Guidelines for the management of behavioural disturbance and

Brighton and Sussex University Hospitals
Guidelines for the management of behavioural
disturbance and cognitive impairments following
acute brain injury.
Category and number:
Approved by:
Neurosciences Core Clinical
Governance Group
Date approved:
[insert date]
Name of author:
Jackie Powell, Head Injury Nurse Specialist
Michelle East, ITU Sister
Kim Bateup, Ward Manager, Neurosurgical
Name of responsible committee/individual:
Neurosciences Core Clinical
Governance Group
Date issued:
February 2012
Review date:
February 2014
Target audience:
All clinical staff, all Security officers
This policy will be available in electronic
These guidelines have been adapted from The management of patients with cognitive
impairments and post acute behavioural disrurbance within the Greater Manchester
Neuroscience Centre. Salford Royal NHS Foundation Trust
Roles and Responsibilities
Assessment Process
Management Strategies
Treatment Process
Monitoring and Review
Equality Impact Assessment Screening
Links to other Trust policies
Associated documentation
Appendix A
Richmond Agitation and Sedation Scale (RASS)
Appendix B
Withdrawal Syndromes
Appendix C
Sections 5(2) and 5(4) of the Mental Health Act 1983
Appendix D
Deprivation of Liberty Safeguards flowcharts and checklist
Guidelines for the management of behavioural disturbance and cognitive impairments following acute brain injury. HPNC
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1.0 Introduction
This guideline applies to staff working with inpatients within the Hurstwood Park
Neurosciences Centre.
It may also be applicable to staff working within other areas of BSUH who manage patients
with a brain injury however this will require verification at a local level.
It is intended for those patients who, following an acute event such as illness or injury, are
exhibiting cognitive and behavioural problems including confusion and agitation and whose
behaviour is impeding treatment (including rehabilitation), which is felt to be in the patient’s
best interests. This may include patients with a primary diagnosis of acquired brain injury
for example, traumatic brain injury, intracerebral haemorrhage, subarachnoid
haemorrhage, brain tumours, anoxia, or encephalitis.
The guideline has three main aims:
To maximise the patient’s participation in medical and other treatments,
including rehabilitation, in order to minimise long- term difficulties, which may
develop as a result of acquired impairments and learnt inappropriate behaviour
patterns, thus maximising their future abilities
To ensure optimum care whilst the patient is still in an acute stage of their illness as is
the case in those who develop post - traumatic amnesia or other confusional states due
to acquired brain injury.
To ensure optimum safety and protection of other patients, members of the public and
2.0 Roles and Responsibilities:
The implementation of this pathway requires the active collaboration and communication of
all health professionals involved in the patients treatment.
Due to the nature of their illness or injury, the majority of patients will be suffering from
temporary incapacity. Interventions and treatments (environmental, behavioural, physical,
and pharmacological) will need to be carried out on the basis that they are clinically
necessary and in the patient’s best interest.
Medical staff
Investigate and exclude medical reasons for agitation and refer patient to other health
professionals for further assessment as appropriate.
Establish whether the patient suffers from a mental illness within the definition of the
Mental Health Act (1983) and whether they are liable to be detained within the confines of
the Act.
Ensure that the guidelines are disseminated, that the appropriate training is provided and
all nursing staff read and understand this document.
Guidelines for the management of behavioural disturbance and cognitive impairments following acute brain injury. HPNC
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Bleep holder
The bleep holder will adhere to current guidelines and attend appropriate training. The
bleep holder should be aware of any patient that is at risk of absconding and/or has
significant behaviour disturbance. He/she should ensure that the Clinical Site Manager is
made aware of the patient and the current situation, in particular before the night shift
Nursing staff
Attend appropriate training and adhere to current guidelines. Ensure that the appropriate
staffing levels are conducive to a safe environment. Ensure bleep holder is aware of any
patient that is at risk of absconding and/or has significant behavioural disturbance.
Clinical Site Manager
The CSM will have knowledge of the guidelines and can be contacted for advice. The CSM
can ensure guidelines are adhered to and may be in a position to make any necessary
telephone calls if appropriate.
When the CSM has been made aware of a patient that is at risk of absconding and/or has
significant behaviour disturbance he/she should ensure they discuss the patient with the
nursing staff on a shift basis so they are fully aware of the situation particularly with regard
to any mental capacity issues or mental health problems.
Please note that at night there is only one CSM on duty who has to respond to emergency
calls so will not be able to leave the premises unless it is exceptional circumstances.
Be involved in the assessment of mental capacity and assessment of “best interests”
where there is ambiguity about a patient’s cognitive status and where the patient’s
behaviour presents a risk to self or others.
Devise behavioural intervention plans as required and advise staff in their implementation.
Monitor for effectiveness and ethical implementation.
To advise regarding placement options when medically stable
Occupational Therapist
To conduct assessment of function, cognition and perception, and draw up a routine of
tasks and activities for the patient to engage in which can be implemented on the ward by
nursing staff and the patient’s family (if appropriate), incorporating appropriate behaviour
modification strategies as advised by the neuropsychologist. To draw up guidelines to
grade tasks based on the patient’s progress, and to make recommendations regarding
further rehabilitation when medically stable.
Key worker
(The key worker will be allocated at the first MDT meeting)
Monitor the implementation of the policy for the individual patients. Ensure documentation
is completed and kept up to date. Raise issues and problems with relevant health
professionals as appropriate.
Collective responsibility
The implementation of these guidelines within neuroscience wards requires the active
collaboration of different health professionals and requires coordination and monitoring.
This may be best carried out through a designated health care professional within the multi
professional team.
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The Clinical Neuropsychologist is often best placed to carry out assessment of capacity
and risk, but each health professional is clinically and legally responsible for the treatment
that they prescribe or give and they should ensure that the treatment plan agreed is carried
out by appropriately trained staff that are supported and supervised. It is important to
recognise that capacity can vary over time so regular review is essential. All patients have
a right to make decisions for themselves even if eccentric or unwise; this does not
necessarily mean they lack capacity.
All staff to ensure that areas of concern are communicated to their immediate line
Occasions may arise where there is differing opinions about the person’s capacity. If the
MDT cannot agree then the ultimate decision rests with the consultant in charge of that
person’s care.
