acutely disturbed psychiatry patients

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10.1192/apt.11.6.404Access the most recent version at DOI:2005, 11:404-415.APT

Rob Macpherson, Roland Dix and Sally Morganpatients

Guidelines for the management of acutely disturbed psychiatricA growing evidence base for management guidelines : Revisiting...

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404 Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/

Macpherson et al Advances in Psychiatric Treatment (2005), vol . 11, 404415

The authors revisit a topic about which Rob Macpherson andcolleagues wrote in an early volume of APT (Macpherson et al,1996). Their original article, with a comment on it by Trevor Turner,is available on our website (http://apt.rcpsych.org), as a datasupplement to the online version of the present article.

A complementary article that gives a more wide-ranging accountof the prevention and management of violence in psychiatric settingsappeared in the previous issue of APT (Davison, 2005). There isdeliberate overlap between the two articles, allowing each to be readindependently.

The treatment of acutely disturbed patients is

a difficult, inherently stressful, but ubiquitousrequirement of psychiatric practice. When wedeveloped our first guidelines as a multidisciplinarycollaboration almost 10 years ago (Macpherson et al,1996), it appeared to us that a lack of consensusamong senior psychiatrists on appropriate treatmentcontributed to uncertainty about treatment in thisarea. Treatments of dubious rationale were oftenbeing used, without a clear evidence base. Ouroriginal guidelines aimed to set out principlescovering general aspects of management, includingdrug treatment.

There has subsequently been increasing scrutinyof practice in this area. The National Audit Office(2003) noted a 40% increase between 1999 and 2002in self-reported violence experienced by National

Health Service (NHS) staff, rates of violence being2.5 times higher in mental health and learningdisability trusts than in other NHS trusts. Under-reporting was considered widespread, and it wasestimated that violent incidents cost the NHS69 million a year (this figure took no account of thehuman costs). The Audit Office report foundsubstantial variation in training in both risk assess-ment and management of violence, and seriousdeficits in training among doctors in particular. There

was marked inconsistency in staff support followingviolence, and successful prosecution by assaultedstaff was rare. The inquiry into the death of DavidBennett (Norfolk, Suffolk and CambridgeshireStrategic Health Authority, 2003), who collapsed anddied following prolonged restraint in psychiatriccare, raised important concerns about culturalawareness and sensitivity of staff.

In response the UK Government (Department ofHealth, 2005) accepted recommendations formandatory training in cultural awareness andsensitivity of all mental health staff, for the develop-ment of a national system of training in restraint andcontrol and that all medical staff and registerednurses working in mental health should have up-to-date resuscitation training. The failure to accept a

A growing evidence base for managementguidelinesREVISITING... GUIDELINESFORTHEMANAGEMENTOFACUTELYDISTURBED

PSYCHIATRICPATIENTS

Rob Macpherson, Roland Dix & Sally Morgan

Abstract We review key recent research and guidance for staff working with acutely disturbed psychiatricpatients. Assessment of aggressive patients and their situation should enable full risk assessment,which may ideally involve the use of advance directives. We discuss appropriate use of the MentalHealth Act 1983 and consider benefits and adverse effects of rapid tranquillisation. We present a simpleprotocol for oral or intramuscular rapid tranquillisation. Staff using physical restraint should be properlytrained and consider sensitively issues of the patients diginity, gender and the most appropriate locationfor restraint to occur. Simple precautions can improve safety when working with potentially disturbed

patients. Staff need support during and after the management of an aggressive incident.

Rob Macpherson is a consultant rehabilitation psychiatrist who works in an assertive outreach team and a number of 24-hournursed care units in Gloucester (correspondence: Wotton Lawn, Horton Road, Gloucester GL1 3WL, UK. E-mail:[email protected]). He is also Director of the South West Organisation of Psychiatric Training (SWOPT). RolandDix is a consultant nurse in psychiatric intensive care and secure rehabilitation, a visiting research fellow at the University of theWest of England and executive committee member for the National Association of Psychiatric Intensive Care Units. Sally Morganis a specialist registrar in general adult psychiatry.


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Management guidelines

405Advances in Psychiatric Treatment (2005), vol. 11. http://apt.rcpsych.org/

recommendation restricting prone restraint to a3-min time limit has been controversial, althoughPaterson & Leadbetter (2004) have pointed out thatany time limit for such a complex, difficult procedureis arbitrary and probably reflects an awareness(among the authors of the Governments response)of the harsh realities of restraining patients, a process

usually entered into by staff only with considerablereluctance and sometimes real fear.

