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Suicide screening is routine practice in psychiatric emergency (PE) departments, but evidence for screening instruments is sparse. Improved identification of nascent suicide risk is important for suicide prevention. The aim of the current study was to evaluate the association between the novel Colombia Suicide Severity Rating Scale Screen Version (C-SSRS Screen) and subsequent clinical management and suicide within 1 week, 1 month and 1 year from screening.
Consecutive patients (N = 18 684) attending a PE department in Stockholm, Sweden between 1 May 2016 and 31 December 2017 were assessed with the C-SSRS Screen. All patients (52.1% women; mean age = 39.7, s.d. = 16.9) were followed-up in the National Cause of Death Register. Logistic regression and receiver operating characteristic curves analyses were conducted. Optimal cut-offs and accuracy statistics were calculated.
Both suicidal ideation and behaviour were prevalent at screening. In total, 107 patients died by suicide during follow-up. Both C-SSRS Screen Ideation Severity and Behaviour Scales were associated with death by suicide within 1-week, 1-month and 1-year follow-up. The optimal cut-off for the ideation severity scale was associated with at least four times the odds of dying by suicide within 1 week (adjusted OR 4.7, 95% confidence interval 1.5–14.8). Both scales were also associated with short-term clinical management.
The C-SSRS Screen may be feasible to use in the actual management setting as an initial step before the clinical assessment of suicide risk. Future research may investigate the utility of combining the C-SSRS Screen with a more thorough assessment.
A wide range of natural and man-made hazards increases the health risks at mass gatherings (MGs). Building on the Sendai Framework for Disaster Risk Reduction 2015-2030, the World Health Organization (WHO) developed the Health Emergency and Disaster Risk Management (H-EDRM) framework to strengthen preparedness, response, and recovery from health emergencies in the communities and emergency-prone settings, such as MGs. The Jeddah tool is derived from the H-EDRM framework as an all-hazard MG risk assessment tool, which provides a benchmark for monitoring progress made in capacity strengthening over a given period for recurrent MGs. Additionally, it introduces a reputational risk assessment domain to complement vulnerability and capacity assessment matrixes. This paper describes the key elements of the Jeddah tool to improve the understanding of health risk assessment at MGs in the overarching contexts of health emergencies and disaster risk reduction, in line with international goals.
This chapter seeks to give an overview of the place of Quality Management (QM) in contemporary fertility practice. It provides the reader with an understanding of the terminology used in QM and explores the definition of quality and success in fertility care. An examination of process modelling in the organisation of services is outlined and an analysis in practical terms as to how QM is applied in practice is provided, covering key issues such as document control, organisational structure and the role of the quality manager. Audit as a tool for improving quality is a fundamental tool and its use within a clinical governance framework including risk management/assessment, and other key responsibilities is detailed. Measuring what we do, analysing performance and setting targets to improve should be fundamental to how we approach our work in contemporary clinical practice.
Exceptional children, like other children, have the right to be educated in a safe environment. Disasters are considered as serious issues regarding safety and security of educational environments. Following disasters, vulnerable groups, especially children with handicaps and disabilities are more likely to be seriously injured. Thus, the present study aimed to evaluate the safety and disaster risk assessment of exceptional schools in Tehran, Iran.
The cross-sectional study was conducted in exceptional schools in Tehran, 2018. First, 55 exceptional schools in all grades were selected based on census sampling method and evaluated by using a checklist designed by Tehran Disaster Mitigation and Management Organization (TDMMO) and Ministry of Education in 2015. The data were analyzed using Excel software and statistical descriptive tests.
Based on the results, school facilities are worn and have unsafe elevators (least safety: 7.69%), yards (least safety: 9.52%), laboratories (least safety: 16.67%), libraries (least safety: 24.24%), fire extinguishing systems (least safety: 28.99%), and storage rooms and kitchens (least safety: 33.33%) which require immediate considerations. In total, the safety of exceptional schools in this study was 70.13%, which suggests medium-risk level.
The educational settings must be reconsidered, along with identifying the risk and safety at school. In addition, a standard should be established for evaluating safety, especially in exceptional schools.
Secure forensic mental health services treat patients with high rates of treatment-resistant psychoses. High rates of obesity and medical comorbidities are common. Population-based studies have identified high-risk groups in the event of SARS-CoV-2 infection, including those with problems such as obesity, lung disease and immune-compromising conditions. Structured assessment tools exist to ascertain the risk of adverse outcome in the event of SARS-CoV-2 infection.
To assess risk of adverse outcome in the event of SARS-CoV-2 infection in a complete population of forensic psychiatry patients using structured assessment tools.
All patients of a national forensic mental health service (n = 141) were rated for risk of adverse outcome in the event of SARS-CoV-2 infection, using two structured tools, the COVID-Age tool and the COVID-Risk tool.