Any treatment interventions provided under the terms of these guidelines need to be
specified and recorded within the patient’s notes, this will enable the monitoring of
progress and evaluation of their effectiveness.
Any deviation from the guideline must be recorded in the patient’s medical, therapy,
psychology, and nursing notes, with the reason(s) for this. An inability to implement the
guidelines for non-clinical reasons e.g. environmental or staffing issues must be reported
as an adverse incident and brought to the attention of the relevant manager. Should such a
situation result in the use of physical or chemical restraint in order to maintain the safety of
the patient or others; an adverse incident report must be submitted.
2.0 Standards
This guideline provides a framework for the assessment and management of patients who
have cognitive and behavioural difficulties which may result in them lacking capacity; this
incapacity may be temporary. The majority of these patients will have an acquired brain
injury due to trauma or other non-traumatic causes; however the basic principles apply
whatever the cause, be this of sudden onset or progressive.
They may require specific interventions to enhance recovery and minimise impairments,
these may include medical and/or other treatments and encompasses the process of
Any interventions must take account of the physical, emotional, and medical needs of the
individual patient and must be in the patient’s best interests, but also taking into
consideration their privacy and dignity and their Human Rights. The interventions must
also take into account the well being of other patients, relatives, visitors and staff.
This guideline is based upon legislation, published literature, currently accepted best
practice, and theories of behaviour management.
The management of these patients is multidisciplinary in nature and requires active
collaboration by all health professionals involved. Input and support from family or friends
(when possible) is crucial in implementing behavioural interventions and can help to
ensure that treatment decisions are in the best interest of the patient and thus must be
sought whenever possible.
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Before a management plan is agreed and implemented, it is essential that as
comprehensive a clinical assessment as possible is undertaken and a diagnosis made. It is
acknowledged that in some circumstances this assessment may be restricted by the
challenging nature of the behaviours. Ideally the clinical assessment should be
multidisciplinary, however this may not be possible in acute situations where there is a risk
of harm to the patient or others, and immediate treatment is necessary.
The behavioural management of these patients must always start with the least restrictive,
such as changes to the environment and general approaches of staff in redirecting and deescalating behaviour. Other interventions, such as pharmacological management, should
only be used where basic environmental and behavioural approaches are found to be
ineffective and the problem behaviour continues to present a risk to the patient and / or
others; the risk to the patient may be a medical or physical risk.
Physical intervention takes place on a continuum from engaging a patient in an activity
aimed at redirecting their attention, to the actual physical handling of patients. The latter
should only be considered if the immediate health and/or safety of the patient or others,
including staff, is endangered and should represent the minimum amount of intervention
necessary, for the shortest time possible and in line with recognised good practice
Both restrictive physical and pharmacological management of behaviour should only be
considered where environmental and behavioural approaches alone have been unable to
reduce particular problem behaviour. They need to be considered within the overall context
of behavioural and medical management, they should not be used in isolation.
Guidelines for the management of behavioural disturbance and cognitive impairments following acute brain injury. HPNC
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4.0 Assessment Process
Patients Requiring Assessment
An assessment of a particular patient will be required where they are found to
be:  Suffering from a physical illness or having acquired a brain injury; and
Exhibiting cognitive problems and/or behavioural disturbance which prevents
or interferes with treatment including rehabilitation; and
Treatment or rehabilitation cannot be carried out as a result of the above
There is concern for the patients safety or the safety of others
Commence Pathway Pack for Acute Brain Injury Patient with Challenging Behaviour
Identify if there is any previous history of mental
health issues, alcohol or drug misuse,
aggressive or violent behaviour
Pre morbid factors can act to heighten the
likelihood of a particular behavioural or
emotional response to environmental,
physiological and emotional triggers.
ITU patient weaning from ventilator:
Carry out sedation assessment using The
Richmond Agitation and Sedation Scale (RASS;
Appendix A)
Identifying signs of agitation at an early
stage will allow appropriate and timely
Consider withdrawal syndromes i.e.
Withdrawal syndromes will need to be
managed appropriately before agitation can
be attributed to the brain injury and
Benzodiazepine and or opoid withdrawal
appropriate management strategies
if patient has been sedated for a
implemented. Agitation may be due to a
prolonged period
Alcohol and/or drug withdrawal if previous combination of factors which may warrant a
combination of strategies.
history of alcohol and/or drug abuse.
See guidance for managing withdrawal
syndromes in Appendix B
Screen cognitive status with respect to
orientation, memory, reasoning and judgment.
A brief cognitive screen can be performed by
nursing staff using the orientation log (See
pathway pack - Appendix A)
A more in depth screen can be done by the
occupational therapist or the neuropsychologist.
Establish the patient’s perception of the
Impaired cognitive function may affect the
capacity of the patient to comprehend and
retain information and make decisions
related to his treatment and rehabilitation
Level of insight may fluctuate; lack of
awareness of cognitive problems or reason
for being in hospital will have an influence
on behaviour.
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Assess current emotional state.
Observation of behaviour and interaction
with staff. Consider using Agitated Behaviour
Scale (See pathway pack) to give a base line
Difficulties in managing intense feelings
will reduce a person’s tolerance towards
other people and situations
Changes in behaviour can be triggered by
environmental factors and staff behaviour.
Review with partner or other relative/friend
Family/friends are able to give a view as to
the patient’s previous behaviour.
Review with other staff (nursing, therapist
The patient’s behaviour can fluctuate and
some staff are often able to provide a more
accurate picture of this.
Confirm that potential medical problems
have been considered and treated where
Medical Assessment
Medical Assessment, including a review of the
previous medical history, examinations, and
Identification of medical causes or
contributory factors is essential in order to
make a clinical diagnosis, and to guide
The clinical assessment must include
observations made by nurses, therapists,
psychologists, and neuropsychiatrist where
The causes of confusion and / or agitation
are multi-factorial and may fluctuate over
the course of the day.
All available information is necessary to
make an accurate diagnosis
Consider medical causes or contributors to the
patient’s confusion and / or agitation.
An accurate clinical diagnosis is essential.
Medical causes / contributors should be
treated where possible.