Overall, there is little to suggest that the NHSszero tolerance campaign (National Health Service,1999) has had a major impact in reducing theproblem of assaults on mental health or other NHSstaff. However, there appear to have been somesignificant developments in clinical practice andunderstanding in this field. The increasing avail-ability of specialist care provided through the modelof the psychiatric intensive care unit (PICU) hasfacilitated a concentration of skills and expertise, andthis has been associated with a developing evidencebase in the field of rapid tranquillisation. Policies

for rapid tranquillisation and emergency treatmentoperate in most if not all psychiatric hospitals.National Health Service trusts aim to provide in-patient staff with training in control and restraint,de-escalation and breakaway techniques, to dealmore effectively with situations involving violenceor aggression. The development of formal guidelines,first by the Royal College of Psychiatrists (1998) andthen initially in a draft consultation document andsubsequently in clinical guidelines by the NationalInstitute for Clinical Excellence (NICE; 2005), hashelped to clarify and disseminate best practice.

As a result of many positive developments in this

area, our task in writing the present article haschanged significantly from that in 1996. While ourfirst work was an attempt to produce guidelinesbased on experience and research evidence, here wedraw on a wide range of evidence sources, includingpublished evidence-based guidelines. A number ofkey reports and guidelines are now available to assistmental health and other professionals who deal withacutely disturbed psychiatric patients in varioussettings. The most useful of these are listed in Box 1.We have tried to produce simple, user-friendlyguidance distilled from these and other sources andrelating to practice in standard healthcare settings.

Background

Treating acutely disturbed patients can be dangerousfor both patients and staff. The most serious patientrisk is of sudden cardiorespiratory collapse, whichhas been associated with the use of antipsychoticsparticularly during physical arousal (Lader, 1992).Banerjee et al (1995) examined the deaths of 206

detained patients, identifying 15 as iatrogenic.Concerns were raised about the use of high-dosemedication and polypharmacy by inexperiencednurses and trainee psychiatrists who are not directlysupervised by seniors.

An interesting paper by Hyde et al (1998),describing practice in a psychiatric intensive careunit, found that patient dissatisfaction and non-understandable provocation were related to violentincidents, suggesting that environmental factors,education and remedial action may reduce risks ofviolence.

Simpson & Anderson (1996) raised concerns aboutthe lack of adequate resuscitation facilities, trainingand guidelines in acute psychiatric units. It will beinteresting to see whether the publication of the NICEand other guidelines (Box 1) results in a moreconsistent, evidence-based approach to treatment instandard clinical settings.

A recent review of treatment approaches (DeFruyt& Demyttenaere, 2004) identified a number oflimitations in research in this area, including

unclear definitions of agitation and of therapeuticgoals, small sample size and a lack of the patientsperspective. Research findings have been in-consistent and the implications for practice notalways clear. Inevitably, there are practical problemsin studying this complex, ethically fraught areaof clinical practice. Recent guidelines regulate theuse of restraint more than at any previous time(Appelbaum, 1999; Department of Health, 2004).

Box 1 Important recent guidelines

Short-term management of violent behaviourDetailed sections on prevention, training, serviceuser perspectives, psychosocial and other inter-ventions; advice for accident and emergencysettings; recommendations for research; useful

algorithm covering rapid tranquillisation andother interventions (National Institute forClinical Excellence, 2005)

Treatment of bipolar disorderBritish Association for Psychopharmacologysadvice on clinical management and pharma-ceutical agents for acute treatment of mania(Goodwin, 2003)

Management of aggressive, violent or suicidal patientsCommissioned by the United Kingdom CentralCouncil for Nursing, Midwifery and HealthVisiting with the aim of improving policy,practice and education in the management ofviolence (Health Services Research Department,Institute of Psychiatry, 2002)


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Macpherson et al

Assessment of disturbed patients

Assessment of patients

It is not usually possible to take a full history froman acutely agitated patient and it is often necessaryto accept some degree of diagnostic uncertainty inthe early stages of treatment. Nevertheless, it is

important to obtain as full a history as possible fromthe patient, and from family, old case notes and thepolice and/or general practitioner. Take particularnote of information regarding comorbid medicalconditions such as cardiac disease and impairedhepatic or renal function. Previous response totreatment is important as it will influence treatmentchoice. Information about substance misuse shouldbe sought (preferably backed up with urinalysis), asthis could complicate the presentation and/or treat-ment (e.g. through respiratory depression or cardiacarrhythmias). Existing regular and as-required(p.r.n.) medication should be checked. It is also

important to carry out a comprehensive mental stateexamination, with particular attention to hostility,aggression and withdrawal, and their relationshipto manic and psychotic symptoms. Thoroughphysical assessment, including appropriate investi-gations, should be carried out as soon as possible.

On the basis of a preliminary assessment, it shouldbe possible to make a provisional diagnosis, whichis likely to be among the following:

acute psychosis or mania acute confusional state acute stress reaction in a vulnerable individual drug- or alcohol-induced or dual diagnosis state.

