Pharmacological management of acute behavioural disturbance management (ABDM) in Queensland Mental Health Alcohol and Other Drugs (MHAOD) inpatient services (adults and older adults)

Guideline number: QH-GDL-966:2021

Effective date: 8 October 2021

Review date: 8 October 2024

Supersedes: Version 2.0

On this page:

1. Purpose
2. Scope
3. Related documents
4. Acknowledgements
5. Legislation and consent
6. Principles for the management of acute behavioural disturbance
7. Guideline for pharmacological management of acute behavioural disturbance (adults and older adults)
8. Adverse reactions
9. Guidelines for flumazenil use for reversal of benzodiazepine-induced respiratory depression
10. Definitions of terms used in the policy and supporting documents
11. Approval and implementation
12. Version control

1. Purpose

This Guideline describes the processes for pharmacological management of adults and older adults presenting with acute behavioural disturbance within Queensland Mental Health Alcohol and Other Drugs (MHAOD) Inpatient Services.

Reducing restrictive practices is essential to the provision of MHAOD services that are safe for all consumers, visitors and health staff, and therefore pharmacological management must only be used after all appropriate less restrictive options have been implemented.

2. Scope

This Guideline provides information for all Queensland Health employees (permanent, temporary and casual) and all organisations and individuals acting as its agents (including Visiting Medical Officers and other partners, contractors, consultants and volunteers) working within Queensland MHAOD Inpatient Services.

3. Related documents

Authorising policy and standard/s

Queensland Health policies and guidelines are available by searching the policies and standards section of the Queensland Health website.

• Mental Health Act 2016 (Queensland)
• Human Rights Act 2019 (Queensland)
• Chief Psychiatrist Policy, Clinical need for medication (2020)
• Chief Psychiatrist Policy, Notification to Chief Psychiatrist of Critical Incidents and Non-Compliance with the Mental Health Act 2016 (2020)
• Medicines and Poisons Act 2019
• Medicines and Poisons (Medicines) Regulation 2021
• Departmental Standard – Monitored Medicines
• National Safety and Quality Health Service Standards 2017

Procedures, guidelines and protocols

• Guideline for acute behavioural disturbance management (including acute sedation) in Queensland Health Authorised Mental Health Services (children and adolescents) (currently under review)
• Management of patients with Acute Severe Behavioural Disturbance in Emergency Departments (2016)

Forms and templates

• National Inpatient Medication Chart
• Queensland Adult Deterioration Detection System (Q-ADDS) – mental health facilities
• Post Sedation Monitoring Chart

Additional resources

• Australian Clinical Guidelines for Early Psychosis, Orygen, 2016
• Guideline for Safe Care for Patients Sedated in Health Care Facilities for Acute Behavioural Disturbance, Royal Australian and New Zealand College of Psychiatrists (RANZCP), 2019
• Approach to Managing Acute Behavioural Disturbance, Therapeutic Guidelines, 2021

4. Acknowledgements

This Guideline is informed by the Metro South Health Addiction and Mental Health Services’ Adult - Acute Behavioural Disturbance Management (ABDM) within the Acute Adult Inpatient Psychiatric Unit Procedure.

5. Legislation and consent

The use of acute sedation does not preclude the consumer from providing consent to treatment. Wherever possible, consumers should be offered the opportunity to consent to treatment. If the consumer lacks the capacity to provide (or withhold) consent to treatment, involuntary treatment under the Mental Health Act 2016 (MHA) or the Guardianship and Administration Act 2000 (GAA) may be possible, if the criteria within the legislation are met. Refusal of treatment is not a criterion for involuntary treatment under either the MHA or GAA.

The involuntary administration of medication, including the use of acute sedation, may be provided under the following/in the following ways:

• Under the MHA – to a person subject to a treatment and authority, Forensic Order (Mental Health), Treatment Support Order or to a person absent from an interstate mental health service and detained in an Authorised Mental Health Service (and awaiting their return interstate)
• Under the MHA – to an involuntary patient for the purpose of safe transport of the person under the MHA, immediately prior to the transportation occurring
• GAA – if the adult lacks capacity to consent and urgent healthcare is required to meet imminent risk to their life, health or to prevent significant pain or distress.

The Queensland public sector must consider the impact on the human rights of individuals when making decisions, and to ensure that decision is compatible with the Human Rights Act 2019 (Queensland). This guideline must be implemented in a way that is consistent with the rights outlined in the Act. Queensland Health staff have obligations under the Human Rights Act 2019 to make decisions and act in ways that are compatible with human rights.

