As part of ongoing efforts to improve care and reduce incidents of aggression and injuries to patients and staff at Michigan’s four state psychiatric hospitals, the Michigan Department of Health and Human Services (MDHHS) has implemented daily risk assessments and care planning.

This new process has resulted in a 47% reduction in patient injuries and a 27% decrease in serious patient-related staff injuries.

“We take the health and safety of our staff and patients seriously and continually strive to improve the care our patients receive as well as working conditions for our staff,” said Elizabeth Hertel, MDHHS director. “Patient-to-staff aggression is the leading cause of workplace injury among our staff. Implementing this risk assessment tool has helped us make great strides in reducing incidents and injuries as well as improving staff retention.”

The Dynamic Appraisal of Situational Aggression (DASA) is a seven-item risk assessment rating used to evaluate the likelihood of aggression in behavioral health inpatients within 24 hours. Patients are rated daily by direct care nursing staff on the following categories:

• Irritability.
• Impulsivity.
• Unwillingness to follow directions.
• Sensitive to perceived provocation.
• Negative attitudes.
• Verbal threats.

Staff completing the DASA consider whether each of the seven behaviors are present and then determine a rating of low, moderate or high risk of aggression.

Based on their DASA score, the Aggression Prevention Protocol is used to develop individualized intervention strategies that are implemented to prevent aggressive behavior before it begins.

Strategies can include reassurance and distraction techniques, one-to-one nursing, medication or setting limits and establishing boundaries of acceptable behavior, as well as increased observation.

MDHHS operates four in-patient psychiatric hospitals serving about 600 patients, Caro Psychiatric Hospital, Kalamazoo Psychiatric Hospital (KPH), Walter Reuther Psychiatric Hospital and the Center for Forensic Psychiatry (CFP). DASA was implemented at KPH in March 2024, Caro and Walter Reuther for adult patients in July 2024 and CFP and Walter Reuther for youth patients in September and August 2025, respectively.

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