Possible causes may include:
 Direct complication of brain injury,
obstructive hydrocephalus, CNS infection
 Seizure disorder
 Infections outside the CNS e.g. respiratory,
urinary tract
 Hypoxia due to respiratory or cardiac disease
 Metabolic - check blood glucose,
 Endocrine e.g. hyper/hypothyroidism,
cortisol deficiency
 Fat embolism if poly trauma
 Adverse effects of medication
 Withdrawal from alcohol or drugs
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Risk assessment
The assessment of risk must include the:
Patient’s best interest
Risk to the patient and others should
he/she leave the unit
Risk to the staff if the patient stays
Risk to the staff if the patient leaves
Risk for other in-patients
Risk to visitors
(See pathway pack)
Psychiatric Assessment
If it appears that the patient may be suffering
from a mental disorder, referral to the psychiatric
team should be arranged, with an appropriate
degree of urgency, depending on the patient's
condition and/or any risk factors identified to the
patient or others.
The assessment and balance of risk
influences the implementation of
management strategies
A patient may be identified as suffering
from a mental disorder, for which he may
need to be considered for formal detention
under the Mental Health Act 1983.
If the patient attempts to leave the unit
before the psychiatric assessment has been
carried out, staff should be aware of their
powers to temporarily hold the patient,
pending psychiatric assessment, under the
authority of sections 5(2) and 5(4)
respectively of the Mental Health Act 1983.
(Appendix C)
NB It is not always necessary or appropriate to
“section” a patient for the purpose of providing
“authority” for medical treatment of the patient’s
mental disorder and may be unlawful
Assessment of Capacity
Establish whether patient has the capacity to
make their own treatment decisions.
Capacity is decision-specific i.e. someone may
be capable of making a simpler decision but not
a more complex one.
(Ensure all assessments and decisions are
Assessment of capacity relates to whether or not
a person is able to:
1) Understand the information relevant to the
2) Retain that information
3) Use or weigh that information as part of the
process of making the decision
4) Communicate the decision either by talking,
using sign language or any other means.
*The Trust has a duty to ensure that the
Provision of medical treatment to a patient
who is mentally incapable may be
authorised under common law, if the
treatment is considered to be in the
patient’s “best interests”
Patients who recover from a brain injury or
illness may suffer from temporary
incapacity and be unable to make some or
all decisions including those related to their
The Mental Capacity Act 2005 deals with
the assessment of a person’s capacity and
acts by carers of those who lack capacity.
An assessment of whether or not the
patient has capacity to consent to
treatment / rehabilitation is a key factor
in determining how to proceed in terms
of the treatment programme.
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information relevant to the decision to be made
is communicated to the patient in a way which is
appropriate to their circumstances eg using
simple language, visual aids or any other means
 Even if the person can only retain the
relevant information for a short period this
does not invalidate their decision.
 Relevant information? – includes information
about the reasonably foreseeable
consequences of –
(a) Deciding one way or another, or
(b) Failing to make the decision at all
For more guidance see Trust Policy on the
Mental Capacity (TCP 199)
Deprivation of Liberty Safeguard (DoLS)
A DoLS may be applied for if the patient lacks
the capacity to make their own decisions and
where personal freedom needs to be restricted
in the patient’s best interests, to the extent that it
amounts to a deprivation of liberty. The MCA
states that restraint is appropriate when it is
used to prevent harm to the person who lacks
Use DoLS flowcharts and checklist
capacity and that it is proportionate to the
(Appendix D)
likelihood and seriousness of harm.
You should use least intrusive and minimum
amount of force for the shortest possible time
and it must be in the best interests of the patient.
There is no clear definition of deprivation of
liberty but the difference is the degree of
intensity, the duration and the frequency; so with
the more restriction and restraint you put in
place the more likely you are to be depriving a
person of their liberty.
Before applying for an authorisation you
should always think about providing care or
treatment in ways which avoid depriving
someone of their liberty.
It is also important to understand that an MCA
DoLS authorisation does not, in itself, authorise
care or treatment.
Any care or treatment still needs to be carried
out under the wider “best interests” provision of
the MCA.
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Temporary incapacity may apply for as little as one
day, or last as long as several weeks/months, in
patients with significant and extensive cognitive
The ability to consent to treatment must be regularly
Re-assessment needs to establish whether a
patient continues to suffer from temporary
If the patient has expressed a wish to be discharged
from hospital, it is important that the issue of the
patient’s right to liberty is also regularly revisited.
In a person recovering from acquired
brain injury, acute confusional states or
post- traumatic amnesia can be short
and a person may exhibit agitated
behaviour on one or two occasions and
for a short period of time only.
Recovery after acquired brain injury
may be prolonged and some patients
with severe brain injury do have posttraumatic amnesia lasting several
Cognitive abilities can show
considerable fluctuation.
Patients recovering from acute illness or
trauma often express a wish to self
discharge whilst in a confused state or
whilst in a post-traumatic amnesic state.
Their safety could be at risk if
discharged at that point.
Re-assessment establishes whether a
patient continues to suffer from
temporary incapacity and whether
treatment and rehabilitation as an inpatient remains in the patient’s best
Assessment of capacity to consent to treatment is to This approach ensures consistency in
be carried out by the health care professionals who
the assessment and intervention
have previously proposed and supervised the
patient’s treatment
The timing of re-assessment is variable and
depends on the clinical condition of the individual
Where a patient is found to have regained capacity
to consent to treatment, the treatment/rehabilitation
may be continued, subject to their consent being
A patient who has recovered from
temporary incapacity may be
discharged if they no longer wish to
remain in hospital, following
consultation with the patient’s family, if
Discharge arrangements can be instigated once a
patient has recovered from their temporary illness
and suitable follow up by appropriate health care
professionals has been arranged.
Patients often experience a range of
longer term problems and benefit from
multidisciplinary follow up.
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5.0 Management Strategies
General Principles
The multitude of problems requires input from
different health professionals. Successful
interventions are based on shared
understanding and consistency
in their approach.
Interventions must be patient centred.
The rehabilitation process must treat the patient
as a whole person, view the disability in terms of
its subjective impact, and understand the patient
in terms of his/her previous and future social and
physical contexts.
Interventions must be discussed with the
The patient’s family has a key role in the
patient’s family, where appropriate to do so. rehabilitation process. The family’s help in this is
Relatives should be informed about
often crucial and the success of a particular
treatment plans, subject to patient
intervention may depend on the
confidentiality. The treatment
input and support provided by family and friends.
plans/interventions and discussion with
family should be clearly documented in
patient’s medical/nursing notes.
