Management Of Acute Behavioural Disturbance Research Articles

Evaluation of a Simulation Based Training Course for Non-Consultant Hospital Doctors (NCHDS) in Psychiatry

IntroductionSimulation-based training (Sim) is an established method of teaching in medical education and can help bridge the gap between medical theory and clinical practice. While sim is well-established in medical and surgical specialties, it is less well developed in psychiatry. Psychiatric emergencies often occur out of hours when there are fewer senior staff available on-site. Sim offers a safe setting for development of essential clinical skills with carefully delivered feedback.Sim can be high-cost involving specialized simulation facilities, especially when utilising high-fidelity equipment. Even lower-fidelity techniques requiring standardized patients (SPs) require funding for actors and this can be a barrier to utilising Sim.ObjectivesWe piloted a Sim course to NCHDs working in psychiatry in a tertiary university hospital with the aim of improving trainee skills and confidence in managing psychiatric emergencies on-call including risk assessment, involuntary admission and acute behavioural disturbance. A low-fidelity approach was taken with minimal use of SPs.MethodsA sim handbook developed by Irish Centre for Applied Patient Safety and Simulation (ICAPSS) was used for reference in developing the simulation modules. Three modules were delivered in a structured manner over three hours; involuntary admission, risk assessment and management of acute behavioural disturbance. Each module involved the simulation exercise (20 minutes) followed by debrief (20 minutes). The facilitated debrief involved open discussion and prompted reflective learning. Anonymous, paper-based questionnaires were used to collect feedback on participants’ experience of the training.ResultsThere were 12 attendees and ten participants completed the feedback. All participants (100%, n=10) agreed or strongly agreed that sim helped them to learn and all agreed that the topics covered were relevant to their clinical role. All participants (100%, n=10), indicated that they enjoyed the workshop. Eighty percent (n=8) agreed or strongly agreed that they would like to do more sim-based workshops. The supportive environment and debrief sessions were reported as the most enjoyable aspects of the workshop.ConclusionsParticipants unanimously agreed that the training was useful to them in their clinical roles and helped them to learn. Sim was effective in teaching high risk complex psychiatric cases to psychiatry NCHDs and consideration should be given to expand this teaching method within postgraduate psychiatry training in Ireland.Disclosure of InterestNone Declared

Psychosis in acute methamphetamine intoxication is usually self-limiting and can be managed in the emergency department: A retrospective series.

There is little recent published data characterising acute psychosis associated with methamphetamine intoxication. We aim to describe the clinical features of psychosis, management of acute behavioural disturbance and disposition of patients with psychosis associated with acute methamphetamine intoxication. This is a retrospective review of patients presenting with acute (use within 24 h) methamphetamine intoxication, with features of psychosis (presence of delusions, hallucinations or formal thought disorder), to an ED over 4 months in 2020. All presentations were extracted from a toxicology unit database and each medical record reviewed. Demographics, past mental health diagnoses, clinical features and disposition were extracted. There were 287 presentations of methamphetamine intoxication over the period. Of these 287 presentations, 205 (71%) had features of acute psychosis, occurring in 171 patients (111 males [65%], median age 36, range 16-57 years). Paranoid delusion occurred in 134 of 205 (65%) presentations and was the most common feature of psychosis. Chemical sedation was given to 194 (95%), with 143 (70%) receiving parenteral sedation to manage acute behavioural disturbance. Complete resolution of psychotic symptoms occurred in 170 of 205 (83%) of exposures. There were 9 of 205 (4%) presentations that resulted in a mental health admission. Most presentations - 200 of 205 (98%) - were managed within the ED, primarily the short-stay unit. The median length of stay was 15 h (interquartile range 11-20 h). In this series of patients presenting to ED with acute methamphetamine intoxication, psychosis appeared to occur commonly and was mostly short-lived, resolving within 24 h in the majority of patients.

The pharmacological management of acute behavioural disturbance in pregnancy

SUMMARYAcute behavioural disturbance is relatively common during the perinatal period. The management of agitation in pregnant women is similar to that in the general population, although with some additional considerations, such as modifications to restraint techniques, careful medication selection, monitoring of maternal and fetal well-being and the importance of a debrief. There are benefits of agreeing a pre-determined care plan for women who are at risk.

