MI L
Volume 9, No. 6
This Medicines Information Leaflet is produced locally to optimise the use of medicines by encouraging prescribing
that is safe, clinically appropriate and cost-effective to the NHS.
Management of Acutely Disturbed Behaviour for Adults (including Rapid Tranquilisation)
gitated and aggressive behaviour from
A patients is common. Such behaviours
increase the risk of harm to the patient
themselves, other patients, and hospital staff.
The clinical practice of Restraint and, or Rapid
Tranquilisation (RoRT) is used when psychological
and behavioural approaches have failed to de-
escalate acutely disturbed behaviour. It is
essentially a management approach of last resort.
This policy applies to:
 Inpatients only, receiving care or treatment
within the OUH NHS trust (The Trust) from
age 18 years upwards.
 Patients in the A&E department.
N.B.: for those with recurrent bouts of agitation in
the context of delirium please refer to the Trust’s
delirium MIL. Additionally, The Trust’s Rapid
Tranquilisation policy should be consulted for
further detail on all subjects covered in this MIL.
DEFINITIONS:
Restraint is classified as the use of force – or
threat of force – to make someone do something
that they are resisting or the restriction of a
person’s freedom of movement, whether they are
resisting or not. In other words ‘Stopping a person
doing what they appear to want to do’.
Rapid Tranquilisation (RT) is defined as the use
of psychotropic medication to calm or lightly
sedate the patient, achieving a reduction in
agitation and aggression sufficient to minimise the
risk posed to the patient and others.
Oral medication is the first step in pharmacological
management of short term agitation and RT is
defined as the subsequent steps in this process.
1. This guidance may not apply to every clinical
situation but aims to provide reasonable
direction in the majority of circumstances.
2. Physical Restraint and RT is not first line
treatment of acutely disturbed or violent
behaviour.
3. Seclusion or mechanical restraint are never
used within The Trust.
January 2017
LEGAL FRAMEWORK
The following statute must be taken into
consideration when considering RoRT
procedures: The Mental Capacity Act 2005,
Deprivations of Liberty Safeguards or The Mental
Health Act (MHA) 1983.
MEDICAL CONSIDERATIONS
The following risks should be actively borne in
mind and managed during RoRT:
o Loss of airway
o Cardiovascular and respiratory arrest
o Interaction with pre-existing prescribed
medications
o Potential interaction with illicit substances
o Underlying relevant or co-incidental physical
comorbidities
o Potential for damage to the patient-staff
therapeutic relationship
Establish patient’s comorbidities and the reason for
admission. This may require a collateral history.
Resuscitation equipment must be available.
DE-ESCALATION TECHNIQUES
Verbal de-escalation should always be attempted
prior to any form of RoRT.
During this process the members of staff should:
 Avoid placing themselves in situations of
unnecessary risk – staff should ensure the
nearest exit is readily available and they are
not within the patient’s arm’s reach
 Continue to use verbal de-escalation even if
other interventions are necessary.
See Appendix 1 for detail on other aspects of non-
pharmacological management.
RESTRAINT
SAFETY
 Restraint should only be considered
following a clinical assessment and a
(prompt) assessment of the risk posed to the
patient or others.
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 Staff members should avoid unnecessarily
putting themselves or others at risk.
 Clinical staff should alert security as early as
possible.
 If possible, move other patients and visitors
away from the situation, or encourage the
patient to move away from others.
 Restraint should be administered by at least
two trained professionals (ideally security
staff) with medical and nursing support.
 Restraint on the floor or in the face-down
position should be avoided. If this is
unavoidable, it should be for the shortest
possible time.
PROCEDURE
 As senior a clinician as practically possible
should take the lead and delegate those
responsible for:
 Protecting the patient’s head and neck,
and ensure the patient’s airway is not
compromised.
 Provide ongoing verbal de-escalation
(unless it is deemed another individual
more familiar with the patient should
assume this role).
 Identifying a designated clinician to monitor
vital signs.
 In the exceptional circumstance where the
restrained individual needs to be held in
the face down position, this should be for
the shortest possible time necessary to
bring the situation under control.
RAPID TRANQUILISATION
AIM:
a. Minimise patient distress.
b. Reduce the risk of harm to others by
maintaining a safe environment.
c. Induce a state of calm sufficient to minimise
risk / distress / agitation (not to render the
patient unconscious).
SAFETY
The following risks should be actively borne in mind
 Loss of airway.
 Cardiovascular and respiratory arrest.
 Interaction with pre-existing prescribed
medications, alcohol or illicit drugs.
 Underlying relevant or co-incidental physical
disorders.
 Presence of medications that can directly or
indirectly lengthen the QTc interval.
 Not to exceed the British National Formulary
limits through the use of PRN medication
given in combination with regular medication.
 The introduction of antipsychotics in the
antipsychotic naïve patient.
 Caution regarding Anti-psychotics use in
patients with Lewy Body dementia.
PROCEDURE
1. Safety and procedural concerns as per restraint
section.
2. Oral (PO) medication should be offered in the
first instance.
3. PO and intramuscular (IM) routes of
administration are preferable to intravenous
(IV).
4. The IV route should only be used in very
exceptional circumstance.
5. Patients with a prolonged QTc interval should
be medicated with caution (benzodiazepines do
not affect QT interval).
6. The patient’s next of kin should be contacted
and notified of the rationale to sedate as early
as possible pre/post event.
See Appendix 3 for further detail.
Physical Health Monitoring
A number of adverse effects are associated with
the medicines used in RT including, extrapyramidal
side effects (EPSE), respiratory depression,
seizures, over-sedation or loss of consciousness,
hypotension and neuroleptic malignant syndrome.
Of particular concern, is the possibility of sudden
cardiac death and arrhythmias.
After RT is administered, nursing staff should
monitor physical observations on Track and Trigger
charts. Prescribers should be aware of actions to
be taken if a patient’s physical condition
deteriorates as a result of RT (see Appendix 2).
If unsafe to perform some of the physical
monitoring, then this should be recorded in the
patient’s notes. The observations that are possible,
even if only commenting on appearance and
behaviour, should nonetheless be recorded.
If a patient is unconscious, then close observation
of physical well-being with a 1:1 nurse is
recommended.
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OBSERVATION LEVELS
Following Restraint and or RT, a decision should
be made by the clinical team on the level of
observations, reviewed at each ward round.
Clinicians should adhere to the following NICE
terminology on observations:
General observation (the minimum
acceptable level for all patients): Involves
awareness of the location of the patient at all
times but they are not necessarily within eye-
sight.
Intermittent observation: The patient’s
location should be checked every 15-30 mins.
Within eyesight: The patient should be
accessible and in eyesight view at all times
day-and-night.
Within arm’s reach (Reserved for the patient
at the highest risk of harming themselves or
others): The patient should be in close
proximity to the supervising trained healthcare
professional. This may often require
supervision of more than one healthcare
professional.
The ward manager should be made aware of
when observation is above the general level
so that adequate numbers and grades of staff
can scheduled for future shifts.
OLDER PATIENTS (OVER 64 YRS)
The pharmacokinetics and pharmacodynamics of
most medicines are different in this patient group.
Older patients often have multiple comorbidities for
which they have been prescribed a number of
different medicines. This leads to an increased risk
of medicine-related adverse effects in this
population group. when elderly or frail patients
require medication, it is advisable to start with
low dosages of sedating agents and only if
needed titrate up to the maximum dosage in
Appendix 3.
DEBRIEIFING
Debriefing should be held within 2 weeks of the
more severe cases of RoRT (e.g. those involving
injury). This should involve all staff involved in the
event. Offer a separate debrief to the patient
concerned where possible.
DOCUMENTATION
A comprehensive record should be made of any
intervention necessary to manage a patient’s
disturbed behaviour, including documentation of
indication for such a measure. This must
additionally include completion of an online incident
report Datix.
LONGER TERM MANAGEMENT
The underlying cause of the patient’s disturbance
should be addressed using treatment of any
contributory factors.
Consideration should be given to the reason for
inpatient care with a weighing of the risks and
benefits of an ongoing inpatient admission.
Alternatives such as re-admission at a later stage,
whether the patient could return home, or be
moved to a quieter environment (e.g. side room).
Whilst such consideration should also include the
possibility of transfer to a psychiatric bed it is
important to be aware of the very limited medical
input available in such faculties. We suggest
discussion with the department of Psychological
Medicine for advice in such circumstances.
References
1. The Maudsley Prescribing Guidelines in
Psychiatry. Twelfth Edition. 2014.) David
Taylor, Carol Paton, Shitij Kapur.
2. National Institute for Health and Care
Excellence (NICE) NG10; Violence and
Aggression: short term management in
mental health, health and community
setting. May 2015.
3. OUH Trust Policy on Restraint and Rapid
Tranquilisation
Prepared by:
Dr. David Okai (Consultant Psychiatrist) on behalf of
OUH Psychological Medicine; Helen Turner (Medicines
Safety Pharmacist).
Review date: January 2019.
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Appendix 1: Non-Pharmacological management