We found high rates of relevant physical comorbidities. Mean chronological age was 45.5 years (s.d. = 11.4, median 44.1), mean score on the COVID-Age tool was 59.1 years (s.d. = 19.4, median 58.0), mean difference was 13.6 years (s.d. = 15.6), paired t = 10.9, d.f. = 140, P < 0.001. Three patients (2.1%) were chronologically over 70 years of age, compared with 43 (30.5%) with a COVID-Age over 70 (χ2 = 6.99, d.f. = 1, P = 0.008, Fisher's exact test P = 0.027).
Patients in secure forensic psychiatric services represent a high-risk group for adverse outcomes in the event of SARS-COV-2 infection. Population-based guidance on self-isolation and other precautions based on chronological age may not be sufficient. There is an urgent need for better physical health research and treatment in this group.
Suicide prediction models have been formulated in a variety of ways and are heterogeneous in the strength of their predictions. Machine learning has been a proposed as a way of improving suicide predictions by incorporating more suicide risk factors.
To determine whether machine learning and the number of suicide risk factors included in suicide prediction models are associated with the strength of the resulting predictions.
Random-effect meta-analysis of exploratory suicide prediction models constructed by combining two or more suicide risk factors or using clinical judgement (Prospero Registration CRD42017059665). Studies were located by searching for papers indexed in PubMed before 15 August 2020 with the term suicid* in the title.
In total, 86 papers reported 102 suicide prediction models and included 20 210 411 people and 106 902 suicides. The pooled odds ratio was 7.7 (95% CI 6.7–8.8) with high between-study heterogeneity (I2 = 99.5). Machine learning was associated with a non-significantly higher odds ratio of 11.6 (95% CI 6.0–22.3) and clinical judgement with a non-significantly lower odds ratio of 4.7 (95% CI 2.1–10.9). Models including a larger number of suicide risk factors had a higher odds ratio when machine-learning studies were included (P = 0.02). Among non-machine-learning studies, suicide prediction models including fewer risk factors performed just as well as those including more risk factors.
Machine learning might have the potential to improve the performance of suicide prediction models by increasing the number of included suicide risk factors but its superiority over other methods is unproven.
Individuals attending emergency departments following self-harm have increased risks of future self-harm. Despite the common use of risk scales in self-harm assessment, there is growing evidence that combinations of risk factors do not accurately identify those at greatest risk of further self-harm and suicide.
To evaluate and compare predictive accuracy in prediction of repeat self-harm from clinician and patient ratings of risk, individual risk-scale items and a scale constructed with top-performing items.
We conducted secondary analysis of data from a five-hospital multicentre prospective cohort study of participants referred to psychiatric liaison services following self-harm. We tested predictive utility of items from five risk scales: Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS, Modified SAD PERSONS, Barratt Impulsiveness Scale and clinician and patient risk estimates. Area under the curve (AUC), sensitivity, specificity, predictive values and likelihood ratios were used to evaluate predictive accuracy, with sensitivity analyses using classification-tree regression.
A total of 483 self-harm episodes were included, and 145 (30%) were followed by a repeat presentation within 6 months. AUC of individual items ranged from 0.43–0.65. Combining best performing items resulted in an AUC of 0.56. Some individual items outperformed the scale they originated from; no items were superior to clinician or patient risk estimations.
No individual or combination of items outperformed patients’ or clinicians’ ratings. This suggests there are limitations to combining risk factors to predict risk of self-harm repetition. Risk scales should have little role in the management of people who have self-harmed.
Clinical decision-making in psychiatry is affected by many factors, including how best to reduce risks of harm while promoting autonomy and personal recovery. This article proposes guidance for clinical decision-making that is consistent with civil liability law. It emphasises collaboration, clarification of the available information and communication of decisions as a basis for recovery-oriented risk management.
Bovine respiratory disease (BRD) is the leading natural cause of death in US beef and dairy cattle, causing the annual loss of more than 1 million animals and financial losses in excess of $700 million. The multiple etiologies of BRD and its complex web of risk factors necessitate a herd-specific intervention plan for its prevention and control on dairies. Hence, a risk assessment is an important tool that producers and veterinarians can utilize for a comprehensive assessment of the management and host factors that predispose calves to BRD. The current study identifies the steps taken to develop the first BRD risk assessment tool and its components, namely the BRD risk factor questionnaire, the BRD scoring system, and a herd-specific BRD control and prevention plan. The risk factor questionnaire was designed to inquire on aspects of calf-rearing including management practices that affect calf health generally, and BRD specifically. The risk scores associated with each risk factor investigated in the questionnaire were estimated based on data from two observational studies. Producers can also estimate the prevalence of BRD in their calf herds using a smart phone or tablet application that facilitates selection of a true random sample of calves for scoring using the California BRD scoring system. Based on the risk factors identified, producers and herd veterinarians can then decide the management changes needed to mitigate the calf herd's risk for BRD. A follow-up risk assessment after a duration of time sufficient for exposure of a new cohort of calves to the management changes introduced in response to the risk assessment is recommended to monitor the prevalence of BRD.