The pharmacological management of acute behavioural disturbance: Data from a clinical audit conducted in UK mental health services

Background:A quality improvement programme addressing prescribing practice for acutely disturbed behaviour was initiated by the Prescribing Observatory for Mental Health.Method:This study analysed data from a baseline clinical audit conducted in inpatient mental health services in member trusts.Results:Fifty-eight mental health services submitted data on 2172 episodes of acutely disturbed behaviour. A benzodiazepine alone was administered in 60% of the 1091 episodes where oral medication only was used and in 39% of the 1081 episodes where parenteral medication (rapid tranquillisation) was used. Haloperidol was combined with lorazepam in 22% of rapid tranquillisation episodes and with promethazine in 3%. Physical violence towards others was strongly associated with receiving rapid tranquillisation in men (odds ratio 1.74, 1.25–2.44; p<0.001) as was actual or attempted self-harm in women (odds ratio 1.87, 1.19–2.94; p=0.007). Where physical violence towards others was exhibited, a benzodiazepine and antipsychotic was more likely to be prescribed than a benzodiazepine alone (odds ratio 1.39, 1.00–1.92; p=0.05). The data suggested that 25% of patients were at least ‘extremely or continuously active’ in the hour after rapid tranquillisation was administered.Conclusion:The current management of acutely disturbed behaviour with parenteral medication may fail to achieve a calming effect in up to a quarter of episodes. The most common rapid tranquillisation combination used was lorazepam and haloperidol, for which the randomised controlled trial evidence is very limited. Rapid tranquillisation prescribing practice was not wholly consistent with the relevant National Institute for Health and Care Excellence guideline, which recommends intramuscular lorazepam on its own or intramuscular haloperidol combined with intramuscular promethazine. Clinical factors prompting the use of rapid tranquillisation rather than oral medication may differ between the genders.

Brief interventions to de-escalate disturbances in emergency departments.

This study aimed to systematically review evidence to assess the efficacy of non-pharmacological brief interventions in the emergency department to reduce the incidence, severity and impact of acute behavioural disturbances. The literature search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A total of 18 articles were identified as meeting the inclusion criteria and read in full. Following a full read and a consensus discussion, it was subsequently considered the studies chosen had not met the inclusion criteria. Research into the use of non-pharmacological brief interventions in the management of acute behavioural disturbance in the emergency department is warranted given the absence of evidence found by this systematic review.

Rapid tranquilization: An audit of Irish mental health nursing practice.

Rapid tranquillization is a pharmacological intervention sometimes employed in mental health care for the management of acute behavioural disturbance. It is a form of restrictive practice, which, along with seclusion and restraint, is a conventional and controversial intervention in the therapeutic management of risk in mental health settings. This study surveyed mental health nurses practice in rapid tranquillization. A self-report questionnaire was utilized which addressed aspects such as definitions of rapid tranquillization, presence of rapid tranquillization policy, types of incidents where it is used and postintervention monitoring. The results demonstrate that rapid tranquillization is an intervention used in the management of acute behavioural disturbance in various mental health settings in Ireland. Respondents showed a basic understanding of rapid tranquillization as an intervention; however, some areas reported not having a specific rapid tranquillization policy. There was some evidence of a variation in postrapid tranquillization monitoring of psychiatric/mental health and physical health. Service user debriefing following rapid tranquillization was reported to be common; however, the content of this was not elaborated on. In the light of variations in practice, specific training and the development of rapid tranquillization policies are recommended.

A naturalistic study of pharmacological management of behavioural disturbance in psychosis

Objective: To explore, using a naturalistic design, the efficacy of typical and atypical antipsychotics in the management of behavioural disturbance in people with psychiatric disorders.Method: Prospective naturalistic study of 15,278 incidents of behavioural disturbance perpetrated by 1,059 patients, over a two year period.Results: Typical and atypical antipsychotics did not differ in terms of their efficacy, overall. In terms of specific agents, haloperidol and quetiapine tended to show equal efficacy, with olanzapine being somewhat less effective on two of three outcome measures.Conclusions: Overall, atypical antipsychotics were as effective as typical agents in the management of acute behavioural disturbance in a mental health setting. Further work is required to determine the relative side effect burden of those agents.

