Emergency Department

Acute Behavioural Disturbance

Sandy Hopper RCH, Melbourne

Emergency Department

Oliver 10 year old PHx: autistic spectrum disorder Having a blood test Becomes very agitated Bites the doctor doing the test

Emergency Department

Chelsea 14 year old PHx: in state care, substance use, social Becomes angry and aggressive in rooms Screaming and shouting Raises a chair above her head

Emergency Department

Xavier 16 year old Found wandering outside a party Shouting, swearing, coherent Lashing out with his fists

Emergency Department

Mr Jones Around 40 years old Child has leukaemia Upset by the wait in clinic Yelling at the receptionist

Emergency Department

Sam 13 year old PHx: acquired brain injury, seizures, OSA, obese Seizure at his accommodation As he’s waking up he shows a fearsome display

of aggression

Emergency Department

Behavioural disturbance

Autonomy

Duty of care Beneficence

Mental Health law Zero tolerance

OH&S

Emergency Department

An approach to acute behavioural disturbances

Emergency Department

Describe an approach to acute behavioural disturbances

Prevention

Management- Verbal de-escalation Restraint Use of medication

Emergency Department

Prevention Prediction: Not always possible

Environment Systems

Emergency Department

Acute behavioural disturbance

Imminent or actual

Emergency Department

Universal approach

Acute brain/ intoxicated

Verbal de-escalation

Collaborative sedation

Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection

Actively violent

fails

Y

N fails

Y

Reception and assessment

N

After Hilt RJ, 2008

Emergency Department

Verbal de-escalation

You cannot reason with an unreasonable person

Emergency Department

de-escalation Non-verbal: position, posture, body language Verbal style: low slow and quiet Verbal content: care and understand, appeal to

reason

Emergency Department

understand the problem I am here to help you.

Tell me how I can help

Tell me what’s bothering you

Emergency Department

active listening I can see you want to…. That must really upset you

Emergency Department

clarify goals I can help you…. But first I need to make sure

you are safe.

Emergency Department

simply rephrase Let’s make sure you are OK and then you can….

Emergency Department

externalise the problem behaviour

The anger I am seeing here makes it hard for me to help you.

Emergency Department

externalise your response The law tells me/ it is my job to make sure you

are OK, so I need to…… before you can….

I am not happy about the long wait either. It is very frustrating for me too.

Emergency Department

become part of the solution If you help me to make sure you are safe, then I

can……

Emergency Department

suggest/request an alternative, positive solution

It’s OK to be angry/disappointed/frustrated. Tell me how angry… you are.

Emergency Department

meet some needs Food Nicotine Water Elimination

Emergency Department

offer choices to give control Cool drink/warm drink Orange/ lemon Straw/ no straw Sitting down/ standing up

Emergency Department

Universal approach

Acute brain/ intoxicated

Verbal de-escalation

Collaborative sedation

Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection

Actively violent

fails

Y

N fails

Y

Reception and assessment

N

After Hilt RJ, 2008

Emergency Department

Collaborative medication

Whatever they are on Whatever worked last time

Diazepam, Olanzapine

Emergency Department

Universal approach

Acute brain/ intoxicated

Verbal de-escalation

Collaborative sedation

Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection

Actively violent

fails

Y

N fails

Y

Reception and assessment

N

After Hilt RJ, 2008

Emergency Department

Behavioural Resuscitation Enhanced verbal de-escalation A show of overwhelming force Containment Ejection Physical restraint Mechanical restraint Chemical restraint

Emergency Department Team approach

7-8 persons skill mix Trained Equipped

Emergency Department

Enhanced verbal de-escalation A show of overwhelming force

Require a reasonable person

Emergency Department

Ejection/ Police behaviour is unequivocally not due to mental

health or medical concern.

“Acting out” Criminality

Emergency Department

Containment: A goldilocks option

Emergency Department

Seclusion

Not too agitated Must be searched

Not too sleepy

Emergency Department

Most patients will require physical and chemical restraint

Emergency Department

Physical restraint

5 person Trained Universal precautions Supine

Emergency Department Chemical restraint

O vs S/L vs IM vs IV Choice of agent: Midazolam Diazepam Haloperidol Droperidol Olanzapine

Emergency Department

Midazolam: rapid onset, short duration, amnestic, commonly used in acute health

Diazepam: longer acting, oral or IV, not IM Haloperidol: onset 20’, duration 2 hrs, sedating,

risks EPS and NMS Droperidol: shorter acting than HPD, ?risk of

long QT? Olanzapine: similar profile to HPD perhaps less

sedating, less EPS, NMS

Emergency Department

Choice of agent Anxiety, acute brain, intoxication : benzo All others: benzo plus antipsychotic

