The country's largest mental health hospital frequently re-evaluates patients who might be aggressive or violent to ensure doctors and nurses have the most up-to-date assessment possible, says one of its top directors.

That's in stark contrast to the London Health Sciences Centre (LHSC), which evaluates patients for potential violence when they first come in and keeps that assessment indefinitely, every time they come into the hospital, regardless of subsequent behaviour. ​

Toronto's Centre for Addiction and Mental Health (CAMH), the largest psychiatric facility in Canada with 34,000 patients a year, has to adhere to the same Occupational Health and Safety Act rules as the LHSC.

But the two organizations have very different approaches to violence assessment.

As the LHSC undertakes a review of its violence assessment policy and how it scores people's potential for violence, we asked CAMH how its policy works and compared the two:

Assessment

CAMH : Done by an interprofessional team

: Done by an interprofessional team LHSC: Done by a triage nurse

All patients are assessed for potentially violent behaviour when they come to CAMH, said Jane Paterson, the hospital's director of interprofessional practice.

Staff are trained to assess escalating behaviour and to work with patients to de-escalate situations, Paterson said. The assessment is done wherever someone is being treated, including the psychiatric emergency department or in the acute waiting area or one of the units, Paterson said.

"Every patient is assessed by an interprofessional team," Paterson added, noting there are different assessments for different patients.

At LHSC, all inpatient and outpatient mental health patients are screened by a triage nurse. Those visiting the emergency room and those being admitted are also screened and assessed.

Flagging a patient

CAMH : Flags put electronic chart and a unit white board

: Flags put electronic chart and a unit white board LHSC: Flags put on electronic chart and flagged patients must wear purple armbands during follow up appointments

At CAMH, there are different flags for aggression or violence, for sexual aggression, a history of weapons, a risk of arson, if someone is being involuntary committed and could be a flight risk.

Those flags are put on a patient's electronic chart, which can be seen by medical professionals, and on an electronic white board in the nurses' station. That electronic white board can also be seen by porters and cleaners.

"The white board is a visual cue. It's like a little round magnet, so if someone has a flag for arson, there's a little round disk with a fire symbol, as a visual cue."

Paterson admits that's raised some patient privacy concerns because electronic white boards are in public view, but "often, safety will trump privacy."

At LHSC, patients who are assessed as being potentially violent, with observed behaviours such as irritability, paranoia, confusion or intoxication, are flagged. Anyone who is flagged, no matter what their risk level, is given a purple armband to wear. Those who refuse must have an escort wherever they go in the hospital.

Those who refuse the escort cannot be treated that day, the LHSC policy states.

Re-assessment

CAMH : Reassessment as patients progress through the care system

: Reassessment as patients progress through the care system LHSC: No reassessment

At CAMH, patients are reassessed at every "transition of care," Paterson said.

So, if a patient is transferred to another unit or are discharged, their flag is reassessed.

"The flag doesn't stay indefinitely. If a flag is initiated, the requirement is that it be reassessed. We want to make sure that all the clinicians are as up to date on the file as possible," Paterson said.

"With something like a risk of aggression, these things change over time. A person might be highly agitated at one point in time and that status might change. This is a dynamic process."

At LHSC, a patient who is flagged is flagged indefinitely, no matter their level of violence risk assessment. Every time they come back to the hospital for any reason, they must wear the purple armband or have an escort. If a patient wants to be reassessed, they have to file an appeal with patient relations.

Since the policy was put into practice in May of 2018, the London hospital has had almost 100 appeals. Officials refuse to say how many have been dealt with or how many have been successful, citing patient privacy.