Assessment of the situation

As in-patient aggression has become better under-stood, it is clear that situational variables can oftenbe as important as the patients psychiatric symp-tomatology (Crichton, 1997; Dix, 2001). Therefore,beyond the patients clinical profile, a systematicassessment of the situational variables should alsobe undertaken. This may involve identifying real orperceived injustices, breakdown in relationships,frustration and provocation. An understanding ofthe causes of the aggressive episode will be useful

for the development of effective preventive strategies,overall management and future care planning. Oftenthe nature of the aggression will fall into one or acombination of the following categories:

clinical aggression, arising specifically frompsychiatric symptoms;

purposeful aggression, used as a goal-directedmeans of achieving an outcome, for example todeal with staff efforts to prevent absconding;

habitual aggression, arising from the patientspersonality;

discharge of frustration, resulting from real orperceived injustice.

Risk assessment

Risk assessment should take account of historicalfactors known to be associated with increased riskof violence, the strongest of which being history ofprevious violence. This should be combined with aview of the individual and his or her circumstances,leading to a clinical judgement informed by the factthat risk changes with personal, illness and treatmentfactors. In predicting risk of violence, empiricallyproven risk assessment instruments such as theHistorical, Clinical and Risk Assessment Manual(HCR20; Webster et al, 1997) are effective andreliable as an additional aid to clinical judgement(Belfrage, 1998). Instruments of this type should also

be used to inform the development of local riskassessment policy.

Training in risk management is mandatory formost staff in NHS trusts, although the quality andevidence base used for much of this training has beenquestioned (Leadbetter & Perkins, 2002).

Advance directives

Ideally, patients who have been identified as at riskof disturbed or violent behaviour should be giventhe opportunity to have their treatment needs and

wishes recorded in the form of an advance directive.This should fit within the context of their overallcare and should clearly state what interventions theywould and would not wish to receive in the event ofacute relapse. This documentation should bereviewed periodically. In practice, it is evident thatthe system of advance directives is as yet poorlydeveloped and lengthy work is needed involvingpatients, families, clinicians and hospital manage-ment (Amering et al, 2005). Time will tell whether theintensive training and substantial administrativecommitment required to support this process isforthcoming.

Mental Health Act status

Staff who deal with emergency psychiatric treat-ment need regular training on the relevant legalissues, including Mental Health Act 1983 legislationand the requirements of the European Conventionon Human Rights 1950. Comprehensive, detailedrecording of all aspects of treatment is essential.


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Informal patients

If an informal patient (one not detained under theMental Health Act) is resisting and aggressive, andrefusing treatment or threatening to leave the ward,the responsible medical officer or duty consultantshould be called to make a Mental Health Act assess-

ment. Use of Section 5(2) of the Act may be necessaryto prevent an informal patient from leaving the ward,although it does not allow treatment without thepatients consent. However, under common law intra-muscular medication may be given without consentin an emergency, to calm and make safe a dangerouspatient detained under Sections 5(2), 5(4) or 136 whilea full Mental Health Act assessment is being arranged.

Sectioned patients

Patients who have been detained under Sections 2or 3 of the Mental Health Act can be given intra-muscular antipsychotics, including zuclopenthixolacetate, without consent. Appropriately qualifiedmental health professionals have the authority notthe right to treat such patients in the absence ofconsent. This distinction requires staff to makedetermined, documented efforts to obtain consentbefore that authority may be used.

Rapid tranquillisation

Rapid tranquillisation is the administration of medi-cation to calm or sedate an agitated, aggressive patient.The aim is to reduce patient suffering, allow improved

communication, reduce risks to the patient and others,and to do no harm. It is used only when less coerciveapproaches such as diversion and verbal de-escalation have failed. Antipsychotics are often usedin rapid tranquillisation, and can bring about rapidimprovement in symptoms of psychosis and mania,to a greater extent than benzodiazepines (Agid et al,2003). However, the antipsychotic side-effect akathisiahas been associated with suicidality and physicalassault (Crowner et al, 1990), and the presence of thisand other extrapyramidal side-effects means that theimportant role of antipsychotics in behaviour controlhas to be balanced carefully against risks of side-effects. Ideally, they should be used at the minimum

dose sufficient to achieve therapeutic benefits.Rapid tranquillisation and physical interventions

such as restraint and seclusion are managementstrategies, not primary treatment techniques. Theyshould be considered only if de-escalation and otherstrategies summarised below fail. The clinical need,the safety of the patient and others and, wherepossible, advance directives should be taken intoaccount when deciding appropriate interventions.

The intervention must be a reasonable and propor-tionate response to the risk posed by the patient.Rapid tranquillisation can be used to avoidprolonged physical intervention.

It is clear that rapid tranquillisation is required ina number of healthcare settings as a regular androutine part of clinical practice. A survey in a London

hospital (Pilowsky et al, 1992) found that 8 differentdrugs were used in 102 episodes of emergencytreatment over 160 days.

