Prevention of violence due to severe mental disorders in psychiatric hospitals may require intrusive, restrictive and coercive therapeutic practices. Research concerning appropriate use of such interventions is limited by lack of a system for description and measurement. We set out to devise and validate a tool for clinicians and secure hospitals to assess necessity and proportionality between imminent violence and restrictive practices including de-escalation, seclusion, restraint, forced medication and others. In this retrospective observational cohort study, 28 patients on a 12 bed male admissions unit in a secure psychiatric hospital were assessed daily for six months. Data on adverse incidents were collected from case notes, incident registers and legal registers. Using the functional assessment sequence of antecedents, behaviours and consequences (A, B, C) we devised and applied a multivariate framework of structured professional assessment tools, common adverse incidents and preventive clinical interventions to develop a tool to analyse clinical practice. We validated by testing assumptions regarding the use of restrictive and intrusive practices in the prevention of violence in hospital. We aimed to provide a system for measuring contextual and individual factors contributing to adverse events and to assess whether the measured seriousness of threating and violent behaviours is proportionate to the degree of restrictive interventions used. General Estimating Equations tested preliminary models of contexts, decisions and pathways to interventions. A system for measuring adverse behaviours and restrictive, intrusive interventions for prevention had good internal consistency. Interventions were proportionate to seriousness of harmful behaviours. A ‘Pareto’ group of patients (5/28) were responsible for the majority (80%) of adverse events, outcomes and interventions. The seriousness of the precipitating events correlated with the degree of restrictions utilised to safely manage or treat such behaviours. Observational scales can be used for restrictive, intrusive or coercive practices in psychiatry even though these involve interrelated complex sequences of interactions. The DRILL tool has been validated to assess the necessity and demonstrate proportionality of restrictive practices. This tool will be of benefit to services when reviewing practices internally, for mandatory external reviewing bodies and for future clinical research paradigms.

中文翻译：

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一种评估法医精神健康环境中使用限制性惯例的比例和必要性的工具：DRILL工具（Dundrum限制，侵入和自由阶梯）

在精神病医院中，要预防由于严重精神疾病引起的暴力行为，可能需要采取侵入性，限制性和强制性的治疗措施。由于缺乏描述和衡量系统，有关适当使用此类干预措施的研究受到了限制。我们着手设计和验证一种工具，以供临床医生使用并确保医院评估即将发生的暴力行为与限制行为（包括降级，隔离，约束，强迫用药等）之间的必要性和比例。在这项回顾性观察性队列研究中，每天评估一个安全的精神病医院在12张床位男性入院病房中的28名患者，为期6个月。有关不良事件的数据是从案件记录，事件登记簿和法律登记簿中收集的。使用先例的功能评估顺序，行为和后果（A，B，C），我们设计并应用了结构化的专业评估工具，常见不良事件和预防性临床干预措施的多元框架，以开发分析临床实践的工具。我们通过测试有关在医院预防暴力中使用限制性和侵入性做法的假设进行了验证。我们旨在提供一种系统，用于测量导致不良事件的环境和个人因素，并评估所测得的威胁和暴力行为的严重性是否与所采用的限制性干预措施的程度成比例。一般估计方程式测试了环境，决策和干预途径的初步模型。一种衡量不良行为和限制性行为的系统，预防性干预措施具有良好的内部一致性。干预与有害行为的严重性相称。“帕累托”患者组（5/28）负责大部分（80％）不良事件，结局和干预措施。降水事件的严重性与安全管理或治疗此类行为所受限制的程度有关。观察量表可用于精神病学中的限制性，侵入性或强制性措施，即使这些措施涉及相互作用的相互关联的复杂序列。DRILL工具已经过验证，可以评估必要性并证明限制性做法的合理性。当内部审查实践，强制性外部审查机构和未来的临床研究范例时，该工具将对服务有益。