• De-escalation techniques
• The approach should be to positively engage with the patient, establish a rapport, grounded in trust.
• Staff should accept that in a crisis situation, they are responsible for avoiding provocation. It is not realistic to expect
the person exhibiting disturbed behaviour to simply calm down.
• Environment
• Manage others in the environment, for example removing other patients, enlisting the help of colleagues, and creating
space
• Move towards a safe place and avoid being trapped in a corner or with the patient in front of the exit
• Where there are potential weapons, the staff member should ask for the weapon to be placed in a neutral place rather
than handed over.
• Consider enlisting the patient’s carer or nearest relative for help in all such situations.
• Consider additional nursing staff observation (E.g. 2:1 within arm’s reach).
• Interaction
• Speak slowly and clearly
• Speak in short sentences and ask only one question at a time
• Ask open questions and inquire about the reasons for the patient’s anger
• Ask for facts about the problem to encourage reasoning
• Attempt to establish a rapport and emphasise co-operation
• Offer and negotiate realistic options and avoid threats
• Keep the patient informed of intended next steps
• Give clear, brief instructions
• Show concern and attentiveness through non-verbal and verbal responses
• Listen carefully, do not be afraid to show empathy, acknowledging any grievances, concerns or frustrations
• Avoid minimising the patient's concerns

