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

Abstract

Background: The 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.

Methods: All 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).

Results: The 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.

Conclusions: The 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.

Figures

Figure 1

DUNDRUM-1 Triage Security Items. For full content, see [16]

Figure 2

DUNDRUM-1 Triage Security score. April to June 2009, those not transferred from prison to hospital (n = 216) v transferred from prison to any hospital (n = 30) Area Under the Curve = 0.984 (95% confidence interval 0.971 to 0.997)

Figure 3

DUNDRUM-1 Triage Security score. Two year period 2008 to 2009, those transferred to open wards (n = 27) compared to those transferred to psychiatric intensive care units (n = 26) Area Under the Curve = 0.805 (95% confidence interval 0.680 to 0.930)

Figure 4

DUNDRUM-1 Triage Security score. Two year period 2008 to 2009, those transferred to psychiatric intensive care units (n = 26) compared to those transferred to forensic medium and high security at Central Mental Hospital (n = 47) Area Under the Curve = 0.866 (95% confidence interval 0.784 to 0.949)