Staff must ensure that clinical documentation is accurate, comprehensive and contemporaneous in relevant records including observation and medication charts.

6. Principles for the management of acute behavioural disturbance

This guideline focuses upon the pharmacological management of acute behavioural disturbance management and it should be used with two further resources:

• Guideline for Safe Care for Patients Sedated in Health Care Facilities for Acute Behavioural Disturbance | Royal Australian and New Zealand College of Psychiatrists (RANZCP), 2019
• Approach to Managing Acute Behavioural Disturbance | Therapeutic Guidelines, 2021

These documents outline:

• the assessment of acute behavioural disturbance
• non-pharmacological management of acute behavioural disturbance, and
• post-sedation monitoring requirements.

7. Guideline for pharmacological management of acute behavioural disturbance (adults and older adults)

7.1 Indications

Sedative medication may be the only clinically appropriate treatment option when consumers are extremely agitated, threatening violence, are violent and/or are a danger to themselves or others. In alignment with the above documents, pharmacological therapy should only be administered after attempts to manage the behavioural disturbance with de-escalation techniques delivered by mental health staff have proven unsuccessful.

7.2 Precautions

Consideration of pharmacological and physiological factors impacting on the safe and effective delivery of sedating medications should occur individually for all consumers. Consumer groups which require particular care, including consideration of lower doses than standard adult doses include:

• older adults
• pregnant women
• consumers with an intellectual impairment and/or acquired brain injury
• medically compromised
• consumers with low body weight.

It is always important to use lowest possible effective dose and to seek specialist advice where relevant. This is particularly the case for consumers who have not previously received psychotropic medications. A consumer’s previous response to medication should be considered where possible.

Specific suggestions for consideration include:

7.3 Prior to administration

A medical assessment should be performed on admission and again, where possible, prior to acute sedation. More specific information pertaining to assessment is available in the RANZCP and Therapeutic Guideline resources listed above.

Note: The implementation of and consumer’s response to non-pharmacological measures should be documented.

7.4 Process for pharmacological management of acute behavioural disturbance management for adults 18 – 65 years

7.4.1 Administration of oral medication (preferred medication option)

Principles

• Aim to calm with minimal pharmacological sedation.
• Align dosing decisions with assessment of level of arousal and related risks.
• Prior to administration of medication, calculate the total daily dose of all oral and intramuscular (IM) psychotropic medications (i.e. regular and prn medication) given in the previous 24 hours, whether in the unit or home or in other health care settings including the emergency department and/or ambulance. If two doses are given without effect, consider consultant psychiatrist advice.
• The use of multiple psychotropics with overlapping side effect profiles should be avoided but if used should be according to any local protocols and/or documented risk mitigation strategies.
• Monitor for delirium using a locally endorsed screening tools (for example, 4AT).
• Treat underlying medical causes.
• Ensure concise accurate documentation of medications and responses, including rationale for change.

Process

• Contact consultant psychiatrist if a higher than recommended dose or shorter interval times between doses are being considered.
• Therapeutic choice points:
  • First line medication is the preferred option. If a subtherapeutic response is obtained after the first dose, titrate with second dose at the lower end of interval time and dose.
  • If a nil or minimal response is obtained after the first dose, consider moving to second line medication.

Note: Oral chlorpromazine should only be administered in consultation with a consultant psychiatrist.

7.4.2 Administration of short acting intramuscular (IM) medications

Principles

• Issues of consent must be addressed – refer to section 4. Legislation and consent.
• IM droperidol and midazolam are not recommended within Queensland MHAOD Inpatient Services due to their short duration of action and higher incidence of side effects which may be more difficult to monitor and treat than in other clinical settings.

• If two sequential IM doses given without effect, seek consultant psychiatrist’s advice.
• Prior to administration of medication, calculate the total daily dose of all oral and IM psychotropic medications (i.e. regular and prn medication) given in the previous 24 hours, whether in the unit or home or in other health care settings including the emergency department and/or ambulance. If two doses are given without effect, consider consultant psychiatrist advice.
• Medical officer to review every 12 hours and transition back to oral medications as soon as possible.
• Recommend consultant psychiatrist review in 24 hours if no response.
• Ensure concise accurate documentation of medications and responses, including rationale for change.