Emergency Department

Olanzapine vs Haloperidol Khan: Olanzapine: effective in 90%, no AEs

apart from sedation, restraint time 40 minutes Sonnier: EPS less common in atypicals- 8%

(?long term use)

All give rise to sedation, all can prolong QT

Bottom line: Olanzapine is a little less unpleasant, and possibly safer

Emergency Department

Sedation: complications Respiratory depression hypotension, tachycardia. Extra pyramidal reactions

Titrated to effect Close care: monitoring, 1:1 nursing

Emergency Department Mechanical restraint

Slow to settle: whilst waiting for chemical restraint to take effect

Likely to wake up agitated or violent

Sole method in special circumstances

Emergency Department

Mechanical restraint: complications

Distressing and crude Caution with risk of vomiting, aspiration,

asphyxiation. Attention to skin and elimination

Close care: monitoring, 1:1 nursing

Emergency Department

Universal approach

Acute brain/ intoxicated

Verbal de-escalation

Collaborative sedation

Behavioural Resuscitation Team approach Verbal De-esc Show of force Physical restraint Mechanical restraint Chemical sedation Containment Ejection

Actively violent

fails

Y

N fails

Y

Reception and assessment

N

After Hilt RJ, 2008

Emergency Department

?

Emergency Department Summary

Prevention Environment, Self Verbal de-escalation

Behavioural resuscitation Ejection Containment Restraint Use of medication

Emergency Department

Assessment By mental health staff.

Downstream care

Emergency Department

Background Epidemiology Administrative framework

Emergency Department

Acute brain syndrome Drugs, infection most common

Suspect when delirium, young, rapid onset, no

psychosocial setup, abnormal examination

Emergency Department

references 1 Correll CU, Penzner JB, Parikh UH et al. Recognizing and monitoring adverse events

of second-generation antipsychotics in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2006;15:177-206.

2 Grover S, Malhotra S, Bharadwaj R et al. Delirium in children and adolescents. Int J Psychiatry Med. 2009;39:179-187.

3 Hilt RJ, Woodward TA. Agitation treatment for pediatric emergency patients.[Erratum appears in J Am Acad Child Adolesc Psychiatry. 2008 Apr;47(4):478]. J Am Acad Child Adolesc Psychiatry. 2008;47:132-138.

4 Twomey B. Code Grey Procedure. 2010 [accessed 2011 25 August 2011]; Available from: http://www.rch.org.au/policy_rch/index.cfm?doc_id=10197

5 Downes MA, Healy P, Page CB et al. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009;21:196-202.

6 Stewart C, Spicer M, Babl FE. Caring for Adolescents with Mental Health Problems : Challenges in the Emergency Department. J. Paediatr. Child Health. 2006;42:726-730.

7 Dorfman DH, Mehta SD. Restraint use for psychiatric patients in the pediatric emergency department. Pediatr. Emerg. Care. 2006;22:7-12.

Emergency Department

references 8 Clinical Practice Guideline Group of Royal Children's Hospital Melbourne. Emergency

Restraint & Sedation- Code Grey. 2006 [accessed 02 February 2010]; Available from: http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5243

9 Victorian taskforce on violence in nursing. Final report: Victorian taskforce on violence in nursing. 2005 [accessed 20 July 2010]; Available from: http://www.health.vic.gov.au/__data/assets/pdf_file/0007/17674/victaskforcevio.pdf

10 Policy and Strategic Projects Division DoHS, Victorian Government , Melbourne, Victoria, Australia. Occupational violence in nursing: An analysis of the phenomenon of code grey/black events in four Victorian hospitals. 2005 [accessed 20 July 2010]; Available from: http://www.health.vic.gov.au/__data/assets/pdf_file/0008/17585/codeblackgrey.pdf

11 Woolfenden S, Dossetor D, Nunn K et al. The Presentation of Aggressive Children and Adolescents to Emergency Departments in Western Sydney. J. Paediatr. Child Health. 2003;39:651-653.

12 Dorfman DH. The Use of Physical and Chemical Restraints in the Pediatric Emergency Department. Pediatr. Emerg. Care. 2000;16

13 Brayley J, Lange R, Baggoley C et al. The violence management team. An approach to aggressive behaviour in a general hospital. Med. J. Aust. 1994;161:254-258.

Emergency Department

references Khan SS, Mican LM.A naturalistic evaluation of intramuscular

ziprasidone versus intramuscular olanzapine for the management of acute agitation and aggression in children and adolescents. J Child Adolesc Psychopharmacol. 2006 Dec;16(6):671-7.

Sonnier L, Barzman D. Pharmacologic management of acutely agitated pediatric patients. Paediatr Drugs. 2011 Feb 1;13(1):1-10.