PREVENTION
- Very minor incidents can escalate into a violent situation
- Communicate clearly to minimise escalation
RECOGNITION
Warning signs of impending violence
- Spontaneous self-reporting of angry or violent feelings
- Fluctuating levels of consciousness with prominent persecutory ideas
Carers warn of imminent violence
- Increased restlessness, bodily tension, pacing, arousal
- Increased volume of speech, erratic movements
- Facial expression tense and angry, discontented
- Refusal to communicate, withdrawal
- Unclear thought processes, poor concentration
- Delusions or hallucinations with violent content
- Audible threats, or aggressive gestures
- Recognition of signs apparent in earlier episodes
Context
- Aggression or agitation can occur in:
- psychiatric illness
- physical illness
- substance abuse
- personality disorder
- confusional state irrespective of underlying cause
- patients who have received drugs affecting CNS
ASSESSMENT
- Assessment must be by a fully registered doctor (FY2 or above)
- FY1 doctors must not assess mental capacity
- Inform senior member of medical team (SpR or consultant).
- If there are signs of impending violence, inform site manager who will identify any staff on duty who have been trained in restraint techniques
Personal (staff member’s own) behaviour
- Maintain adequate distance
- Move towards safe place, avoid corners
- Explain intentions to patient and others
- Be calm, self-controlled, confident
- Ensure own body language is non-threatening
- Avoid sudden movements
Safety
- Do not attempt to deal with a violent patient on your own
- Keep other patients clear
- Keep other staff clear but within helping distance
- If possible, move patient to a quiet area
Assess using verbal de-escalation
- Engage in conversation, acknowledge concerns and feelings
- Ask for reasons for disquiet, encourage reasoning
- Ask for any weapon to be put down (not handed over)
- If patient too disturbed for such measures, or fails to respond:
- consider physical restraint by trained staff and/or police (see below)
History
- Try to take a history from the patient and those who know the patient
- ask whether this has happened before and how it was handled
- ask about any regular psychotropic medication
Mental state examination
- General appearance and behaviour of patient
- Speech
- Attention and concentration
- Mood: subjective and objective
- Thought: evidence of loosening of association
- irrelevant thoughts, delusions, thoughts of self-harm or harm to others
- Hallucinations
- Evidence of cognitive impairment
- Insight
Assess risk factors for violence
- Young, male, history of violence
- Alcohol or other substance misuse, irrespective of other diagnosis
- Poor compliance with suggested treatments
- Antisocial, explosive or impulsive personality traits
- Active symptoms of schizophrenia or mania, in particular with:
- delusions or hallucinations focused on a particular person
- delusions of control, particularly with a violent theme
- specific preoccupation with violence
- agitation, excitement, overt hostility or suspiciousness
Assess mental capacity (Mental Capacity Act 2005)
- Assessment is task/decision specific.
- The legal definition of someone who cannot make autonomous decisions is one who is unable to undertake the following:
- understand information about proposed treatment, its purpose and why it is being proposed
- retain that information long enough to be able to make a decision
- use or weigh that information as part of decision-making process
- communicate his/her decision – by any means possible (e.g. talking, using sign language or other means)
- See Capacity section in Consent guideline
Any doubt or disagreement?
- An application to the court will be necessary. Seek advice
Physical examination
- If safe to do so, gain patient’s consent and attempt a thorough physical examination
- look for sources of infection and/or neurological deficits
- if unsafe, document reasons and carry out examination once stable
IMMEDIATE MANAGEMENT
Principles
- If acute mental illness suspected (e.g. schizophrenia or hypomania), refer to psychiatry
- If patient elderly with acute confusion, see Delirium (acute confusional state) in older people guideline
- If patient has symptoms and signs of alcohol withdrawal, see Alcohol withdrawal guideline
- If patient intoxicated, but fit to be arrested and taken into custody, request police assistance
- If none of the above applies, options available depend on patient’s mental capacity. See Capacity section in Consent guideline
Capable of making decisions
- Hold patient accountable for his/her actions
- Manage underlying cause of agitation
- Do not administer medication without patient’s consent
Patient lacks capacity
- Ensure that any intervention used is the least harmful or restrictive of patient’s basic rights and freedom
- immediately necessary, reasonable, and in their best interest
- Conduct multidisciplinary discussion to decide whether rapid sedation is safe and appropriate
- Take all necessary means to prevent injury to self, other staff or patients, or damage to property
- consider use of physical restraint and/or medication – see below
- Manage underlying cause of agitation
Physical restraint
Decision
- The use of any physical holding is the last resort
- once staff attempt to restrain a patient, a threatening situation may turn violent
- Assessment must be by a fully registered doctor (FY2 or above)
- the person taking action must reasonably believe that restraint is necessary to prevent harm to the person who lacks capacity or staff and other patients
- Use restraint only if there are sufficient staff to achieve this effectively and you perceive imminent danger because patient is:
- displaying prolonged and serious verbal abuse, threatening staff, or disrupting ward
- threatening or attempting self-injury
- at risk of prolonged over-activity with risk of exhaustion
- at risk of serious accident to self and/or others
- attempting to abscond if detained under Section and in an open ward
Who to undertake restraint?