There is no national or international consensuson the most effective drug treatment. The drugs mostfrequently used in the UK are antipsychotics andbenzodiazepines, separately or together. Mannionet al (1997) found that combined regimes were mostcommon, and in 39% of cases a high-dose anti-psychotic was given. Recent systematic reviews ofthe effectiveness of antipsychotics in treating acutepsychosis (e.g. Carpenter et al, 2004; Cure et al, 2004)have concluded that no individual antipsychoticdrug has demonstrated greater efficacy or superiority

over standard treatment. Further work to assess theefficacy of benzodiazepines (Gillies et al, 2001) andolanzapine (Belgamwar et al, 2004) is underway. Areview of zuclopenthixol acetate (Fenton et al, 2001)found no specific benefits, other than the possibilityreported in just one study that it may produce earlierand more intense sedation than oral haloperidol.

Published reviews have often called for the use ofwell-conducted randomised controlled trials toproperly assess drug differences in this area. In theabsence of clear evidence, clinical decisions must bemade on the basis of clinical experience, and ourknowledge of the relative propensity of different

drugs for causing adverse effects (Table 1).Interestingly, it is possible that there is greaterconsistency of treatment in other countries. A surveyfrom the USA (Binder & McNeil, 1999) found apreference for haloperidol and lorazepam incombination for rapid tranquillisation. A survey ofemergency room practice in Rio de Janeiro (Hufet al,2002) found that a haloperidolpromethazinemixture was used for 80% of cases. Promethazine isan antihistamine that has a slow onset of action, butis often an effective sedative. It is rarely used in theUK for rapid tranquillisation, but may have a placeas an alternative to benzodiazepines in benzo-diazepine-intolerant patients. It should be noted that

promethazine is not licensed for use in rapidtranquillisation and caution is advised regardingdosage and safety.

Management of aggression by non-chemical formsof restraint also varies internationally. It is restrictedto immediate physical containment and seclusionin standard UK practice, but mechanical restraint isin common usage in many countries, including theUSA and former communist countries.


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Adverse effects associatedwith rapid tranquillisation

If possible, the patients drug history must bereviewed to identify the drug of choice and anycontraindications. If this is not available, considerthe following issues carefully in planning immediatemanagement strategies.

Respiratory depression

Patients treated acutely with benzodiazepines orbarbiturates should be monitored for respiratorydepression. There should be immediate access to apulse oximeter and staff trained in its use. If therespiratory rate drops below 10 breaths per minuteor oxygen saturation is less than 90% while onbenzodiazepine treatment, give flumazenil intra-venously, starting with 200 g over 15 s, then 100 gat 60 s intervals (maximum dose 1 mg in 24 h). Liethe patient flat on their back with the legs slightlyraised; check that airways are open and ventilatemechanically if necessary. Seek urgent medical/paramedic support. Note that flumazenil has a short

half-life, so respiratory function may deteriorateagain. Flumazenil may cause seizures in regularusers of benzodiazepines.

Hypotension

Hypotension is present if systolic blood pressuredrops by more than 30 mmHg on standing, or if

diastolic blood pressure falls below 50 mmHg. Liethe patient flat on their back with the legs slightlyraised, and monitor closely.

Irregular or slow (


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Rapid tranquillisation of elderly,debilitated or learning-disabledpatients

Reduce recommended doses by 50%. Drugs of choicefor elderly people are lorazepam, starting with 0.5

1 mg orally; or haloperidol, starting with 0.51 mgorally or intramuscularly, with careful monitoringof blood pressure and physical state. As noted below,use of olanzapine or risperidone in elderly patientswith dementia carries an increased risk of stroke andis not recommended (Committee on Safety ofMedicines, 2004).

Physical support

After parenteral rapid tranquillisation, monitorpulse, temperature, blood pressure and respiratoryrate every 510 min for the first hour, then every 30

60 min until the patient is ambulatory. If the patientis unconscious or asleep, pulse oximetry to monitoroxygen saturation is desirable. A nurse shouldremain with the patient until they are ambulatory.An electrocardiogram (ECG) should be recorded ifthere is any concern about cardiac function.

Ensure a balanced diet and adequate fluids. Chartfluid intake if necessary. For patients on recently in-creased high-dose antipsychotics, check temperature,pulse and respiration every 6 h, and consider serialECGs to pick up arrhythmia or QT prolongation. Ascreen of blood tests is helpful, to exclude seriouscoexisting or underlying pathology.

All staff involved in administering or prescribing

rapid tranquillisation or monitoring patients towhom parenteral rapid tranquillisation has beenadministered should receive ongoing training inadult life support techniques, to a minimum ofimmediate life support, and should be trained in theuse of a pulse oximeter. A crash bag containing anautomatic external defibrillator, a bag valve mask,oxygen, cannulas, fluids, suction and first-lineresuscitation should be available within 3 min. Adoctor should be available to attend the scene of arapid tranquillisation intervention quickly and toremain at the scene until there is no further clinicalconcern about the patient.

