Acute behavioural disturbance can occur in the context of psychiatric illness (typically psychosis), physical illness (typically in confusion/delirium), substance abuse (typically in alcohol withdrawal) or personality disorder. Such patients may be at risk to themselves and others and may also be at risk of absconding from the ED department. Both medical and psychiatric involvement is usually necessary early for the purpose of both assessment and management of the behavioural disturbance and its likely causes.
Initial presentation to ED
- The triage nurse should use mental health triage in addition to the standard Manchester triage scale.
- All ED staff should consider their personal safety and the safety of others. ED staff should not interview the patient alone. They should avoid confrontation; wear a personal alarm; consider the need for security staff to be present with the patient; consider the need for a special (1:1) nursing observation staff resource.
- ED staff should contact Liaison or on-call Psychiatry by phone for further advice/assessment if necessary.
- When appropriate psychological and behavioural approaches have failed to de-escalate acutely disturbed behaviour, emergency sedation may be necessary. Where emergency sedation is necessary to manage acute behavioural disturbance, ED staff should follow this Rapid Tranquillisation guideline.
The aims of Rapid Tranquillisation are to: a) to reduce suffering for the patient (psychological or physical) b) to reduce the risk of harm to others by maintaining a safe environment c) to do no harm (by prescribing safe regimens and monitoring physical health).
This will depend on the cause of the acute behavioural disturbance. Patients with medical illness may require ongoing investigation and medical care. Patients with psychiatric illness may require further psychiatric assessment and treatment, in some circumstances, under the Mental Health Act.