- Request assistance from any staff on duty trained in physical restraint techniques and who have completed the clinical holding course/update
- inform site manager who will identify any trained staff
- medical and nursing staff should not attempt to physically restrain the individual
- Best practice guidance is a minimum of 2 staff to hold someone and 3 staff if the person is held on the floor
- If no suitably trained staff available, or patient is making significant physical attacks or serious efforts to destroy property, leave the scene immediately and request police assistance
- the police will always respond to a call for assistance, but are not allowed to assist in restraining patients for treatment
When patient restrained
- Any holding must be reasonable and proportional to the circumstances
- Do not, under any circumstance, inflict deliberate pain
- Wherever possible, avoid holding someone on the floor (particularly in the prone position).
- Hold in any position for the minimum amount of time possible to manage the prevailing or perceived level of risk
Medication
Principles
- If new brain damage suspected, avoid medication until after CT scan.
- Check prescription chart for previously prescribed drugs.
- Reduce dosages of medication appropriately in the elderly or infirm
- Try to persuade patient to accept oral medication
- if this is not possible, use parenteral route (do not mix two drugs in a syringe)
Elderly
- If patient is elderly refer to Delirium (acute confusional state) in older people guideline especially for doses of medication
- olanzapine and risperidone can cause serious side effects including strokes in older patients
- do not use aripiprazole, promethazine or haloperidol
- Unless dose for elderly is specified below, halve doses of medication for older people
Substance abuse
- Treat any symptoms suggestive of withdrawal – see Withdrawal of drug(s) of dependence guideline
Sedation
- Recommended medication options are:
- lorazepam (prefer as first choice) 1 mg oral/IM repeated 6-hrly if necessary – adult maximum dose 4 mg in 24 hr (elderly 0.5–1 mg; maximum 2 mg in 24 hr)
- for IM injection, dilute lorazepam with an equal volume of water or sodium chloride 0.9%
- Use IM only when oral route not available
- If no response 1 hr after oral lorazepam, give oral olanzapine 10 mg (elderly 5 mg) or risperidone 1–2 mg (elderly 0.5–1 mg)
- If 1–2 mg of lorazepam (elderly 0.5-1 mg) used, have flumazenil to hand in case of respiratory depression
- If oral medication fails, consider IM treatment
- Alternatives (not for the elderly) are aripiprazole 9.75 mg, promethazine 50 mg or as a last resort, and only after an ECG has been checked, consider haloperidol 5 mg
- do not use haloperidol in elderly, patients with Parkinson’s disease, heart disease or if patient has a prolonged QT interval or taking other drugs that prolong QT interval
- if using haloperidol, have procyclidine available in case of dystonic reaction
- If no response to 2 forms of medication, seek advice from on-call psychiatry team
- Do not prescribe beyond BNF limits, and be aware of the cumulative effect of combination medications
SUBSEQUENT MANAGEMENT
- Monitor vital signs
- Record BP, pulse, respiratory rate, hydration, pulse oximeter and level of consciousness until fully conscious
Documentation
- Record incident clearly and fully afterwards
- Complete an adverse incident/Datix report with witness statements
- Record further care plan
Once stable
- Continue close observation as inpatient for at least 24 hr
- Reassess mental state and review patient’s status under Mental Health Act
- Continue management of underlying condition
- When transferring patient between units, send details of:
- incident
- medication management
- subsequent management plan
- any unwanted effects
- any advance directives
© 2022 The Bedside Clinical Guidelines Partnership.
Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.
Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa