Violence and Aggression NICE Guideline - important implications for practice

1. Violence and Aggression NICE
guideline – Important implications
for practice
Peter Tyrer, Imperial College, London
Rampton, June 2015

2. 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
Rampton, June 2015

3. 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
Rampton, June 2015

4. 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
Rampton, June 2015

5. 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
Rampton, June 2015

6. 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
Rampton, June 2015

7. 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?
Rampton, June 2015

8. 2. Inclusion of community settings –
total numbers of violent episodes
against NHS staff
Rampton, June 2015
52000 54000 56000 58000 60000 62000 64000
2010-2011
2011-2012
2012-2013

9. Separation by setting (2012-3)
0 10000 20000 30000 40000 50000
Acute services
Mental health
Primary care
Ambulance
Rampton, June 2015

10. 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.
Rampton, June 2015

11. 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’
Rampton, June 2015

12. 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’
•
Rampton, June 2015

13. 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’
Rampton, June 2015

14. 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’
Rampton, June 2015

15. 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
Rampton, June 2015

16. 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
Rampton, June 2015

17. 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.
Rampton, June 2015

18. 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 side-
effect 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
Rampton, June 2015

19. 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
Rampton, June 2015

20. 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.
Rampton, June 2015

21. 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
Rampton, June 2015

22. 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 self-
injurious behaviour of very frequency
• Consider mechanical restraint such as
handcuffs when transferring patients to high
secure settings
Rampton, June 2015

23. 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
Rampton, June 2015

24. 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
Rampton, June 2015

25. 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
Rampton, June 2015

26. Key research recommendations
1. Which medication is effective for promoting de-
escalation 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?
Rampton, June 2015

27. Research recommendations pertinent
to high risk environments
4. What is the content and nature of effective de-
escalatory 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)
Rampton, June 2015

28. 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
Rampton, June 2015