• Medium terms strategies (for confused patients)

• Re-orientation: the healthcare practitioner should identify themselves each time there is contact with the patient.
• Establish a regular sleep routine
• Check sensory deficits
• Try to ensure periodic access to a day room
• Ensure lighting levels are adequate
• Consider access to day-room, permitting wondering or negotiation with the patient regarding regular visits to outdoor
areas under supervision, if safe and settled
• Monitor for pain and ensure regular and PRN pain relief is available and offered
• Encourage family and friends to visit
• Ensure patient is eating and drinking adequately
• Ensure continuity of care with a stable and consistent team
• Attempt diverting patient’s attention
• Familiar objects (e.g. photos) and people can all help to orientate the patient.

Appendix 2: Remedial Measures in Rapid Tranquillisation

Problem Remedial Measure
Acute Dystonia (including oculogyric Give intramuscular (IM) procyclidine 5-10mg
crisis)
Reduced Oxygen saturation (less Give oxygen; raise legs, ensure patient is not lying face down.
than 90%) or respiratory rate (less
than 10 breaths/min) Give flumazenil if benzodiazepine-induced respiratory
depression suspected.

Flumazenil 200 micrograms dose to be administered

intravenously over 15 seconds. An additional dose of 100
micrograms can be administered after 60 seconds if
required level on consciousness not achieved. Further
doses of 100 micrograms can be administered following
discussion with a senior clinician (max total dose 1mg in
24 hours).

Note the risk of seizure and further agitation.

Irregular or slow (50bpm) pulse or Lie patient flat, tilt bed towards head or raise legs on pillows.
Drop in blood pressure (more than Monitor blood pressure closely.
30mm Hg diastolic)
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