• Very minor incidents can escalate into a violent situation
• Communicate clearly to minimise escalation

Warning signs of impending violence

• Spontaneous self-reporting of angry or violent feelings
• Fluctuating levels of consciousness with prominent persecutory ideas

Carers warn of imminent violence

• Increased restlessness, bodily tension, pacing, arousal
• Increased volume of speech, erratic movements
• Facial expression tense and angry, discontented
• Refusal to communicate, withdrawal
• Unclear thought processes, poor concentration
• Delusions or hallucinations with violent content
• Audible threats, or aggressive gestures
• Recognition of signs apparent in earlier episodes

Context

• Aggression or agitation can occur in:
  • psychiatric illness
  • physical illness
  • substance abuse
  • personality disorder
  • confusional state irrespective of underlying cause
  • patients who have received drugs affecting CNS

• Assessment must be by a fully registered doctor (FY2 or above)
  • FY1 doctors must not assess mental capacity
• Inform senior member of medical team (SpR or consultant).
• If there are signs of impending violence, inform site manager who will identify any staff on duty who have been trained in restraint techniques

Personal (staff member's own) behaviour

• Maintain adequate distance
• Move towards safe place, avoid corners
• Explain intentions to patient and others
• Be calm, self-controlled, confident
• Ensure own body language is non-threatening
• Avoid sudden movements

Safety

• Do not attempt to deal with a violent patient on your own
• Keep other patients clear
• Keep other staff clear but within helping distance
• If possible, move patient to a quiet area

Assess using verbal de-escalation

• Engage in conversation, acknowledge concerns and feelings
• Ask for reasons for disquiet, encourage reasoning
• Ask for any weapon to be put down (not handed over)
• If patient too disturbed for such measures, or fails to respond:
  • consider physical restraint by trained staff and/or police (see below)

History

• Try to take a history from the patient and those who know the patient
  • ask whether this has happened before and how it was handled
  • ask about any regular psychotropic medication

Mental state examination

• General appearance and behaviour of patient
• Speech
• Attention and concentration
• Mood: subjective and objective
• Thought: evidence of loosening of association
  • irrelevant thoughts, delusions, thoughts of self-harm or harm to others
• Hallucinations
• Evidence of cognitive impairment
• Insight

Assess risk factors for violence

• Young, male, history of violence
• Alcohol or other substance misuse, irrespective of other diagnosis
• Poor compliance with suggested treatments
• Antisocial, explosive or impulsive personality traits
• Active symptoms of psychosis or mania, in particular with:
  • delusions or hallucinations focused on a particular person
  • delusions of control, particularly with a violent theme
  • specific preoccupation with violence
  • agitation, excitement, overt hostility or suspiciousness

Assess mental capacity (Mental Capacity Act 2005)

• Assessment is task/decision specific.
• The legal definition of someone who cannot make autonomous decisions is one who is unable to undertake the following:
  • understand information about proposed treatment, its purpose and why it is being proposed
  • retain that information long enough to be able to make a decision
  • use or weigh that information as part of decision-making process
  • communicate his/her decision - by any means possible (e.g. talking, using sign language or other means)
• See Capacity section in Consent - Basics guideline

Any doubt or disagreement?

• An application to the court will be necessary. Seek advice

Physical examination

• If safe to do so, gain patient's consent and attempt to record vital signs and NEWS score and a thorough physical examination
  • look for sources of infection and/or neurological deficits
• if unsafe, document reasons and carry out examination once stable

Principles

• If acute mental illness suspected (e.g. psychosis or hypomania), refer to mental health liaison team or on-call psychiatrist via switchboard
• If patient aged ≥65 yr and has delirium = acute confusional state, see elderly care section of Delirium (acute confusional state) in older people guideline
• If patient has symptoms and signs of alcohol withdrawal, see Alcohol withdrawal guideline
• If patient intoxicated, but fit to be arrested and taken into custody, request police assistance by dialling 9-999 and say clearly 'I am in fear of my safety'
• If none of the above applies, options available depend on patient's mental capacity. See Capacity section in Consent - Basics guideline

Capable of making decisions

• Hold patient accountable for his/her actions
• Manage underlying cause of agitation
• Do not administer medication without patient's consent

Patient lacks capacity

• Ensure that any intervention used is the least harmful or restrictive of patient's basic rights and freedom
  • immediately necessary, reasonable, and in their best interest
• Conduct multidisciplinary discussion to decide whether sedation is safe and appropriate - see medication below
• Take all necessary means to prevent injury to self, other staff or patients, or damage to property
  • consider use of physical restraint and/or medication - see below
• Manage underlying cause of agitation

Physical restraint

Decision

• The use of any physical holding is the last resort
  • once staff attempt to restrain a patient, a threatening situation may turn violent
• Assessment must be by a fully registered doctor (FY2 or above)
  • the person taking action must reasonably believe that restraint is necessary to prevent harm to the person who lacks capacity or staff and other patients
• Use restraint only if there are sufficient staff, appropriately trained (see below), to achieve this effectively and you perceive imminent danger because patient is:
  • displaying prolonged and serious verbal abuse, threatening staff, or disrupting ward
  • threatening or attempting self-injury
  • at risk of prolonged over-activity with risk of exhaustion
  • at risk of serious accident to self and/or others
  • attempting to abscond if detained under Section and in an open ward

Who to undertake restraint?

