Determining the safety of intervening in acute behavioural disturbance

Managing a patient with acute behavioural disturbance is a detailed flowchart for managing a patient with acute behavioural disturbance.

The approach to assessing and managing a patient with acute behavioural disturbance varies according to individual patient factors, the risk of significant harm to self or others, and the setting.

In adults, particular behaviours are suggestive of imminent significant harm; see Behaviours in adults with acute behavioural disturbance that suggest imminent significant harm.

Figure 1. Behaviours in adults with acute behavioural disturbance that suggest imminent significant harm.

[NB1]

anxiety
agitation
command hallucinations to harm self or others
demeaning or hostile language
excessive, apparently purposeless motor activity not influenced by external stimuli
intentional property damage
intense staring
irritability
labile affect
motor restlessness and pacing
mumbling
physically threatening or intimidating behaviour
signs of imminent self-harm
verbally threatening, shouting, demanding

Note: NB1: Behaviours that suggest imminent significant harm differ in children and in people with developmental disability or cognitive impairment (eg mumbling and pacing may be baseline behaviours in some individuals).

To direct management, it is important to establish early whether the patient’s behaviour:

can be safely addressed by available healthcare staff (eg no weapons are involved, significant harm is unlikely)
is likely to have been precipitated by a medical disorder, substance intoxication or withdrawal, and/or a psychiatric disorder.

A Sedation Assessment Tool (SAT) score can assist clinical decision making in an acute behavioural disturbance. It can be used to assess the imminent risk of significant harm to self and others and guide the clinician as to whether repeat doses of sedative drugs are required. Consider the SAT score in the context of the situation and the individual—see Sedation Assessment Tool (SAT).

The SAT has been validated in adults to assess the efficacy of pharmacological management in acute behavioural disturbance and guide the requirement for repeat doses of sedative drugs. Individualise the target SAT score based on patient factors (eg response to nonpharmacological interventions, whether the patient needs to be sedated for investigations) and the ability to maintain patient and staff safety.

The SAT has not been validated for use in children and older people, but has been used in trials to assess the effect of sedation in acute behavioural disturbance in these groups.

Note: A Sedation Assessment Tool (SAT) score can be used to assess the imminent risk of significant harm to self and others, and guide whether repeat doses of sedation are required—consider the SAT score in the context of the situation and the individual.

In adults, a SAT score of +2 or +3, may indicate an imminent risk of significant harm and immediate intervention is indicated. In children, older people, and people with a developmental disability or cognitive impairment, measure the SAT score once the environment and their unmet needs are optimised (eg the patient is in a quiet space, attempts have been made to address hunger, thirst, pain and toileting). Consider the SAT score in the context of the patient’s baseline function and communication style (eg loud outbursts may be usual for individuals with dementia or a developmental disability). Give the patient space and observe them to understand their behaviour; ask their carer whether their behaviour is different to normal.

Table 1. Sedation Assessment Tool (SAT)
Score	Responsiveness	Speech
+3	Combative, violent, out of control	Continual loud outbursts [NB1]
+2	Very anxious and agitated	Loud outbursts [NB1]
+1	Anxious, restless	Normal, talkative
0	Awake but calm, cooperative	Speaks normally
-1	Asleep but rouses if name is called	Slurring or prominent slowing
-2	Responds to physical stimulation	Few recognisable words
-3	No response to stimulation	Nil
Note: NB1: Loud verbal outbursts may be usual for some groups (eg patients with dementia or developmental disability). Reproduced with permission of John Wiley & Sons, Inc. from: Calver LA, Stokes B, Isbister GK. Sedation assessment tool to score acute behavioural disturbance in the emergency department. Emerg Med Australas 2011;23(6):732-40. [URL]. © 2011 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

If there is an imminent risk of significant harm to self or others, and it is unsafe to intervene, summon support early (which may include security staff and/or police for adults) to assist in disarming and restraining the patient. Security staff are less often required or involved when managing a child compared to an adult. Tailor the approach to the individual—a noncoercive approach, where the patient feels safe, promotes de-escalation and reduces the risk of trauma.

Note: If the situation is too dangerous to intervene, summon security staff and/or police early.

Isolated practitioners, including general practitioners or community nurses, should not attempt to manage a patient with an acute behavioural disturbance when they are alone in the community (eg in the patient’s home). Seek help from an ambulance service and/or police and if possible, ensure personal safety by moving to a safe environment.