Choice of drug for rapidtranquillisation

Benzodiazepines

Benzodiazepines have been found helpful in thetreatment of mania (Chouinard, 1985), mild behav-iour disturbance resulting from substance misuse

(Dubin, 1988) and acute schizophrenia (Stimmel,1996). They may therefore have a particular rolewhere diagnosis is not yet clear. Benzodiazepinesare the treatment of choice in those sensitive to anti-psychotics (e.g. with a history of neurolepticmalignant syndrome or severe allergic reaction) orwhose physical health is of special concern (e.g. who

have cardiac disease). They are relatively safe in care-fully supervised use and the effects can be reversedby the antagonist flumazenil. Lorazepam is the mostused in the UK, having the advantage of a short half-life. It is available for parenteral use. With longer-acting drugs such as diazepam there is a risk ofaccumulation. With all benzodiazepines there is arisk of respiratory depression (Broadstock, 2001), andpatients with chronic respiratory disease such asasthma or emphysema who are retaining CO

2should

not be given benzodiazepines. There is also a risk ofbehavioural disinhibition, such that these drugs maybe inappropriate in some cases (Fava, 1997).

Antipsychotics

Antipsychotics may be a first-line treatment if benzo-diazepines have in the past proved ineffective inrapid tranquillisation, or are contraindicated. Thereare a number of options (Fig. 1), and the final choiceshould depend on the results of previous exposureand a risk/benefit analysis of each option. Recentconcern has focused on the risk of cardiac arrhythmiaand potential cardiorespiratory collapse. ProlongedECG QT interval is a marker for this risk, variablyassociated with different antipsychotics (see Table1). Physical exertion, stress, illicit drug use (ecstasy

and cannabis) and metabolic factors are risk factors.

Typical antipsychotics

Haloperidol Haloperidol has been widely used inrapid tranquillisation and is often the preferredoption in guidelines. Its use is associated withserious dystonic reactions and other extrapyramidalside-effects (Dix, 2004), which can generally berapidly reversed by giving antiparkinsonianmedication such as procyclidine and may beprevented with prophylactic anticholinergics ifsusceptibility is known. It is important to note thatrapid tranquillisation with haloperidol has also been

linked with sudden death, probably because itexacerbates the already prolonged QT

cassociated

with acute behavioural disturbance (McAllister-Williams & Ferrier, 2002).

Droperidol and thioridazine Concerns about thecardiotoxic effects of typical antipsychotics led towithdrawal of droperidol from the UK market andthe placing of limitations on the use of thioridazine.


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has a sedative effect that usually starts about 2 hafter injection, peaks after 12 h and lasts for up to72 h. Indications for use are patients with establishedpsychosis who are not neuroleptic nave, who haverequired repeated injections of short-acting sedativeor antipsychotic drugs, and are unlikely to acceptoral medication for at least the next 72 h. It should be

used only to help patients who would otherwisecontinue to present disturbed behaviour while themanagement of their psychosis is being initiated.This process can last for several days. It should notbe given at the same time as any other parenteralantipsychotic (including depot). It should not begiven to patients who are unconscious, pregnant,prone to extra-pyramidal side-effects, or who havehepatic or renal impairment or cardiac disease.

The dose for zuclopenthixol acetate is 50150 mgup to a maximum of 400 mg over a 2-week period.Injections should be at least 24 h apart. Oral zuclo-penthixol dihydrochloride can be given alongsidethe acetate preparation, to reduce polypharmacy and

to enable the dose to be titrated sensitively whilemanagement of the psychosis is being initiated.

Atypical antipsychotics

Olanzapine This has a lower risk of extra-pyramidal side-effects than other atypicals, but highrisk of weight gain in longer-term use (Duggan et al,2002). A rapid-acting (within 1545 min) intra-muscular preparation and a rapidly dispersing oraltablet are available. In a review, McAllister & Ferrier(2002) reported that these formulations showedsome promise but recommended continuing use of

benzodiazepines as the mainstay of pharmacologicalrapid tranquillisation.

The intramuscular preparation appears to have alow risk of prolonged QT interval (Lindberg et al,2003), but other potential side-effects have beennoted. These include possible association withdizziness or collapse due to vasovagal bradycardia/syncope, a phenomenon that is generally viewed asbenign and a self-limited reflex. Particular cautionis necessary with patients who are concurrentlytaking other drugs that can induce hypotension,bradycardia or depression of the respiratory orcentral nervous systems.