A New Clinical Protocol for the Pharmacological Management of Acute Behavioural Disturbance

Psychiatry is awash with pharmacological acute behavioural disturbance protocols which list oral or intramuscular benzodiazepines and antipsychotics with numerous options. This results in frequent over-sedation and occasional profound sedation and death. This paper describes the development of a simplified sedation protocol for the pharmacological management of acute behavioural disturbance. Following the wider availability of intramuscular lorazepam in 2008, Metro North Mental Health developed a protocol utilizing only two products - oral or intramuscular lorazepam or olanzapine - which was subsequently developed into a statewide protocol. The advantage of utilizing only two sedating medications is that it greatly reduces the risk of profound sedation and theoretically reduces the risk of other complications including deaths. Clinical staff who have utilized the protocol report a reduction in over-sedation of inpatients. A simplified protocol makes the pharmacological management of acute behaviour disturbance safer for both patients and staff.

Audit of medication management of acute behavioural disturbance: exploring the impact of a clinical practice guideline

Abstract Objective This paper describes an evaluation of the impact of a concise, portable guideline for the medication management of acute behavioural disturbance in adult psychiatric inpatient units. Setting Waitemata District Health Board provides inpatient psychiatric care for an adult catchment population of about 800 000 at two units located in west and north Auckland, New Zealand with a total of 68 beds. Method A retrospective clinical audit of the first 72 hours' medication management for patients admitted in acute crisis was completed before and after formal guideline implementation. Key findings Benzodiazepines were the medication of choice. Total daily doses for both benzodiazepines and antipsychotics were within recommended ranges. Areas of practice that appeared to improve after guideline implementation included reduced use of antipsychotic and short-acting injectable medications and use of lorazepam as sole treatment, but differences were not statistically significant. Conclusion Pharmacological management was found to be consistent with best clinical practice before and after guideline implementation.

Clinical management of acute behavioural disturbance associated with volatile solvent intoxication

Summary This case study reports on the management of a 20-year old girl who presented to an Emergency Department (ED) in a combative and drug affected state. Her acute care management is described. Salient learning tips are presented in respect to some of the dangers associated with substance abuse, the use of physical restraint and pharmacological interventions in managing such patients. The importance of maintaining patient dignity in the physical environment of ED and issues in managing people with ‘challenging behaviours' in EDs are explored. The positive role that appropriately trained mental health nurses can have in these situations is highlighted.

Developing Clinical Practice Guidelines for the Medication Management of Acute Behavioural Disturbance

ABSTRACTThis paper describes the development process of a concise, portable clinical practice guideline for the medication management of acute behavioural disturbance in adult psychiatric inpatients in Auckland, New Zealand. It was developed to aid psychiatry registrars and is a decision aid only. A literature search identified evidence‐based reviews and guidelines implemented elsewhere. This formed the basis for development of a locally relevant tool, finalised for implementation by a process of consensus agreement. This clinical practice guideline was developed collaboratively over 2 years in response to local need. Development was requested by junior medical staff and actively supported by clinical leaders. The guideline resulted from a review of the evidence for medication management of acute behavioural disturbance and adaptation of the UK National Institute for Clinical Excellence guidance in combination with local consensus agreement.

Management of acute behavioural disturbance in the emergency department setting

Management of acute behavioural disturbance in the emergency department setting

An audit of drug management of acute behavioural disturbance

The management of acute behavioural disturbance in psychiatric patients is an area that continues to require investigation, as it is potentially dangerous for both patients and staff. We conducted an audit of the management of these episodes, looking particularly at the drugs given, the doses and any polypharmacy. We also examined whether the issue of guidelines led to any changes in prescribing patterns. We found that we were prescribing appropriately and that the guidelines did lead to some shift toward safer prescribing.

Neuroleptic drug use in psychiatric intensive therapy units: problems with complying with the consensus statement

The pharmacological management of acute behavioural disturbance in psychosis is not straightforward. The real, or perceived, dose:effect relationship of the various neuroleptics in common use has an important influence on prescribing patterns leading, in certain situations, to very high doses of neuroleptic medication being prescribed. Data from a study of the use of neuroleptic medication in two psychiatric intensive therapy units illustrate the potential extent of the problem. Over half of the cases were not amenable to accurate dosage monitoring due to the use of depot neuroleptics, Clopixol Acuphase or polypharmacy. The majority received doses exceeding the limit suggested by the British National Formulary. Efforts to standardise the use of such drugs would help to optimise the clinical management of this challenging group of patients.