Process

7.4.3 Administration of medication via intravenous (IV) route

Principles

• Intravenous sedation should be used only when other methods to secure safety of consumer and staff have failed.
• Prior to administration of intravenous sedation, calculate the total daily dose of all oral and IM psychotropic medications (i.e. regular and prn medication) given in the previous 24 hours, whether in the unit or home or in other health care settings including the emergency department and/or ambulance. If two doses are given without effect, consider consultant psychiatrist advice.
• Intravenous sedation consideration must involve the consultant psychiatrist, who should involve as necessary specialists with relevant expertise in management of acute intravenous sedation such as anaesthetists or intensivists.
• Planning for intravenous sedation must consider capacity for safe and effective sedation within the acute mental health inpatient unit (AMHIU) setting, including, guided by local protocols, need for medical emergency team (MET) calls.
• Intravenous sedation should be administered in AMHIU settings only by, or under the direct supervision of, an advanced life skills (ALS) competent staff member with careful monitoring.
• Monitor the consumer’s respiratory rate, oxygen saturation, oxygen delivered, blood pressure, heart rate, temperature and level of consciousness on the Queensland Adult Deterioration Detection System (Q-ADDS) document or similar early warning tool.
• Intervals between observations should be in alignment with Table 1.
• Escalate in accordance with the documented ‘Action Required for Mental Health Facilities’ which are included on the Q-ADDS for mental health facilities form or similar early warning tool guidance.
• If the consumer becomes unresponsive, a MET call should be made as appropriate, in alignment with MET call criteria.

7.4.4 Administration of longer acting IM medications

Principles

• Must be specifically approved by a consultant psychiatrist
• Not recommended for routine use for acute behavioural disturbance management but may be considered as an option when disturbed/violent over extended time (24–48 hours), a previous history of response including adverse reactions should be considered in such decisions.

Process

7.5 Process for pharmacological management of acute behavioural management for older adults >65 years, the psychotropic naïve or physically frail

Principles

• Lower medication doses used for older persons are also generally appropriate for consumers who are psychotropic naïve or physically frail.
• Prior to administration of medication, calculate the total daily dose of all oral and IM psychotropic medications (i.e. regular and prn medication) given in the previous 24 hours, whether in the unit or home or in other health care settings including the emergency department and/or ambulance. If two doses are given without effect, consider consultant psychiatrist advice.

Process

7.6 Monitoring/observation–post parenteral acute sedation

Principles

• Post-acute sedation monitoring is mandatory after any parenteral (IM or IV) medications.
• Monitor the consumer’s:
  • respiratory rate
  • oxygen saturation
  • oxygen delivered
  • blood pressure
  • heart rate
  • temperature, and
  • level of consciousness on the Queensland Adult Deterioration Detection System (Q-ADDS) score, or similar, early warning tool.

Table 1. Level of observations required according to level of sedation:

*Vital observations— the consumer’s respiratory rate, oxygen saturation, oxygen delivered, blood pressure, heart rate, temperature and level of consciousness.

• Check for signs of dystonia or any deterioration.
• Vital observations should continue until the consumer is alert and mobile or whilst they are receiving acute sedation.
• Due to the potential for delayed side effects, if discharged from hospital, consumers and their carers if possible, should be provided with written documentation of medications, doses given, side effects and warnings.

Note: If a consumer is uncooperative, documentation of observations on the Post Sedation Monitoring Chart may be useful until the consumer is cooperative and can have their vital observations monitored. An excerpt of this document has been included below:

8. Adverse reactions

Adverse reactions may include:

• dystonic reactions and akathisia, particularly with high doses of antipsychotic agents
• hypotension secondary to benzodiazepine administration or antipsychotic use
• excessive sedation—risking aspiration and/or delirium
• hyperthermia / neuroleptic malignant syndrome
• paradoxical disinhibition (with benzodiazepines)
• prolonged QT, cardiac arrhythmia
• sudden cardiac death secondary to antipsychotic use (rare).

For further guidance refer to the relevant product information brochure.

For acute laryngospasm or extrapyramidal side effects (EPSE):

• benztropine—2 mg either IM or IV should be available.

For reversal of benzodiazepine induced respiratory depression:

• flumazenil—see guidelines for use below.

9. Guidelines for flumazenil use for reversal of benzodiazepine-induced respiratory depression

10. Definitions of terms used in the policy and supporting documents

11. Approval and implementation

Endorsement: Queensland Psychotropic Medication Advisory Committee

Approving Officer: Chief Psychiatrist, Mental Health Alcohol and Other Drugs Branch

Policy Custodian: Director, Clinical Governance, Office of the Chief Psychiatrist, Mental Health Alcohol and Other Drugs Branch

Approval date: 8 October 2021

Effective from: October 2021

Next review: July 2024

12. Version control