Intramuscular olanzapine and parenteral benzo-

diazepine should not be given simultaneously andit is recommended that treatment with these agentsshould be separated by at least 1 h. If the patient hasreceived parenteral benzodiazepine, intramuscularolanzapine should be considered only after carefulevaluation of clinical status, and the patient shouldbe closely monitored for excessive sedation andcardiorespiratory depression (Lilly product safetyinformation, 2005).

Zuclopenthixol acetate Sudden deaths andfatalcardiac events have been reported with zuclo-penthixol acetate (Royal College of Psychiatrists,1997), and standard current guidance suggests thatit should not be used for rapid tranquillisation. It

Fig. 1 Rapid tranquillisation by oral and by intra-muscular routes.

Rapid tranquillisation by oral route

Lorazepam12 mg

Wait 45 min

Patient settled?

Yes No

Disturbedbehaviour unresponsive

to de-escalation

Lorazepam 12 mgand/or eitherHaloperidol 510 mg

orOlanzapine 10 mg

(orodispersible)or

Risperidone 12 mg(liquid/orodispersible)

Wait 45 min

Patient settled?

Yes No


to de-escalation

Diagnosis unknown Diagnosis psychotic illness

Rapid tranquillisation by intramuscular route


to de-escalation

*Lorazepam 12 mgand/or either

Haloperidol 510 mgor

*Olanzapine 10 mg


to de-escalation

Lorazepam12 mg

Patient settled/acceptingoral treatment?

Wait 45 min

Wait 45 min

Patient settled?

Yes No

Yes No

Diagnosis unknown Diagnosis psychotic illness

*It is not recommended to give i.m. olanzapinewithin 1 h of i.m. lorazepam


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Risperidone Other atypical antipsychotics may besuitable for oral rapid tranquillisation, notablyrisperidone, which also has a rapidly dispersing oralpreparation.

Risk of stroke with olanzapine and risperidone TheCommittee on Safety of Medicines (2004) has

reported evidence of increased risk of stroke in elderlypatients with dementia who are treated withrisperidone or olanzapine. It concludes that the riskoutweighs the benefits and therefore advises thatneither risperidone nor olanzapine should be usedfor the treatment of behavioural symptoms ofdementia and that use in elderly people should belimited to short-term management of acute psychoticconditions associated with dementia.

Prescribers should consider these issues carefullybefore treating any patient with a history of stroke,transient ischaemic attack or other risk factors forcardiovascular disease such as hypertension,diabetes and smoking.

Route of administration of rapidtranquillisation

Whenever possible, rapid tranquillisation drugsshould be given orally. It is sometimes necessary forthese drugs to be administered by intramuscularinjection while a patient is being restrained. Intra-venous administration is the most hazardous routeand should be limited to situations where immediatetranquillisation is deemed essential. This decisionshould not be made by junior staff in isolation, and

the circumstances should be carefully recorded. Intra-venous haloperidol or lorazepam should be used,with close monitoring of needs for immediate lifesupport. The patient should not be left unattended.

The use of restraint

The combination of a struggling patient, intra-muscular injection and physical restraint must beconsidered a potentially dangerous mix (Kumar,1997; Paterson et al, 1998). The traumatic, humili-ating nature of restraint and its effect on thedevelopment of trusting professional relationships

between patients and staff cannot be under -estimated.

Preparation

In some circumstances the need for rapid tranquil-lisation arises without warning. In the vast majorityof cases, however, there is time to plan for its use. Ifall verbal and other interventions have failed and

the decision for rapid tranquillisation has been madethe following principles apply:

one person should be responsible for coordi-nating the whole rapid tranquillisation team;

it should be decided where the patient will beapproached; considerations in choosing anappropriate area include its privacy, the spaceavailable, ease of access and exit, the presenceof potential weapons and the likelihood thatprolonged restraint will be necessary;

each member of the team should have a clearrole with pre-arranged methods of com-munication;

one person should be clearly identified toadminister the injection, which should beprepared before the patient is approached.

Dignity

Intramuscular administration of rapid tranquil-lisation often requires unavoidable securing of thepatient by restraint and the removal of clothing toexpose the upper outer quadrant of the patientsbuttocks. In effect, a patient is held down whileembarrassing areas of their body are exposed.There should be no doubt that the procedure haspotentially serious physical and psychologicalconsequences for the patient.

Gender

Every effort should be made to ensure that the staffdelivering rapid tranquillisation are of the same

gender as the patient receiving it. This will minimiseperceptions of abuse or sexual assault that may beexperienced by confused, disoriented patients. If staffof the same gender are unavailable on a ward, staffshould be acquired from other areas of the hospital.It is not acceptable to deliver intramuscular rapidtranquillisation on the basis of convenience withoutfirst exhausting all opportunities of assembling ateam of the same gender as the patient.

