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Research Study:

ABRAT (Aggressive Behaviour Assessment Tool) Provides a 'HeadsUp' That a Patient May Lash Out

Published on Fri Jan 13, 2012

Two nurse researchers give you the inside scoop on this questionnaire.

A study on the ABRAT (Aggressive Behaviour Assessment Tool) showed that "if patients had "at least two of the [tool's] marker indicators, they had a 41 percent chance of becoming violent, which is pretty significant," says Kristyn Ideker, MSN, RN, a researcher in the study.

More stats: "With a score of 1, 8.1 percent became violent," states an article by Ideker and Son Chae Kim, PhD, RN, on the study in the Journal of Advanced Nursing (J Adv Nurs. 2012 Feb; 68 (2):349-357). "As the ABRAT scores increased further, the percent of violent patients continued to increase and with scores [greater than or equal] to 4, 85.7% became violent," the article states.

"Being able to identify patients at risk for aggression really improves the quality of care and nursing safety," says Kim, professor of nursing at Point Loma Nazarene University in San Diego, Calif.

Potential downside: If staff "were forewarned, they would be more wary and could avoid injury," says Ideker, a nurse practitioner at Scripps Hospital in San Diego. "But if they avoid the patient or don't work up something that could be brewing," such as delirium -- that could be a problem, she tells MDS Alert. Thus, "the tool needs to be used along with appropriate nurse education to help nurses identify the signs of delirium -- as well as how to deal with the aggressive patient."

How the Study Worked

"When we started [the research project], we had two tools -- the STAMP and the M55," Ideker says. "The M55 was retrospectively [validated] in Canada in acute care hospitals," she adds. The STAMP "was developed qualitatively to try to identify patients who were aggressive in the ED. We put those two tools together to test them."

"By combining the two, we were able to make direct observation of more than 2,600 [medical-surgical hospital] patients," says Kim."When a patient came to the medical-surgical unit, the patient's primary nurse within 24 hours did a checklist observation," which had 17 items. "A second nurse went in and made the observation a little bit later. The inter-rater reliability was really high," Kim adds. "We were able to calculate the sensitivity and specificity and shrunk the 17 items to 10 items" for the ABRAT.

Tool Includes These 10 Indicators

The ABRAT has 10 "yes or no" indicators that nurses look for when a medical-surgical patient is admitted to the hospital, say Kim and Ideker. The list of indicators, which they note also includes a "none of the above" option, are as follows:

  • Agitation
  • Anxiety
  • Confusion/cognitive impairment
  • History, signs/symptoms of mania
  • History of physical aggression
  • Mumbling
  • Physically aggressive/threatening
  • Staring
  • Shouting/demanding
  • Threatening to leave

"The five most common predictors of violence were confusion/cognitive impairment, anxiety, agitation, shouting/demanding and a history of physical aggression," states a Journal of Advanced Nursing press release on the study article.

"Half of the violent incidents involved patients aged over 70, despite the fact that they only made up 40 percent of the patients studied," the press release notes. Three percent of the patients in the study "were involved in one or more of the violent incidents. These included 35 episodes of verbal abuse, 26 physical attacks, 15 threats of physical attack, 12 incidents where an emergency call went out to security personnel and three cases of sexual harassment," the release states.

"Although verbal abuse or threats of physical attack may not appear to be as serious as actual physical assaults, the actual impact on nurses may be equally distressing (Winstanley & Whittington 2004)," the Journal of Advanced Nursing article points out.

How to Answer the Questions

"You don't ask the person directly" about a history of physical aggression, Ideker explains. "A history of physical aggression may be something that you don't know about" but nurses may hear about it in the report on the floor, she says. "The family may not be willing to say that their family member has a history of physical aggression, but they may sometimes say that the patient is an abusive person or maybe he's currently in custody for that."

"Mania is something you can identify by looking for a bipolar diagnosis in the chart," and mania can be observed, says Ideker.

Also: "Demented patients or patients with brain tumors may also have a history of becoming physically aggressive" -- information that could be in a report, Ideker adds.

Assess for Potential Delirium

Ideker notes that "it's been shown that the incidence of delirium in hospitalized patients over age 65 is approximately 50 percent -- and may be higher in post-surgical and ICU patients of this age." And "if you do see signs of delirium, it's an acute medical condition that can lead to death pretty rapidly without intervention -- and it greatly increases morbidity as well," cautions Ideker. "You have to find a source for the delirium and treat it." (To review the Delirium (C1300) section of the MDS 3.0, see the Coding Quizzer on page 10 of this issue.)

Sexual harassment, which falls in the category of aggression, "is something you often see in delirium or demented patients," Ideker adds. "In dementia, the frontal lobes may be affected which causes lack of inhibition or impulsivity. It's a psychiatric symptom," she stresses, and thus "something a doctor needs to know about when he/she does a work-up."

Review the Patient's Medications

The assessment tool doesn't include a patient's medications, Ideker says. "In the study, we wanted to identify patients right away," she explains. "The tool is something nurses use on admission within the first 24 hours."

"You could, however, look at medications that can make someone delirious -- for example, if the person were started on opioids, benzodiazepenes, steroids, and/or anticholinergics," Ideker says. "These are all classes of medications that can lead patients to having a higher risk of delirium." (For more information on anticholinergic drugs, see page 8 of this issue.)

"If a demented patient is on an antipsychotic, then it could indicate a history of physical aggression," Ideker adds. That "would be a hint to the nurse that she or he should probe deeper into why the patient is on a particular medication."

Also: "If a person has a diagnosis or history of bipolar, it may be something that needs to be looked at if the person is going to get steroids," Ideker says.

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