Charge Nurses

The structured professional judgment instrument the DUNDRUM-1 is the product of an iterative drafting process. This commenced in early 2008 with a brainstorming and consultative session amongst the consultant forensic psychiatrists who are responsible for the decision to admit patients to the Central Mental Hospital. Nine consultant forensic psychiatrists were consulted, all of whom had worked or were working at the Central Mental Hospital. The nine had worked variously in nine medium or high secure forensic mental health services in five different jurisdictions. Colleagues in other disciplines were also consulted. The second phase consisted of an iterative process of refinement of definitions based on observation of discussions and practice at the weekly referrals meeting at the Central Mental Hospital at which all referrals are discussed and assessments prioritised. This meeting is chaired by the consultant forensic psychiatrist on call for that week and is attended by the leaders of all multi-disciplinary teams (consultant forensic psychiatrists), the heads of all disciplines (nursing, psychology, social work, occupational therapy), nurses in charge of wards and hospital managers. Clinicians from the psychiatric court liaison and prison in-reach service in the main remand prison also attend and those providing in-reach clinics in the other prisons. Referrals for assessment with a view to admission from local mental health units are allocated to consultant forensic psychiatrists and when assessed these are also considered for admission at this meeting. The structured professional judgment instrument described here - the DUNDRUM-1 triage security instrument is part of the 22^nd revision of this draft. It forms part of a suite of structured professional judgment instruments [16 ] along with the DUNDRUM-2, an instrument for assessing the urgency of need for admission and prioritisation of waiting lists, and two instruments for assessing readiness for movement to less secure places, the DUNDRUM-3 programme completion instrument and the DUNDRUM-4 recovery instrument.
The assessment of the appropriate level of therapeutic security for those requiring mental health interventions was assessed using an 11 item scale (figure 1 and additional file 1). Each item is rated using a five point scale from 0 (no security needed, or no mental disorder), 1 (could be managed in an open hospital ward), 2 (could be managed in a local psychiatric intensive care ward/low secure unit), 3 (could be managed in a medium secure unit) and 4 (special/high security required). The ratings for each item are tethered to operational definitions [16 ] (and additional file 1).
Ratings were made jointly by two senior clinicians based on the unstructured but detailed pre-admission assessments and court reports prepared by the psychiatric in-reach team. These ratings were prepared blind to the eventual outcome of the case. There was no missing data. This reflects the relevance of the item content.
For cross-validation, the HCR-20 [21 ] 'H' and 'C' items were assessed on a sub-sample. The clinicians making the ratings were trained in the use of the HCR-20 and were blind to outcome.

To qualify for inclusion, both full- and part-time staff had to have worked in the unit (including those not based in the unit, but with a significant work commitment to it) for at least one month prior to administration of the questionnaire. The "rule of thumb" we applied was that all personnel within a clinical area who either influence or are influenced by the "working environment" in that clinical area were invited to participate (e.g., Attendings/Staff Physicians, Resident Physicians, Registered Nurses, Charge Nurses, Pharmacists, Respiratory Therapists, Technicians, Ward Clerks, Other:_____________). Response was voluntary, and administration techniques included hand-delivery, meeting administrations, and in-house mailing administrations.

The EMRMS was established in November, 2016 to assist rheumatologists in conducting ASDAS assessments and comprehensively evaluating clinical outcomes in all patients with AS attending TCVGH. The EMRMS database contains information necessary to determite ASDAS, including CRP, level and erythrocyte sedimentation rate [ESR], patient comorbidities, patient history, and family history. The reliability and validity of the data have been verified^{14 (link)}.Patients with AS were consecutively enrolled in the TCVGH-AS cohort after they received a confirmed AS diagnosis from a TCVGH rheumatologist according to the 1984 modified New York criteria^{10 (link)}. The CRP and ESR data were automatically uploaded to the TCVGH healthcare information system (HIS) to reduce human error. The baseline information, which was collected by trained nurses during the initial visit, including clinical characteristics, onset age, comorbidities at presentation (hypertension, diabetes mellitus, hyperlipidemia, hepatitis B, hepatitis C, renal insufficiency, gout, coronary artery disease, stroke, periodontal disease, osteoporosis, and tuberculosis history), periarticular extraspinal features (synovitis, enthesitis, and dactylitis) and nonarticular manifestations (psoriasis, uveitis, and IBD), family history of autoimmune disease, and patient history of arthropathy, obtained through standardized questionnaires and worksheets to ensure reproducibility and adherence to good laboratory practice. The rheumatologist in charge then confirmed patients’ clinical characteristics, and nurses assisted the patients with AS to complete the self-assessment questionnaires for disease evaluation. The following measures were used: global assessment of disease activity on a numerical rating scale (NRS) of 0–10, back pain on an NRS of 0–10, duration of morning stiffness on an NRS of 0–10, and peripheral pain or swelling on an NRS of 0–10. Before every 3-month visiting clinic, the patient would first to have blood examination. Blood reports can be uploaded to EMRMS through the HIS system, trained nurses assist patient fills out the questionnaire on EMRMS, the assessment of disease activity completed before visiting the doctor. All laboratory data, including CRP and ESR, have been uploaded to the HIS. The IT at TCVGH help "feed-forward" the patient reported outcomes to HIS, and do the auto-calculation of ASDAS-ESR, ASDAS-CRP using the ESR, CRP data in HIS, then "feed-back" these data to both HIS and EMRMS, showing the data on the summary overview "dashboard" in the EMRMS, which was shown both in HIS and the devices (iPAD handled by a nurse in charge and smartphones of patients with AS).