Interventions must be goal based.
A goal-based approach ensures that
interventions are tailored to the needs of the
individual. Goals must be acceptable to the
individual patient, health professionals and,
ideally, to family members. They must be
specific, realistic, measurable, and achievable
and time bound.
Interventions must be subject to evaluation. Ongoing evaluation helps to ensure that
effective treatments are used and that human
rights are safeguarded.
Behavioural disturbance needs to be
By creating an atmosphere and environment in
prevented as far as is possible.
which patients’ needs and wishes are
anticipated in advance, many incidents of
behavioural disturbance are preventable.
Potential problem behaviours need to be
Being aware of potential problem behaviours
recognised and targeted for intervention as and ensuring appropriate and consistent
soon as they develop.
management at an early stage may prevent the
development of more intractable problems later.
Interventions need to be preceded by a
Members of the MDT must specify the precise
functional analysis.
nature of the behaviours they wish to address.
The behaviours may then be analysed according
Use the Agitated Behaviour Scale and ABC to possible triggers (Antecedents) of the
chart which are part of the Pathway Pack
Behaviour and possible maintainers
(Consequences) of the behaviour. All staff must
participate in data collection using ABC charts
aimed at analysing the function of the
behavioural disturbance.
All interventions are multidisciplinary and
require a coordinated and consistent
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Medication should be used to help alleviate
agitation, where environmental and
behavioural approaches alone are
insufficient, or where there is a risk of harm
to the patient
Medication should be used to help alleviate
agitation, where environmental and behavioural
approaches alone are insufficient, or where
there is a risk of harm to the patient
Environmental / Behavioural Interventions
The principles are aimed at preventing behavioural disturbance from arising in the first instance and
include the following:
 modifying the environment
 communication strategies
 engaging in therapeutic tasks
 family & visitors
 staffing issues
 behavioural management strategies
Modifying the environment
The patient should have a structured day with time
tabled events and rest periods, there should be
focal points during the day (e.g. meals, rest
periods) that do not change from day to day
Many patients become distressed through
being disorientated. A structured time
table and environment may help to reduce
disorientation (Kaschel et al 1995)
If the patient is disorientated, reminders of location
and time should be prominently placed within
his/her room i.e. calendars, get well cards,
personalized folders with ward information,
hospital charts etc.
But the room should not be too cluttered.
The general ward environment should also include
reminders of location & time i.e. clocks, signs etc.
in order to help orientate all patients.
Example: A weekly time table indicating
OT. Physiotherapy, Speech Therapy
sessions and meal times should be drawn
up with the patient. This should be kept
next to the patient’s bed and referred to
with the patient at the beginning of
therapy sessions.
The patient should be moved to a quieter part of
the ward or a side room if noise and excessive
stimulation have been identified as stressful for
the patient
Patients who are still in PTA should wherever
possible, be admitted to a single quiet room to
reduce excessive stimulation
For patient’s with a short-term memory /
attention deficit a busy environment may
place too many demands upon their ability
to process information (Gervasio &
Matthies 1995)
Patients who are restless or physically active in
To maintain the patient’s safety
bed, and put themselves at risk must be nursed on
a low bed.
The patient should not move beds within the ward
unless it is likely to reduce distress and
behavioural problems.
Movement between beds may increase
disorientation and cause more distress
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At night consider nursing the patient in an area of
the ward that has more lighting.
Employ 1:1 supervision if necessary see risk
rating matrix and levels of observation in Pathway
Pack (Appendix A)
Patients who wander should be allowed to with an
appropriate level of supervision.
Perceptual difficulties (e.g. visual neglect) should
be considered when organising a patients ward
Agitation and confusion can be worse at
night because there are reduced
environmental cues due to low light, there
may be reduced surveillance from staff
and the patient often has a disordered
sleep/wake pattern.
Confinement may increase the agitation
and irritability.
An environment, which presents the
patient with difficulties in moving around
or observing activities is likely to cause
frustration & distress e.g. patient with right
sided visual neglect should have his/her
bed placed so that staff and visitors are
likely to approach from the left side
Communication Strategies
Staff should introduce themselves and what Introducing yourself and the task required may
they are going to do at each new episode
help to reduce distress caused by disorientation.
of care whilst a patient remains in PTA.
If organising a meeting/case conference
that the patient will attend restrict the
number of attendees.
The brain injury person can easily become
overwhelmed in large groups with a lot of
information being exchanged and more than one
person talking at a time.
Ensure during the meeting that only one
person at a time talks and advise those
present to speak slowly.
Keep the number of people present during
clinical sessions to a minimum and decide
who will do the talking during the session.
Keep instructions and explanations to a
 Use Yes/No questions
 If the patient is unable to verbalise
ensure that a reliable means of
expressing yes and no has been
identified and that this is understood
by everyone to prevent confusion.
 Speak slowly.
 Use short sentences
 Communicate in a non-confrontational
and calm manner.
Many cognitively impaired patients have
difficulty in following complex instructions or
requests. The resulting confusion may lead to
irritation or defensive reactions La Vigna &
Donnelan, 1986).
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Avoid asking too many questions
Leave pauses and gaps in
conversations and in between giving
Give one piece of information/
command/ direction at a time
If you are giving important points of
information leave a written record so
that this can be referred to later by
patient, carers, relatives etc.
Use exaggerated non- verbal
communication (facial expressions
gestures) alongside verbal
Adapt a communication style to the
ability and background of the patient
Check that the person has
understood what you have said.
Staff should adopt a firm but gentle
tone and avoid either a harsh or
mothering tone and remain calm.
Keep background noise and
directions to a minimum whilst talking
By adapting communication styles, the patient
may be helped to express his/her needs and
The person may need extra time to process a
question/command/ piece of information
Many patients may perceive certain tones of
voice as being punitive or patronising This may
serve to increase their irritation (Gervasio &
Matthies 95)
communication by the brain injury person so it
may increase agitation if you do not remain calm
and so not use a gentle tone of voice.