• Request assistance from any staff on duty trained in physical restraint techniques and who have completed the clinical holding course/update
  • inform site manager who will identify any staff trained in restraint; input from security can be requested
  • medical and nursing staff without appropriate training should not attempt to physically restrain the individual
• Best practice guidance is in addition to one staff to observe and communicate, a further minimum of 2 staff to hold someone and 3 staff if the person is held on the floor
• If no suitably trained staff available, or patient is making significant physical attacks or serious efforts to destroy property, leave the scene immediately and request police assistance by dialling 9-999 and say clearly 'I am in fear of my safety'
  • the police will always respond to a call for assistance, but are not allowed to assist in restraining patients for treatment

When patient restrained

• Any holding must be reasonable and proportional to the circumstances
• Do not, under any circumstance, inflict deliberate pain
• Wherever possible, avoid holding someone on the floor (particularly in the prone position).
• Hold in any position for the minimum amount of time possible to manage the prevailing or perceived level of risk

Medication

Principles

• If new brain damage suspected, avoid medication until after CT scan.
• Check prescription chart for previously prescribed drugs.
• Reduce dosages of medication appropriately in the elderly or infirm
• Try to persuade patient to accept oral medication
  • if this is not possible, use parenteral route (do not mix two drugs in a syringe)

Elderly

• If patient is elderly (aged ≥65 yr) refer to Delirium (acute confusional state) in older people guideline especially for doses of medication
  • olanzapine and risperidone can cause serious side effects including strokes in older patients
  • do not use aripiprazole
• Unless dose for elderly is specified below, halve doses of medication for older people

Substance abuse

• Treat any symptoms suggestive of withdrawal - see Withdrawal of drug(s) of dependence guideline

Sedation

• Do not prescribe beyond BNF limits, and be aware of the cumulative effect of combination medications
• Recommended medication options are:
  • lorazepam (prefer as first choice) 1 mg oral/IM repeated 6-hrly if necessary - adult maximum dose 4 mg in 24 hr (elderly 0.5 mg; maximum 2 mg in 24 hr)
  • for IM injection, dilute lorazepam with an equal volume of water for injection or sodium chloride 0.9%
  • use IM only when patient refuses to take orally 
• If no response 1 hr after oral lorazepam, give oral olanzapine 10 mg (avoid in elderly patients) or risperidone 1-2 mg (elderly 0.5 mg)
• If 1-2 mg of lorazepam (elderly 0.5-1 mg) used, have flumazenil to hand in case of respiratory depression
  • flumazenil dose: 100 micrograms IV over 15 sec, then 100 micrograms every 1 min, if required; usual dose 300–600 micrograms, maximum 1 mg per course
• If oral medication fails, consider lorazepam IM treatment
• Alternatives are aripiprazole 10 mg PO [9.75 mg IM (not for the elderly)], promethazine 50 mg or as a last resort, and only after an ECG has been checked, consider haloperidol 5 mg oral/IM
  • do not use haloperidol in patients with Parkinson’s disease, heart disease or if patient has a prolonged QT interval or taking other drugs that prolong QT interval 
  • if using haloperidol, have procyclidine available in case of dystonic reaction
    • procyclidine dose: 5-10 mg IV or IM, usually effective in 5-10 min; in elderly start with 5 mg
• If no response to 2 forms of medication, seek advice from mental health liaison team or on-call psychiatrist via switchboard 

• Monitor vital signs
• Record BP, pulse, respiratory rate, hydration, and pulse oximeter every 15 minutes for first hour and then every hour for 4 hours
• Record level of consciousness until fully conscious
• Record ECG at first available opportunity

Documentation

• Record incident clearly and fully afterwards
• Complete an adverse incident/Datix report with witness statements
• Record further care plan

Once stable

• Continue close observation as inpatient for at least 24 hr
• Reassess mental state and review patient's status under Mental Health Act
• Continue management of underlying condition
• When transferring patient between units, send details of:
  • incident
  • medication management
  • subsequent management plan
  • any unwanted effects
  • any advance directives