Many health care professionals undertake roles that require them to visit the home of the client or a range of other possible locations, rather than the client coming into the health care service setting. Primary health care nurses usually work alone and often have little control over the environment so their role requires a different approach to risk management. Assessment of risk is necessary to identify any potential harm or risk to safety. This should be considered from both personal and professional perspectives. Although risk is present in all activities of life, the management of risk is essential when providing services that meet the needs of clients while minimising the chance of undesirable incidents. This chapter identifies common safety concerns when providing health care in people’s homes and explains the purpose of risk assessment and the mechanisms through which risk is managed. It also describes measures for reducing risk and discusses proactive behaviour for self-protection.
Risk assessment – measuring an individual’s potential for offending – has long been an important aspect of most legal systems, in a wide variety of contexts. In most countries, sentences are often heavily influenced by concerns about preventing reoffending. Correctional officials and parole boards routinely rely on risk assessments. Post-sentence commitment of “dangerous” offenders (particularly common in connection with sex offenders) is based almost entirely on determinations of risk, as is involuntary hospital commitment of people found not guilty by reason of insanity and of people who are not prosecuted but require treatment. Detention prior to trial is frequently authorized not only upon a finding that a suspect will otherwise flee the jurisdiction, but also when the individual is thought to pose a risk to society if left at large. And police on the streets have always been on the look-out for suspicious individuals who might be up to no good.
This chapter surveys several entry points through which science becomes legally relevant in WTO law and in trade disputes. It reviews the elaborate techniques of WTO panels and the Appellate Body to engage with scientific evidence in cases involving environmental and health risks. The chapter addresses the WTO’s expert consultation system and discusses the changing canons of deference afforded to WTO members in adopting science-based SPS measures. It extensively analyses the epistemic nature and significance of the two-stage standard of review, under which WTO dispute settlement bodies scrutinize the coherence of the reasoning provided by the risk assessor. The chapter concludes with identifying argumentative techniques in the WTO jurisprudence justifying adjudicatory conclusions concerning scientific evidence and arguments. It distinguishes reasoning methods built on scientific, intuitive, and legal rationality. The chapter also identifies an additional particular reasoning style, which utilizes concepts that are labelled as 'hybrid' benchmarks.
During pregnancy, the imperative to stop smoking becomes urgent due to health risks for mother and baby.
Explore responses to a smoking-related, pregnancy-focused Risk Behaviour Diagnosis (RBD) Scale over time with Aboriginal1 pregnant women.
Six Aboriginal Medical Services in three states recruited 22 eligible women: ⩽28 weeks' gestation, ⩾16 years old, smoked tobacco, pregnant with an Aboriginal baby. Surveys were completed at baseline (n = 22), 4-weeks (n = 16) and 12-weeks (n = 17). RBD Scale outcome measures included: perceived threat (susceptibility and severity), perceived efficacy (response and self-efficacy), fear control (avoidance), danger control (intentions to quit) and protection responses (protecting babies).
At baseline, the total mean threat scores at 4.2 (95% CI: 3.9–4.4) were higher than total mean efficacy scores at 3.9 (95% CI: 3.6–4.1). Over time there was a non-significant reduction in total mean threat and efficacy; fear control increased; danger control and protection responses remained stable. Reduction of threat and efficacy perceptions, with raised fear control responses, may indicate a blunting effect (a coping style which involves avoidance of risks).
In 22 Aboriginal pregnant women, risk perception changed over time. A larger study is warranted to understand how Aboriginal women perceive smoking risks as the pregnancy progresses so that health messages are delivered accordingly.
Qualitative fit testing is a popular method of ensuring the fit of sealing face masks such as N95 and FFP3 masks. Increased demand due to the coronavirus disease 2019 (COVID-19) pandemic has led to shortages in testing equipment and has forced many institutions to abandon fit testing. Three key materials are required for qualitative fit testing: the test solution, nebulizer, and testing hood. Accessible alternatives to the testing solution have been studied. This exploratory qualitative study evaluates alternatives to the nebulizer and hoods for performing qualitative fit testing.
Four devices were trialed to replace the test kit nebulizer. Two enclosures were tested for their ability to replace the test hood. Three researchers evaluated promising replacements under multiple mask fit conditions to assess functionality and accuracy.
The aroma diffuser and smaller enclosures allowed participants to perform qualitative fit tests quickly and with high accuracy.