If a person has short term memory and attention
deficits, a busy environment may place too
many demands upon their abilities to process
information (Gervasio & Matthies1995)
Respond to incorrect information in a nonconfrontational and positive way and avoid
repeating incorrect information
In order to help reorientate a patient, incorrect
information must be corrected. However, this
must be done sensitively, to avoid a patient
feeling humiliated by this Example: say “you are
28” (rather than “no you are not 20”) and then
move the conversation onto another topic
Perceptual difficulties (e.g. visual neglect
auditory impairment) should be considered
when initially approaching a patient.
Many patients may become startled if
approached suddenly and unexpectedly.
Example: a person with a right- sided visual
neglect should be approached from the left side.
If this is not possible, a gentle verbal warning
should be given as you approach the person
from the right.
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Therapeutic Activities
Planned therapeutic activities should be
carried out in the same way each day,
ideally with the same people
Therapy may be best provided in short
sessions and carried out during the patients
everyday activities, e.g. getting washed and
dressed, mealtimes etc.
A consistent approach will help the patient to
understand the nature of the task and become
more orientated to ward procedure.
Where a patient’s cognitive difficulties are such
that complex therapy activities are poorly
tolerated, a reduction in demands placed upon
the patient may make the therapy tasks less
Rest periods in between activities should
be scheduled into the patient’s timetable.
Tasks should be broken up into small
discrete steps and presented one at a time.
Allow time for the patient to respond to
instructions and requests during activities.
Enjoyable and familiar tasks should be
included within a patients timetable
Activities should be planned so that
success rather than failure is likely. Change
the task if it is clear that it is too difficult or
tiring for the patient.
Abrupt changes in routine should be
Any changes in routine should be explained
to the patient and their families/ carers.
Patient may be using scheduled activities to
increase awareness of time and place.
Changes in routine may disorientate and
increase irritation and frustration.
Behaviour Management Strategies
Challenging behaviours must be specified
and described clearly (i.e. what is it that the
patient does).
Once specified, the behaviour must be
assessed formally using behavioural charts
(See Pathway Pack). The assessment will
provide information regarding triggers for
the challenging behaviour Antecedents and
the maintaining factors for the Behaviour
By specifying the particular behaviours to be
addressed, staff may be encouraged to take a
more positive view of other aspects of the
patient’s behaviour and to focus upon particular
behavioural disturbance (Sohlberg and Mateer
Example: the target behaviour may be
specified as “spitting or swearing” rather
than “aggression”.
Gathering data on likely triggers and maintaining
factors for the behavioural disturbance is
essential in drawing up an intervention plan
(Martin and Pear 1996, Alderman 2003).
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After a behavioural and functional analysis
has been completed, an intervention plan
and goal setting should take place and be
reviewed at regular interval.
An intervention plan and goal setting permits
ongoing evaluation of the interventions agreed
upon and facilitates communication amongst
team members.
Meaningful rewards (e.g. time spent off the
ward, additional favourite treats, extra
activities) should be identified through
observing the patient and discussions with
family and friends
These may then serve as potential rewards
for appropriate behaviour and efforts to
control inappropriate behaviour by the
De-escalation is also useful to prevent
agitation or aggression from escalating.
By identifying meaningful rewards a patient may
quickly be provided with positive reinforcement
for displaying behaviour that is more desirable
(Matthies, Kreutzer and West, 1997).
The following procedure can be used
It works best if the patient already knows the
member of staff using the technique respects
and likes him or her. (Matthies and Kreutzer et al
1. Engage the patient in conversation and
gradually shift the conversation onto a
different issue which is relevant to the
2. To gain the patients attention, it is
helpful to initially question the patient
about his concerns and agree with
elements of them.
3. Avoid direct disagreement and make no
demands of the patients.
4. Engage the patient by letting him know
that you recognise and appreciate his
point of view and his right to express it.
5. Be sure to remain calm yourself.
Model calm behaviour with your tone
of voice (low) and body language.
6. Continue to shift conversation and focus
the patients attention on an issue or
topics away from the one which
contributes to the agitation.
Direct disagreements and demands must
be avoided and the staff member is to
model calm behaviour throughout the
interaction via body language and tone of
If the patient stops the challenging
behaviour, staff should acknowledge this
immediately, praise the patient, and
resume conversation/interaction.
De-escalation is a useful method in managing
agitation or verbal aggression.
De-escalation involves the reduction of
confrontation and direct challenge to the patient
whilst providing the patient with a sense of being
listened to, understood and helped. The
procedure also helps to redirect a patient’s focus
of attention on to something more enjoyable
(Yuen and Benzing 1996).
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Verbal reprimands (“don’t…”statements
may be given when the patient persists) in
challenging behaviour.
These must be delivered in a firm,
confident manner standing directly in front
of the patient, followed by a clear and calm
description of what the patient should do
Verbal reprimands may be useful when patients
are not distractible and are not able to engage in
reasoned discussion about the consequences of
their behaviour (Matthies, Kreutzer and West,
If the patient’s behavioural disturbance
persists, staff should consult with the
clinical Neuropsychologist for further
behavioural strategies and a more specific
management plan.
Specific behavioural interventions can be very
helpful but they need to be applied consistently
and ethically.
Physical Interventions
Based on: Guidance for restrictive physical interventions (DOH 2002)
Physical Interventions
Non-restrictive physical interventions
should always be used in the first
Environmental management strategies
are examples of non-restrictive physical
1:1 support may be necessary to distract
the patient and engage him/her in
therapeutic activities See Pathway Pack
Patients emerging from coma and showing
agitation benefit from environmental changes
aimed to reduce arousal levels.
Supervision allows both the anticipation of
patient’s needs and wishes, whilst providing ready
opportunities for the use of de-escalation and
distraction methods.
When a patient is requiring 1:1 ensure
security staff have been informed and are
aware of the patient and their capacity
If the patient attempts to abscond security staff
are familiar with the patient and the relevant
assessments such as mental capacity.
Behavioural management strategies
involving social and other forms of
reinforcement are also examples of nonrestrictive physical interventions They
should be used in conjunction with other
methods, and with the guidance of the
Behavioural interventions can be very effective if
used appropriately and consistently. Inappropriate
use can inadvertently serve to exacerbate
problem behaviour, or may become a form of
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Unplanned or emergency interventions may be
necessary when a patient behaves in an
aggressive way that cannot be anticipated and
prevented. If appropriate assessments have
been completed unplanned interventions will
be avoided or minimised.
