Violence and Aggression NICE guideline Important implications for practice Peter Tyrer, Imperial College, London
Reason for update of 2005 guideline This guideline was felt to be a little too restrictive in its scope Violence: the short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. There was also concern about continued face down restraint since the Rocky Bennett case and organisations such as MIND (mental health crisis care: physical restraint in crisis) and MP s, especially Norman Lamb (Lib Dem Minister of Health). Also changes in evidence for medication options
Membership of Guideline Development Group 27 individuals, including: 3 general psychiatrists 1 PICU consultant 2 professors of nursing 1 professor of child psychiatry 1 professor of social work 1 matron (Belinda Salt) 1 forensic associate professor (Birgit Vollm) 4 service users 1 clinical nurse specialist 1 pharmacist 1 detective constable 10 NICE staff
Main areas of change from earlier guideline (2005) Inclusion of children and adolescents Inclusion of community settings Greater emphasis on service user concerns Revision of rapid tranquillisation Revision of guidance on restraint and seclusion
1. Inclusion of children and adolescents Very little trial evidence to guide the group (not surprising in view of ethics) No recommended training for restraint of children and young people, with no national accreditation of trainers, no standardisation of techniques, and no audit or inspection standards. Only clear evidence of prediction factors is prior history of aggression No pharmacological studies of relevance
Clinical practice recommendations A. Staff in CAMHS should be trained in the management of violence and aggression and in manual restraint methods for adults (with allowance for size and weight) B. Use de-escalation techniques as for adults and only use mechanical restraint in high-secure settings C. Sedation with intramuscular lorazepam recommended (dose adjusted) D. Seclusion should only be used with the approval of a senior doctor
Research recommendation (children) What is the most appropriate physical restraint technique to use should it become necessary for the short-term management of violent and aggressive behaviour in children and young people?
2. Inclusion of community settings total numbers of violent episodes against NHS staff 2012-2013 2011-2012 2010-2011 52000 54000 56000 58000 60000 62000 64000
Separation by setting (2012-3) Ambulance Primary care Mental health Acute services 0 10000 20000 30000 40000 50000
3. Greater awareness of service user concerns The NHS Constitution for England now includes the need to take into account individual needs and preferences (formalised as advance decisions or statements), and the opportunity to make informed decisions about their treatments. This leads to a more cooperative approach that is incorporated into restrictive intervention reduction programmes now required for all hospital trusts (and likely to be taken notice of by the police also.
Advance decisions and statements Advance decision: A written statement by a person aged 18 or over that is legally binding and conveys a person s decision to refuse specific treatments and interventions in the future Advance statement: A written statement that conveys a person s preferences, wishes, beliefs and values about their future treatment and care. An advance statement is not legally binding
Reducing restrictive interventions Training for staff in person-centred values-based approach to care, skills to assess why behaviour may escalate to aggression, and training in techniques to reduce or avert imminent violence, and also to defuse aggression when it arises, and ths skills to undertake a formal post-incident review in collaboration with service users who are not currently using the service
Essentials of framework to reduce violence and aggression on in-pt wards Therapeutic team approach Ensure psychological therapies available Recognise teasing, bullying, unwanted sexual or physical contact Individual recognition of violence triggers Anticipate reaction to regulatory processes Improve or optimise physical environment Anticipate and manage personal factors occurring outside the hospital
4. Revision of rapid tranquillisation Rapid tranquillisation is the use of medication by the parenteral route (usually intramuscular or, exceptionally intravenous). Former definition (2005 guideline) the use of medication to control severe mental and behavioural disturbance, including aggression It is now a restrictive intervention
PRN medication Guidance for giving medication given when required (prn) a. Do not prescribe routinely b. Tailor to individual need c. Clarity over rationale for prn medication d. Ensure maximum daily dose is specified e. Only exceed BNF maximum dose if this is planned to achieve an agreed therapeutic goal under the direction of a senior doctor f. Ensure interval between prn doses is specified
Specific recommendations for rapid tranquillisation Use either intramuscular lorazepam or combined intramuscular haloperidol and promethazine for rapid tranquillisation in adults If evidence of cardiovascular disease use intramuscular lorazepam If no response to first choice use other If partial response, consider a further dose Prescribe as single dose and do not repeat until effect of initial dose reviewed
5. Review of restrictive interventions One of the matters that greatly concerned our group was the large number of private organisations that run Violence Training Workshops at greatly different costs. We had some evidence that in those Trusts that had used these workshops there were a greater number of violent incidents after the training. The implication was that staff were using their training either prematurely or instead of de-escalating approaches that would have prevented violence.
