Reducing the risk of harm in acute behavioural disturbance

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

Always take steps to ensure the safety of the patient (eg self-harm, unrecognised systemic illness, iatrogenic complications) and others (eg aggression or significant harm to staff or others present).

Use environmental management (or adaption) and verbal de-escalation and psychological intervention as first-line strategies for all patients with acute behavioural disturbance, unless there is an imminent risk of significant harm to self or others, and/or an immediate risk to life. These measures can help to defuse the situation, instil trust between the clinician and the patient, and avoid more invasive interventions. If the patient does not respond to these initial strategies, rapid intervention may be required before a comprehensive assessment is possible.

To reduce a patient’s distress and risk of harm to self or others:

• embed a culture and processes that promote engagement and safety for both patients and staff
• maintain the patient’s privacy
• use a nonjudgemental, noncoercive approach
• avoid triggering distress that can lead to aggression
• enlist adequate support from other staff, and/or security and police (if necessary)
• never restrain the patient in the prone position
• optimise the environment
  • allocate an urgent triage category
  • provide the patient a quiet calm space
  • attend to the patient rapidly
  • involve family and/or carers where possible
  • monitor the patient closely
  • ensure there are 2 exits and advise staff to stay close to an exit
  • ensure there is an easily accessible duress alarm
  • ensure there are no items that can be used as weapons (eg furniture, equipment, patient’s belongings).

The optimal approach depends on the patient and the clinician. If the patient has an existing behavioural support plan¹, use it to guide management and try to involve usual carers or family if available. Discussing the patient’s preferences for the management of acute behavioural disturbance in advance can help de-escalation during an event.

If police have brought an adult to a health care facility handcuffed because of their behaviour, urgently assess the person while they remain handcuffed with police in attendance. After the initial assessment, if it is safe to do so, police may remove the handcuffs. If it is unsafe, pharmacological management may be required before police can safely remove the handcuffs. Children and people with developmental disability should never be handcuffed.

To minimise the imminent risk of significant harm to self and others, all patients with acute behavioural disturbance require close observation (eg continuous visual surveillance, very frequent observations). The Department of Health Mental health triage tool is a guide for assessing the severity of disturbance and risk of harm. 

Transporting or transferring a patient between facilities is associated with risks to the patient and healthcare staff. Consider whether the benefit outweighs the potential harms (eg transferring a patient with dementia from a familiar care environment to an acute care facility may escalate their distress). See Transporting or transferring a patient before or after management of acute behavioural disturbance.