency departments, hospitals and ICUs. Risk factors, predictive validity of scores and their relevance to the ICU setting were evaluated.

Results

24 studies were included. Two studies reported the use in general ICU populations, while eight studies were conducted in psychiatric ICUs and 14 studies implemented the use of risk tools in emergency departments or general wards. Ten risk scores were identified using 30 different variables. Those could be categorized into patient demographics, behavior, history of violence, mental status and other items such as sleep disturbances. The Broset Violence Checklist (BVC) was the most commonly used risk score. It showed moderate predictive accuracy in psychiatric settings including psychiatric ICUs, but limited validation for general ICUs. The overall evidence level was low with serious risk of bias. Other tools demonstrated varying sensitivity and specificity but lacked validation in ICUs.

Implications for clinical practice

ICU nurses and physicians are often subjected to violence. There is little evidence on scores to predict patients‘ behavior. Most assessments come from outside the ICU, but may be promising in critical care.

Conclusion

This review underscores the need for the development of violence risk assessment tools tailored to the ICU, as the challenges with violent ICU patients differ from other populations. New predictive models must be developed including factors associated with patients’ violent behavior in ICUs as compiled in this review.