5. Review of restrictive interventions Recommended that a policy should be implemented in all Trusts to train staff where restrictive interventions are likely, with emphasis on (i) their risks, (ii), the sideeffect profiles of medication used for sedation, and (iii) communication of this information to service users. Trusts and other health care providers should define staff-patient ratios for each in-patient ward and the numbers of staff required to undertake restrictive interventions, ensure that such interventions are only used when there are sufficient staff available, and ensure the safety of these staff when performing these interventions
Other requirements Resuscitation equipment should be immediately available if restrictive interventions are used, including an automatic external defibrillator, bag valve mask, osygen, cannulas, intravenous fluids and first-line resuscitation drugs available Staff trained in immediate life support and a doctor trained to use resuscitation equipment should be immediately available if restrictive interventions are to be used
Only carry out restrictive interventions If de-escalation (defusion) approaches have failed, plus Other preventive strategies, including prn medication, have failed, There is potential for harm to come to the service user or other people if no action is taken.
Manual restraint Health and social care provider organisations should ensure a team approach to manual restraint When using manual restraint, avoid taking the subject to the floor, but if this becomes necessary, use the supine (face up) position if possible, and if face down position does have to be used, use it for as short a time as possible One member of staff should lead throughout the use of manual restraint
Mechanical restraint Use only in high secure settings (or when transferring to high secure settings) Use only as a last resort for the purposes of managing extreme violence and limiting selfinjurious behaviour of very frequency Consider mechanical restraint such as handcuffs when transferring patients to high secure settings
Seclusion Use seclusion only if the service user is detained in accordance with the Mental Health Act Use a designated seclusion room which is well insulated and ventilated, has access to toilet and washing facilities, and has damage protected furniture, windows and doors Use for as short a time as possible, review at least every two hours and tell service user the frequency
Post-incident debrief and review All health care provider organisations should be able to conduct an immediate post-incident debrief, including a nurse and a doctor, to identify and address physical harm, ongoing risks and emotional impact Determine factors contributing to incident and ensure service user has opportunity to discuss or write down their account of the incident with a member of staff, advocate or carer. Ditto with all other members of staff and witnesses
Formal external post-incident review The service user experience monitoring group or equivalent should undertake this review no later than 72 hours after the incident This should be led by a service user and include staff from outside the ward where the incident took place, and all of whom are trained in such investigations to learn and improve rather than assign blame Make recommendations to avoid a similar incident happening again
Key research recommendations 1. Which medication is effective for promoting deescalation in people who are identified as likely to demonstrate significant violence? 2. What is the best environment in which to contain violence in people who have misused drugs or alcohol? 3. What forms of management do service users prefer and do advance statements and decisions have an important role in management and prevention?
Research recommendations pertinent to high risk environments 4. What is the content and nature of effective deescalatory actions, interactions and activities used by mental health nurses, including the most effective and efficient means of training nurses to use them in a timely and appropriate way? 5. In what circumstances and how often are long duration or repeated manual restraint used, and what alternatives are there which are safer and more effective? (Exploratory survey work should be commissioned as a matter of urgency)
General conclusions Violent episodes are getting more frequent in NHS settings and this appears to be true finding rather than mere better reporting Reduction programmes to reduce restrictive interventions are needed in all Trusts Greater collaboration is needed between staff and patients and greaer awareness of advance statements and directives Children should rarely be subjected to manual restraint procedures