Location

People who see rapid tranquillisation, for example

other patients and relatives, can find it verydistressing. Obviously, it is sometimes necessary touse restraint in an area that is not particularlyprivate, for example when an individual becomesaggressive and attempts to attack a staff memberduring the course of negotiation, or when a patientsresistance and aggression are so strong that theirrelocation to a more private area would be un-necessarily risky. However, every effort should be


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made to ensure that intramuscular rapid tranquil-lisation in particular is delivered in a private area ofthe ward where maximum attention can be paidto the dignity of the patient.

Prolonged restraint

About 50% of psychiatric intensive care units in theUK have no seclusion room (Dix & Betteridge, 2001).There will be times when restraint is required forextended periods and this must be consideredpotentially very dangerous. Both NICE and theDepartment of Health have published guidelines onsafer prolonged restraint and these must be includedin any hospitals restraint policy (Departmentof Health, 2004; National Institute for ClinicalExcellence, 2005). Box 2 shows key points to beremembered.

Environmental factorsAssaults are more common in corridors andcommunal areas, indicating the role of interpersonaldifficulties in generating conflict. An in-patientenvironment in which patients feel safe and com-fortable and have some degree of control over theirday-to-day life is likely to reduce the risk of violence.Research by the Royal College of Psychiatrists (2001)has raised serious concerns about the basic standardsfor living or working in acute psychiatric units, notingthat staff, patients and visitors often perceive wardsas noisy, smelly and dirty. The Department of Healthhas published national minimum standards for

psychiatric intensive care units, which also includeuseful guidance on effective physical environments(Department of Health, 2002). The ideal is atherapeutic environment that allows individuals asmuch choice, privacy and independence as possible,and although there is little research in this area, it

seems implicit that designing or developing psy-chiatric units with these aims will help to reduce therisks of violence.

Working with disturbed patients

Working with people who are acutely disturbed isdifficult and carries significant risks for staff. Thekey intervention is often referred to as de-escalation,a form of communication intended to minimiseaggression and disruptive behaviour. There is nostandard de-escalation method, but the followingapproaches are important: maintaining a calm,controlled manner; giving choices; moving to a lessconfrontational or busy area; using the relationshipwith the patient to interact therapeutically. Trainingin de-escalation techniques aims to improve self-awareness in difficult, stressful circumstances andhelp staff to analyse the best approach in any givensituation (Dix, 2001).

When a disturbance occurs it is vital that wardteam members are clear about the management ortreatment plan, know how it will be implementedand who is in charge. Patients should be involvedas far as possible in planning what will be doneshould they become violent.

During an incident, repeated clear explanationsabout what is being done and why ensures coordi-nation and clarity within the team. The patient needsrepeated reassurance and explanation that, asdoctors and nurses, you are there to help. It is alsoimportant to explain that it is the aggressive orthreatening behaviour that is the problem, and thatthe patient is not being punished and will not beharmed by the intervention. Patients are usuallyfrightened or anxious and need repeated explanationof what is being done to them and why. Professionalsinvolved in these complicated interventions must beaware that much violence results from patients fearand insecurity when they feel that they have nocontrol over events. Therapeutic approaches that aimto restore control to the individual are likely to be ofparticular value. The doctor supervising treatmentmust stay at the scene until it is clear the situation isresolving and safe.

Separation from stressful family relationships isoften helpful in reducing anxiety and overstimulation.

Observation

Four levels of observation of patients at risk ofviolence are in widespread clinical usage:

general observation intermittent observation continuous observation, within sight continuous observation, within arms length.

Box 2 Basic guidance for prolonged restraint

Do not restrain the patient face down, as thismay hinder breathing

Do not place your weight on the patients

chest or back where it may hinder breathing Remain aware of the patients body temper-

ature, which may rise as a result of sharedbody heat and prolonged struggling: have afan or damp towels available to cool thepatient

Be prepared to discontinue restraint if therisks of prolonged restraint appear to out-weigh potential for further assault


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Observation must be carried out in a sensitivemanner, minimising the patients feeling of beingunder surveillance. Ideally, the patient and key nurseshould discuss and plan it together and it should bethe basis for risk assessment and management.

An advisory report on nursing care for patients inthe acute mental health setting noted that both patientsand many nurses find prolonged observation adifficult and potentially countertherapeutic processthat can be distressing for all concerned (StandingNursing and Midwifery Advisory Committee, 1999).

Staff safety

Staff can and should take precautions to reduce theoccurrence or severity of assaults on them (Box 3).

Remember to put safety of people first. If a situationis escalating beyond the capacity of the hospital teamto cope with it, call the hospital security service ordial (9)999 for emergency police help. Do not attemptrestraint unless there is sufficient back-up (usuallya three-person control and restraint specialistnursing team).

