The DUNDRUM-1 structured professional judgment for triage to appropriate levels of therapeutic security: retrospective-cohort validation study

Abstract

BackgroundThe assessment of those presenting to prison in-reach and court diversion services and those referred for admission to mental health services is a triage decision, allocating the patient to the appropriate level of therapeutic security. This is a critical clinical decision. We set out to improve on unstructured clinical judgement. We collated qualitative information and devised an 11 item structured professional judgment instrument for this purpose then tested for validity.MethodsAll those assessed following screening over a three month period at a busy remand committals prison (n = 246) were rated in a retrospective cohort design blind to outcome. Similarly, all those admitted to a mental health service from the same prison in-reach service over an overlapping two year period were rated blind to outcome (n = 100).ResultsThe 11 item scale had good internal consistency (Cronbach's alpha = 0.95) and inter-rater reliability. The scale score did not correlate with the HCR-20 'historical' score. For the three month sample, the receiver operating characteristic area under the curve (AUC) for those admitted to hospital was 0.893 (95% confidence interval 0.843 to 0.943). For the two year sample, AUC distinguished at each level between those admitted to open wards, low secure units or a medium/high secure service. Open wards v low secure units AUC = 0.805 (95% CI 0.680 to 0.930); low secure v medium/high secure AUC = 0.866, (95% CI 0.784 to 0.949). Item to outcome correlations were significant for all 11 items.ConclusionsThe DUNDRUM-1 triage security scale and its items performed to criterion levels when tested against the real world outcome. This instrument can be used to ensure consistency in decision making when deciding who to admit to secure forensic hospitals. It can also be used to benchmark admission thresholds between services and jurisdictions. In this study we found some divergence between assessed need and actual placement. This provides fertile ground for future research as well as practical assistance in assessing unmet need, auditing case mix and planning care pathways.

Susceptibility (risk and protective) factors for in-patient violence and self-harm: prospective study of structured professional judgement instruments START and SAPROF, DUNDRUM-3 and DUNDRUM-4 in forensic mental health services

“…De Vries Robbé et al found that the use of the SAPROF can be helpful in formulating treatment goals, progressing through stages of treatment, planning the phasing of treatment and facilitating risk communication [46,47]. The DUNDRUM-3 and DUNDRUM-4 are intended to serve the same processes of treatment planning and measurement of treatment outcome in domains relevant to risk reduction and risk management and to provide transparency when reporting to mental health tribunals and boards [22-26]. …”

“…These have been shown to predict moves from more secure to less secure places, along with measures of risk [24] and they have been shown to predict conditional discharge from hospital to the community [25]. The DUNDRUM-1 triage security instrument is a measure of the need for therapeutic security and is designed to be a static measure of a quality that is complementary to and distinct from risk of violence [26]. It has been shown to influence moves between levels of therapeutic security [24] and it is used also as a benchmark to enable comparisons between studies [26].…”

“…The DUNDRUM-1 triage security instrument is a measure of the need for therapeutic security and is designed to be a static measure of a quality that is complementary to and distinct from risk of violence [26]. It has been shown to influence moves between levels of therapeutic security [24] and it is used also as a benchmark to enable comparisons between studies [26]. The SPJ instruments of the DUNDRUM toolkit are all designed to be complimentary to measures of risk of violence or self-harm.…”

Patient characteristics related to length of stay in Dutch forensic psychiatric care

“…Validation studies have shown good psychometric qualities (Flynn, O'Neill, McInerney, & Kennedy, 2011;Freestone et al, 2015;O'Dwyer et al, 2011) and indicated that the DUNDRUM-1 items can predict the level of therapeutic security needed (Flynn et al, 2011;Freestone et al, 2015) and LOS (Davoren et al, 2015) while the DUNDRUM-3 and DUNDRUM-4 can predict moves between levels of therapeutic security (Davoren et al, 2012) and discharge (Davoren et al, 2013).…”

Prospective in-patient cohort study of moves between levels of therapeutic security: the DUNDRUM-1 triage security, DUNDRUM-3 programme completion and DUNDRUM-4 recovery scales and the HCR-20

“…The DUNDRUM toolkit is a suite of structured professional judgement instruments developed at the Central Mental Hospital Dundrum, Dublin, Ireland [1]. The toolkit is a set of instruments designed to assist clinical decision making when assessing the need for therapeutic security (DUNDRUM-1 triage security) [2] and urgency of need for therapeutic security (DUNDRUM-2 triage urgency) [3], assessing a patient's programme completion (DUNDRUM-3) and recovery (DUNDRUM-4) and therefore their ongoing need for security as well as a self rated instrument in which patients assess their own need for therapeutic security [1]. …”