Staff should consider whether the risks of
not employing a restrictive physical
intervention are outweighed by the risks of
using force.
Under the common law anyone may
In such situations staff have a duty of care to
apprehend and restrain a person who appears the patient, other patients, visitors,
to be mentally disordered and who presents an themselves and other members of staff.
imminent danger to themselves or others.
The minimum force necessary to prevent
injury and maintain safety should be used
and it should be proportionate to the
If, in spite of de-escalation techniques and
other methods described above, a patient who
also suffers from temporary incapacity has
absconded from the ward and cannot be
persuaded to return, reasonable force (e.g.
blocking an exit or holding at arms length) can
be used to return the patient to the ward.
If a patient nevertheless leaves the hospital
whilst suffering from incapacity and cannot
immediately be persuaded to return, the
patient needs to be accompanied and if
necessary followed by 2 members of staff with
training in behavioural management
techniques and physical intervention. The two
members of staff should be a member of
nursing staff that is caring for the patient,
ideally someone that has built a rapport with
the patient, and at least one member of
security staff. If the patient is female it is
important that a female member of staff is
In accompanying the patient the staff should
endeavour to redirect the patient’s attention
and focus to persuade him to return to the
The degree of medical or physical
intervention (restraint) should be sufficient to
bring that emergency situation to an end, but
no greater.
In such situations staff have a duty of care to
the patient themselves and other members
of staff.
The risk to the patient of accidental injury
whilst absconding is generally accepted to
be greater than the risk of using physical
There is an ongoing duty of care to the
patient. This duty of care extends to outside
hospital grounds, if the patient lacks mental
In such an emergency situation where a
person’s health and safety are at risk, and
that of other people, a person can be
restrained and brought back to the ward with
the help of the police.
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Whilst accompanying the patient, the staff
should be provided with a mobile phone.
If in spite of the above situation the patient
cannot be persuaded to return to the hospital
and a situation arises where the patient’s
health and the health of staff as well as
members of the public are at risk (such as if
the patient insists on standing in the middle of
the road and refuses to move and staff are of
the opinion that physical restraint is likely to
increase the aggression shown by the patient)
– then the police should be called. However it
may be necessary to use physical restraint
whilst waiting for police assistance, if there is a
serious risk to life of the patient and/or others.
NB Where the patient is clearly expressing
a wish to leave hospital ie not to be an inpatient any longer, consideration must be
given to the patient’s human rights, under
Article 5.
Restrictive physical interventions involving the The use of restraint by staff not trained in
actual physical restraint of a patient can only those methods presents a risk to both the
be carried out by staff who have received the
staff and the patient.
relevant training.
The use of tranquillisers or sedatives as a
means of gaining control over a patient should
not be used except in an emergency when
there is a significant risk of personal injury.
Even in an emergency, if force is required to
administer a tranquilliser or a sedative, the
force must be reasonable.
The use of restrictive physical interventions
should be minimised by the adoption of fully
documented risk assessment and preventative
strategies whenever it is foreseeable that the
use of reasonable force may be required.
Before using such restraint (even in an
emergency) the person concerned should
be confident that the possible adverse
outcomes associated with the intervention
(injury or distress) will be less severe than
the adverse consequences which might
have occurred without the use of such a
physical intervention (Guidance for
restrictive physical interventions, DoH 2002).
In an emergency, restrictive physical
interventions are permissible if they are
necessary to prevent injury or serious
damage to property (Guidance for restrictive
physical interventions. DoH, July 02).
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Restrictive physical interventions (employing
reasonable force), where other strategies have
been tried and found to be unsuccessful,
should only be used where it is necessary, in
the patient’s “best interests” and should be
used as infrequently as possible, with
everything done to prevent injury and maintain
a person’s sense of dignity. If a significant
degree of force is likely to be used on a regular
basis, and/or the patient is likely to suffer
undue distress, legal advice should be sought,
to ensure that such intervention remains
They need to be seen as part of a broader
strategy, which addresses the needs of
adults where behaviour poses a serious
challenge to services (Guidance for
restrictive physical interventions, Dept. of
Health, July 02).
Inappropriate use of restrictive physical
interventions may give rise to criminal
charges, action under civil law or
prosecution under health and safety
legislation (Guidance for restrictive physical
interventions. Dept. of Health, July 02).
Due consideration should be given to whether
use of restraint on a repeated basis may
amount to a violation of the patient’s human
rights, in particular the right to liberty, under
Article 5. Consider application for Deprivation
of Liberty Safeguard (Appendix D)
Family and Visitors
The patient’s family should be informed of
any intervention, subject to the demands of
patient confidentiality.
Families have a key role in helping a person to
recover from their illness or injury. Consultation
with the family will help to ensure that
individual family members can, if appropriate,
work in partnership with staff.
Staff should offer visitors advice on how to
interact with the patient and what to expect.
Therapy goals and behavioural
management strategies also need to be
shared with family and visitors, as
A consistent approach in behavioural
management requires consistency with all
people with whom the patient interacts.
Family members and visitors are expected to
participate in behavioural management
interventions after having been given adequate
explanations, as far as is appropriate.
The family should receive written
information on the effects of the illness or
injury on cognition and behaviour, subject
to patient confidentiality.
The number of visitors at any one time
should ideally not exceed two people.
The family has had to take in a lot of
information. Written information is helpful in
that a person can refer back to it as needed.
The length of visiting time should be limited
according to the patient’s individual clinical
If a person has short-term memory and
attention deficits, a busy environment can be
detrimental and lead to agitation.
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If a patient is tired or agitated, no visitors
If a person is tired and/or agitated additional
should be permitted (except if staff consider stimulation can lead to an escalation of this
this helpful, having considered the patient’s behaviour.
Staffing issues
Staffing levels should be sufficient to allow
time for taking a therapeutic approach in all
interactions with the patient and to ensure
patient safety. This is especially important
when the ward has a number of patients
whose behaviour is deemed as challenging.
Consistent implementation of the above
environmental and behavioural management
guidance depends upon staff having the time
to communicate and consult with other
professionals and consider their own style of
interaction with the patient.