Service user perspectives

The Department of Health (2002) encourages mentalhealth workers to adopt a non-judgemental, non-patronising, collaborative approach to care, and it isclear that environmental and attitudinal factors playa vital part in determining the outcome of emergencypsychiatric treatment. In reality, some staff will haveprejudicial and stereotypical views, and the possi-bility that patients who have exhibited disturbedbehaviour may be given punitive treatment shouldbe considered.

Gender issues must also be taken seriously, andas far as possible we should ensure that patientsfeel safe and that their concerns are heard andattended to.

Management after an incident

Senior staff, including the regular/on-call consul-tant, should be informed early of problems, andshould be involved in regular discussion of progressthereafter. Multidisciplinary team meetings are anessential focus for management planning. Thetreatment regime should be reviewed regularly,initially at least at each nursing shift. It may be usefulto involve the patients family, particularly to ensurethat the frequency of visiting is not causing problemsof excess stimulation.

Staff support after an incident

Despite preventive and coping strategies, aggressiveincidents will happen, and there is a risk ofexacerbating the victims distress by unhelpfulcriticism of the way they handled the crisis. Victimsneed sympathy, support and reassurance, not justin the short term. Remember the stress of beingexposed to a patients aggression and paranoidcriticism and hostility, and try to support colleaguesand admit to your own frailties, anxieties andfeelings of helplessness. It may be helpful to involvethe partner or spouse, and in a severe reactionprofessional counselling should be considered. Theissue of whether to prosecute the aggressor is one for

the victim, who may be helped by talking it throughwith colleagues or managers.

For professionals who have been assaulted, it isadvisable to return to work as soon as possible(perhaps taking no time off), to prevent theincubation of fear that can occur.

In the management of a serious aggressive incident,immediate safety must be secured before anyinvestigation. The investigation should attempt assensitively as possible to compile detailed reportsabout the incident, so that its causes, context andconsequences for both staff and patients can beunderstood. The aim should be to create a positive,

calm atmosphere, in which the incident can bereviewed honestly and openly and constructivelessons learned for the future.

Conclusions

A key challenge for modern mental health services isto provide appropriate training and support for staffwho work with acutely disturbed patients. We needto enable staff to develop the necessary skills,

Box 3 Simple safety precautions for inter-views with potentially violent patients

When interviewing a patient who has apotential for aggressive behaviour, alwaysinform nursing staff of your intentions andlocation

Try to combine medical and nursing assess-ments, to protect interviewers and reducestimulation of the patient

Be aware of the location of panic buttons, andif hand-held assault alarms are availablerequest one and keep it on your personthroughout the interview

Sit at an angle to the patient, at a safe distance,close to the exit: never interview with thepatient between you and the door


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Macpherson et al

expertise and confidence to work in this difficult area.The clinical difficulties faced by professionals areoften exacerbated by the need to work in poorlydesigned, inappropriate and unpleasant settings.Furthermore, low professional morale, staffingrecruitment difficulties and the use of inexperiencedlocum staff inevitably affect patient care.

However, we now have access to a range of clear,evidence-based guidelines to support practice. Thesealso provide opportunities for audit and review ofpractice in a way that has previously been impossible.The Government (Department of Health, 2005)recently recommended the urgent implementationof a national system of training in restraint andcontrol, and it seems likely that practice and under-standing in this area will continue to develop,perhaps at an even greater pace, in the next few years.

We believe that if we follow a considerate,supportive and humane approach to patients at thiscritical phase of their treatment, this can provide thefoundation for continuing positive engagement with

services and may have an important impact on long-term outcomes. We hope that the guidance in thisarticle is of some assistance to colleagues who workin this difficult, challenging, but potentiallyrewarding area of practice.

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MCQs

1 The following organisations have produced recentreviews/guidance in the treatment of acutelydisturbed individuals:

a the UKCCb NICEc the Cochrane Collaboration

d the British Association of Psychopharmacologye the General Medical Council.

2 Rapid tranquillisation:a is the treatment of choice in dealing with any

disturbed individualb should preferentially involve treatment by intra-

venous injectionc is intended to induce a comatose stated is generally free of side-effectse is an effective treatment for acute schizophrenic

symptoms.

3 The following drug treatments are in standard usefor rapid tranquillisation in the UK:

a thioridazineb zuclopenthixol acetatec lorazepamd droperidole haloperidol.

4 Intramuscular lorazepam is commonly associatedwith the following side-effects:

a respiratory depressionb acute dystonic reactionsc hypotensiond cardiac arrhythmiase neuroleptic malignant syndrome.

5 The following approaches may help to manage anacutely disturbed patient:a de-escalation

b giving the patient as much choice as possiblec distractiond temporary separation from stressful family relation-

shipse physical restraint.

MCQ answers

1 2 3 4 5a T a F a F a T a Tb T b F b F b F b Tc T c F c T c F c Td T d F d F d F d Te F e F e T e F e T

acutely disturbed psychiatry patients

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