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Feasibility of a structured risk assessment tool in general adult psychiatry admissions

  • Helen Smith (a1) and Tom White (a2)
Abstract
AIMS AND METHOD

To assess the feasibility of using a structured risk assessment tool (Historical Clinical Risk 20-Item (HCR–20) Scale) in general adult psychiatry admissions and the characteristics of ‘high-risk’ patients. A notes review and interviews were used to conduct an HCR–20 assessment of 135 patients admitted to Murray Royal Hospital, Scotland.

RESULTS

Patients scoring higher on the HCR–20 were discharged earlier and more likely to have a diagnosis of personality disorder and a comorbid diagnosis.

CLINICAL IMPLICATIONS

It was possible to complete an HCR–20 assessment of over 80% of patients within 48 h of admission.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Cooke, D. (2003) Cross cultural aspects of psychopathy. In Psychopathy: Antisocial, Criminal and Violent Behaviour (eds Millon, T., Simonsen, E., Birket-Smith, M., et al), 260277. Guilford Press.
Douglas, K. S. (1996) Assessing the Risk of Violence in Psychiatric Outpatients. The Predictive Validity of the HCR–20 Risk Assessment Scheme. Canada, Simon Fraser University.
Dowsett, J. (2005) Measurement of risk by a community forensic mental health team. Psychiatric Bulletin, 29, 912.
Mental Welfare Commission for Scotland (2006) Report of Inquiry into the Care and Treatment of Mr Land Mr M. Mental Welfare Commission for Scotland.
Munro, E. & Rumgay, J. (2000) Role of risk assessment in reducing homicides by people with mental illness. British Journal of Psychiatry, 176, 116120.
Risk Management Authority (2006) Risk Assessment Tools Evaluation Directory (Version I). Risk Management Authority.
Webster, C. D., Douglas, K., Eaves, D., et al (1997) HCR–20 Assessing Risk for Violence. Canada, Simon Fraser University.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Feasibility of a structured risk assessment tool in general adult psychiatry admissions

  • Helen Smith (a1) and Tom White (a2)
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eLetters

Use of the HCR-20 in general adult psychiatry

Amar Shah, ST3 Psychiatry
11 December 2007

Smith and White (2007) are to be commended for their efforts in introducing a structured risk assessment tool on the general adult psychiatric wards. There are however, some problems in their use of the HCR-20 tool that undermine their conclusions about feasibility of implementation.

The HCR-20 scale is intended to help structure professional judgementon risk of violence. It is not clinically very useful to use the scale as an actuarial instrument, by summing up the number of risk factors in orderto stratify the patient into a high-risk or low-risk group. This approach tells us very little about the patient's individual risk factors and how best to manage them.

The HCR-20 scale takes into account both static and dynamic variables, and hence applying the tool only on admission is not helpful asmany of the clinical and risk management items may be amenable to change.

If a tool such as the HCR-20 is to be implemented clinically in an effort to better assess and manage risk of violence, it should be used to structure regular multidisciplinary discussion on risk, consider future scenario planning, inform risk judgements and decision-making, and guide risk management strategies.

The items of the HCR-20 scale have been chosen based on accumulating evidence-base of variables related to violence in mentally ill patients and prisoners. Structured professional judgement tools such as the HCR-20 recognise risk assessment as a dynamic and continuous process which is mediated by changing conditions, and move the emphasis from one of prediction to risk management.

Declaration of interest : None
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Conflict of interest: None Declared

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