Nursing staff should be allocated to keep Adequate staffing levels will allow staff
staff changes to a minimum.
time to achieve this (Herbel 1990)
Example: when nursing staff levels are
adequate, a nurse will have time to act
management guidance rather than acting
to get a “quick fix”.
Staff must be trained in dealing with Behavioural disturbance will be dealt with
challenging behaviour.
more effectively if staff are confident in their
abilities to handle difficult situations.
Orientation techniques should routinely be
made available to all staff on the ward.
Training is required to ensure that the
patient receives the appropriate level of
care and that the training is updated at an
agreed time scale.
Additional support from line managers should Staff confidence is likely to increase with
be made available when required e.g. when
explicit recognition from management of
staff are concerned about a large number of
the particular difficulties that they are
patients presenting with challenging
facing. Offers of extra resources at
difficult times may indicate further
support to staff.
When a ward is presented with particularly
Standards for patients who require 1: 1
challenging patients 1: 1 Specialing may be
nursing within neuroscience (Specialist
required see Risk rating matrix and levels of
Commissioning Guidelines for the
observation in Pathway Pack for Acute Brain rehabilitation of patients with brain injury
Injury Patient with Challenging Behaviour. A
- definition 7).
senior nurse should decide what level of
special is required e.g. RGN/RMN/HCA.
Time should be made available for
Good communication with team members
communication between team members to
will serve to increase consistency in
ensure that; everybody is up to date with any approaches with patients and provide
patient developments, that consistency is
support for staff members.
maintained and for mutual support. The MDT
meeting should be seen as an integral part of
the work of all staff members.
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Clinical Neuropsychology should become
involved when a patient’s behaviour is
starting to obstruct clinical care and
therapeutic work or is putting the patient or
others at risk.
The Clinical Neuropsychologist can advise
on management based on the ABS and ABC
forms (Appendix C & D) which need to be
completed by the nurse caring for the patient
on a shift basis.
Staff should be offered access to a debrief
session or counselling.
The Clinical Neuropsychologist will
undertake an assessment of the multitude of
factors that contribute to the problem
behaviour and help to identify key variables.
Ensure mental welfare of staff.
Pharmacological Management
Prescribed medication must be reviewed on
daily basis taking into account the following:
 The effectiveness
 Possible adverse effects
 Continuing need
The clinical situation in the post-acute stage
changes rapidly at varying rates.
Patients are more sensitive to the adverse
cognitive effects of sedating medication.
Clonidine should be considered as first line
medication for patients who are weaning
from the ventilator.
Consider a hypnotic if the patient has a
disordered sleep /wake pattern. Zolpidem
10mgs at night is usually chosen because of
its short half life, rapid action and reputed
benefit in brain injury.
The patient can have increased agitation if
they have a disordered sleep/wake pattern
Avoid major tranquillisers e.g. Haloperidol or
There is no clear rationale for their use in the
management of agitation or aggression in the
post acute period following acquired brain
injury. They can cause an increase in
confusion, which may exacerbate agitation.
Other possible harmful effects include:
 adversely affect neuronal recovery
 reduction of the seizure threshold
 increased sensitivity to extra pyramidal
 increased risk of neuroleptic malignant
If it is necessary to use Haloperidol in an
emergency situation where the patient poses
a risk to himself or others. It should not be
used for longer than 48 hours.
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If an immediate response is necessary a
Benzodiazepine should be used.
Lorazepam is the drug of choice at a dose
2mg - 4mg dependent upon response orally,
via PEG/NG/OG or intra muscularly.
Lorazepam is more rapidly effective than
Diazepam and has a shorter duration of
N.B. However be aware of potential
respiratory depression and occasional
paradoxical increase in agitation.
In the presence of severe agitation, which
may be potentially, harmful, where it is not
possible to give intra muscular or oral
medication, intranasal Midazolam (5-10mg of
the parenteral preparation) is an alternative.
Rapid action with no risk of needle stick
injury (Cheng 1993, Knoester et al 2002).
Anticonvulsant medication can be beneficial
in reducing agitation and aggression in some
situations. Carbamazepine is the most
commonly prescribed; alternatively Sodium
Valporate can also be used.
Propanolol can also be used either alone or
in combination with an anti-convulsant.
Both these anti convulsants are effective
mood stabilizers and it is likely that this is the
mode of action following acquired brain injury
(Fleminger et al 2002 and Foster et al 1989).
If Benzodiazepines are ineffective or are
contra-indicated, Valproate semisodium is an
May be useful in patients who are alert labile,
impulsive and disinhibited, who tolerate other
treatments (Chatham et al 2000).
Reduces the physiological reaction to anxiety
which can perpetuate agitation.
6.0 Treatment process
6.1 Patients with capacity to consent to treatment
Patients with capacity to consent to a specific form of treatment can validly give or
withhold their consent to have that treatment. Such consent or refusal must be respected
even if it appears to be an unwise or irrational decision to third parties.
6.2 Where a patient lacks capacity to consent to treatment
No one can give or refuse consent to treatment on behalf of an incapacitated adult.
Treatment can be authorised under the common law if, in the view of the responsible
clinician, the treatment is in the patient's "best interests" (refer to MCA Policy TP199).
Check whether a valid and applicable advance decision exists. If in doubt, seek
further advice
Consider whether patient’s human rights, particularly the right to liberty, are being
adequately respected – see Deprivation of Liberty Code of Practice & pathway
(Appendix D)
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6.3 Where there is doubt about a patient’s capacity
In the first instance, if there is any doubt about the capacity of a patient, it is
recommended that a second opinion be sought. If the issue remains controversial, legal
advice should be sought. It may be appropriate for the Trust to apply to the High Court
for a formal declaration on the issue.
6.4 Patients with mental disorders
Where a patient has a mental disorder, regardless of whether they have capacity to give
consent, treatment may be authorised under certain provisions of the Mental Health Act
1983 (“The Act”). This will be given under the direction of the responsible medical officer
who is usually a Consultant Psychiatrist.
Treatment for the mental disorder only is authorised under the Act. If a patient with a
mental disorder also suffers from a physical disorder, provided they have capacity to give
or refuse consent, their wishes must be respected in terms of any treatment decisions
made. If however that patient lacks capacity to give or refuse consent in relation to the
physical disorder, treatment may be given under the common law provided it is in their
"best interests".