Aroma diffusers show significant promise in their ability to allow individuals to quickly, easily, and inexpensively perform qualitative fit testing. Our findings indicate that aroma diffusers and homemade testing hoods may allow for qualitative fit testing when conventional apparatus is unavailable. Additional research is needed to evaluate the safety and reliability of these devices.
New York City's first case of SARS-associated coronavirus (SARS-CoV-2) disease 2019 (COVID-19) was identified on 1 March 2020, prompting rapid restructuring of hospital-based services to accommodate the increasing numbers of medical admissions. Non-essential services were eliminated but in-patient treatment of psychiatric illnesses was necessarily maintained.
To detail the response of the NYU Langone Health in-patient psychiatric services to the COVID-19 outbreak from 1 March to 1 May 2020.
Process improvement/quality improvement study.
Over this time period, our two in-patient psychiatric units (57 total beds) treated 238 patients, including COVID-19-positive and -negative individuals. Testing for COVID-19 was initially limited to symptomatic patients but expanded over the 62-day time frame. In total, 122 SARS-CoV-2 polymerase chain reaction (PCR) tests were performed in 98 patients. We observed an overall rate of COVID-19 infection of 15.6% in the patients who were tested, with an asymptomatic positive rate of 13.7%. Although phased roll-out of testing impaired the ability to fully track on-unit transmission of COVID-19, 3% of cases were clearly identified as results of on-unit transmission.
Our experience indicates that, with appropriate precautions, patients in need of in-patient psychiatric admission who have COVID-19 can be safely managed. We provide suggested guidelines for COVID-19 management on in-patient psychiatric units which incorporate our own experiences as well as published recommendations.
This article summarises key areas of research informing understanding of vulnerability factors and risk assessment and management across the lifespan, with particular reference to risk to self (self-harm and suicide). It relates the discussion to people attending sexual assault referral centres (SARCs), but is applicable in a range of clinical settings. Although people accessing SARCs often present with mental health difficulties and various other vulnerabilities, SARC practitioners often do not have specialist training in working with mental health difficulties, including individuals at risk to self. We discuss developmental differences that should be considered when assessing and managing risk to self, and examine relationships between mental health difficulties, risk to self, and rape and/or sexual assault. Finally, we offer advice on how to respond to risk presented by individuals who have experienced sexual violence.
The steep rise in the rate of psychiatric hospital detentions in England is poorly understood.
To identify explanations for the rise in detentions in England since 1983; to test their plausibility and support from evidence; to develop an explanatory model for the rise in detentions.
Hypotheses to explain the rise in detentions were identified from previous literature and stakeholder consultation. We explored associations between national indicators for potential explanatory variables and detention rates in an ecological study. Relevant research was scoped and the plausibility of each hypothesis was rated. Finally, a logic model was developed to illustrate likely contributory factors and pathways to the increase in detentions.
Seventeen hypotheses related to social, service, legal and data-quality factors. Hypotheses supported by available evidence were: changes in legal approaches to patients without decision-making capacity but not actively objecting to admission; demographic changes; increasing psychiatric morbidity. Reductions in the availability or quality of community mental health services and changes in police practice may have contributed to the rise in detentions. Hypothesised factors not supported by evidence were: changes in community crisis care, compulsory community treatment and prescribing practice. Evidence was ambiguous or lacking for other explanations, including the impact of austerity measures and reductions in National Health Service in-patient bed numbers.
Better data are needed about the characteristics and service contexts of those detained. Our logic model highlights likely contributory factors to the rise in detentions in England, priorities for future research and potential policy targets for reducing detentions.
Mass gatherings (MGs) grow in frequency around the world. With the intrinsic potential for significant health risks for all involved, MGs pose a challenge for those responsible for the provision of on-site medical care. Belgian law obliges local governments to identify and analyze the risks involving a MG. Though medical risk factors are long known, all too often, resourcing for in-event health services is based on anecdotal and previous experiences.
Despite the fast-evolving science on MGs, the lack of reliable tools – based on empirical and analytical approaches – to predict patient presentation rates (PPRs) at MGs remains.
A two-step method was followed to develop, update, and support a Plan Risk Manifestation (PRIMA) program. First, a continuous systematic literature review was conducted. Once developed, the model was run using data obtained from Belgian Federal Public Service (FPS; Brussels, Belgium) Health, Food Chain Safety, and Environment (HFCSE); event organizers; and municipalities.
In total, 231 studies and documents were included to form the program. With the data provided, three variables were computed to run the calculation model to predict the PPR. Three medical risk axes were defined for this model: (1) isolation risk; (2) population risk; and (3) risk at illness. A combined dataset was derived from the prediction of the PRIMA program combined with the actual data obtained after the MG. This proved a solid basis for the calculation model of the PRIMA program.
Despite that validation is needed, the PRIMA program and its prediction model for PPRs at MGs carries the promise of a general, applicable prediction and risk analysis tool for a multitude of events.