Principles of monitoring patients with acute behavioural disturbance

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

Note: After administering any sedative drug to a patient with acute behavioural disturbance, always monitor them closely to assess the efficacy of interventions and to identify potential harms.

After administering any sedative drug to a patient with acute behavioural disturbance, always monitor them closely to assess the efficacy of interventions and to identify potential harms. Refer to local protocols or consensus state guidelines if they are available. Observe all patients administered a sedative drug with 1:1 continuous visual nursing observation for adverse effects of drugs. Once it is clear they are not oversedated and can maintain a patent airway, intermittent monitoring is sufficient; specify the frequency of nursing observations and medical reviews clearly. Each patient is different and monitoring schedules must be flexible (eg older people who have been administered sedation are at increased risk of falls and require continuous visual monitoring).

The Joint College’s Guidelines for Safe Care for Patients Sedated in Health Care Facilities for Acute Behavioural Disturbance recommend the following minimum monitoring and equipment requirements for a patient who has been administered any sedative drug:

  • a minimum of 3 staff in attendance for any sedation other than oral sedation
  • monitoring the patient’s level of consciousness (eg use a Sedation Assessment Tool [SAT] score)
  • continuous pulse oximetry
  • monitoring cardiorespiratory status (eg regular airway patency checks, frequent observations of heart rate and blood pressure)
  • the capability to administer 100% oxygen if required
  • ready access to an electrocardiographic (ECG) monitor and end-tidal carbon dioxide monitoring device1.

Minimum monitoring and equipment requirements for managing patients after parenteral sedation are:

  • oxygen supply
  • suction source, catheters and sucker
  • bag-valve-mask apparatus and equipment for advanced airway management
  • pulse oximeter
  • heart rate and blood pressure monitoring
  • access to
    • a fully equipped resuscitation trolley
    • an electrocardiographic (ECG) monitor and defibrillator
    • end-tidal carbon dioxide monitoring device1
    • intravenous fluids and infusion equipment.

In community settings (especially in rural and remote areas) if the minimum monitoring and equipment requirements are not available, a senior clinician needs to make a risk assessment about the relative risk of the situation proportionate to the risk of the sedative drug.

Tailor monitoring depending on the:

  • patient’s clinical condition (medical and psychiatric), including evidence of ongoing distress or agitation
  • sedative drug(s) used—type, route of administration, dose(s), onset, duration of action
  • history of past exposure, efficacy or adverse reaction to the drug(s) used
  • level of sedation achieved—use an objective scale to monitor the patient’s conscious state (eg Sedation Assessment Tool [SAT], Glasgow Coma Scale)
  • potential harms associated with the drug(s), including additive drug effects (eg oversedation) or adverse drug effects (eg extrapyramidal effects after an antipsychotic drug), particularly if multiple drugs were used, including recreational drugs and alcohol. See potential harms of sedative drugs in adults, older people and children.

When monitoring the patient, provide a calm and quiet environment, and minimise unnecessary stimulation or irritation; however, balance this with the need to carry out required observations to detect complications and intervene quickly if they arise.

1 End-tidal carbon dioxide monitoring is generally not available in outpatient settings.Return