6.5 Temporary Incapacity
Mental incapacity may be due to temporary factors such as delirium, shock, pain or drugs.
Where a patient has only temporarily lost their capacity to give or withhold consent to
treatment, “best interests” must be considered carefully, particularly with regards to
invasive treatment. If there is evidence that the patient, if they had capacity, would
oppose the form of treatment proposed, this must be an important factor in establishing
whether it is in their “best interests” to proceed.
To the extent that the treatment is not strictly necessary it may be appropriate to await the
return of the patient's capacity, provided there is no detriment to the patient’s health, as a
The state of the patient's capacity should be kept under regular review and if the
treatment becomes necessary over time, perhaps due to a change in the patient's state of
health, treatment should go ahead.
6.6 Best Interests
Please see the following extract from Section 4 of the Mental Capacity Act 2005, which
sets out how “best interests” are to be assessed.
In determining for the purposes of this Act what is in a person’s best interests, the
person making the determination must not make it merely on the basis of
the person’s age or appearance, or
a condition of his, or an aspect of his behaviour, which might lead others
to make unjustified assumptions about what might be in his best interests.
The person making the determination must consider all the relevant circumstances
and, in particular, take the following steps.
He must consider
Whether it is likely that the person will at some time have capacity in
relation to the matter in question, and
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If it appears likely that he will, when that is likely to be.
He must, so far as reasonably practicable, permit and encourage the person to
participate, or to improve his ability to participate, as fully as possible in any act
done for him and any decision affecting him.
Where the determination relates to his life-sustaining treatment he must not, in
considering whether the treatment is in the best interests of the person concerned,
be motivated by a desire to bring about his death.
He must consider, so far as is reasonably ascertainable –
the person’s past and present wishes and feelings (and, in particular,
any relevant written statement made by him when he had capacity),
the beliefs and values that would be likely to influence his decision if he
had capacity, and the other factors that he would be likely to consider if
he were able to do so.
He must take into account, if it is practicable and appropriate to consult them, the
views of –
anyone named by the person as someone to be consulted on the matter
in question or on matters of that kind,
anyone engaged in caring for the person or interested in his welfare,
any donee of a lasting power of attorney granted by the person, and
any deputy appointed for the person by the Court,
as to what would be in the person’s best interests and, in particular, as to the
matters mentioned in subsection (6).
The duties imposed by subsections (1) to (7) also apply in relation to the exercise
of any powers which –
are exercisable under a lasting power of attorney, or
are exercisable by a person under this Act, where he reasonably
believes that another person lacks capacity.
In the case of an act done, or a decision made, by a person other than the Court,
there is sufficient compliance with this section if (having complied with the
requirements of subsections (1) to (7)) he reasonably believes that what he does
or decides is in the best interests of the person concerned.
“Life-sustaining treatment” means treatment which in the view of a person
providing health care for the person concerned is necessary to sustain life.
“Relevant circumstances” are those –
(a) of which the person making the determination is aware, and
(b) which it would be reasonable to regard as relevant.
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Monitoring and Review
The progress of patients through the pathway, and the effectiveness of the intervention
provided, is reviewed on an ongoing basis. Monitoring, evaluation and review takes place
at two levels.
Level 1 - Effectiveness of behavioural interventions
This is evaluated on an ongoing basis with the use of the Agitated Behaviour Scale
The scale has been specifically designed for the assessment of agitation following
traumatic brain injury. It has been used extensively in the evaluation of interventions and
their effectiveness, both pharmacological and behavioural.
It is based on behavioural observations of the patient, easy to use, and can be
administered by any member of staff including health care assistants.
Level 2 - Identification of Adverse Incidents
Adverse incidents are defined as deviations from the policy, which have led or could lead
to adverse outcomes for the patient. These will be brought to the attention of the
Neuroscience Clinical Governance Group. The following have been defined as being
adverse outcomes:
 inappropriate and excessive use of physical restraint such as manual handling when
there is no immediate risk to the patient or others
 inappropriate and excessive use of medication such as the use of sedation as a first
choice of treatment and applied in isolation
 Non-adherence to environmental and behavioural intervention strategies, resulting in an
escalation of challenging behaviour
 delayed discharge occurring as a result of non adherence to the guidelines
 delayed response by health care professionals responsible for assessment and
treatment, resulting in escalation of behaviour leading to inappropriate and excessive use
of sedation and physical restraint.
 persistent failure to address staffing problems within the wider system, resulting in
problems with the implementation of the policy
8.0 Equality Impact Assessment Screening
Equality Impact Assessment is attached in Appendix E
9.0 Links to other Trust Policies
Mental Capacity Act Policy TCP199
Consent to Examination or Treatment TCP 074
Physical Intervention Policy CO28
Health and Safety Policy and General Safety Policy
Management of Violence and Aggression Against Staff
Policy on Support Arrangements for Staff Involved in Potentially Traumatic/Stressful Work
Safeguarding Vulnerable Adults Policy
Caring for Adult Patients with a Leaning Disability in the Acute Hospital
Privacy and Dignity Policy TCP172
Manual Handling of Patients and Other Loads Policy
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10.0 Associated Documentation
Pathway Pack for Acute Brain Injury Patient with Challenging Behaviour
11.0 References
Alderman N. (2003). Contemporary approaches to the management of irritability and aggression
following traumatic brain injury. Neuropsychological Rehabilitation; 13: 211 – 240.
British Psychological Society (1998). Assessment and management of patients presenting a risk to
others - Core mini guides
Bogner JA, Corrigan JD, Stange M, Rabold D (1999). Reliability of the Agitated Behaviour Scale. J Head
Trauma Rehabilitation; 14 (1) 91 - 96.
Chatham Showalter PE, Kimmel DN (2000). Agitated symptom response to divalproex following acute
brain injury. J Neuropsychiatry Clin Neurosci 2000; 12 (3): 395 -7
Cheng ACK. (1993) Intranasal Midazolam for rapidly sedating an adult patient. Anaesth Analg; 76: 904
Consent Policy Salford Royal Hospitals NHS Trust
Corrigan JD (1989). Development of a scale for assessment of agitation following traumatic brain injury.
Journal of Clinical and Experimental Neuropsychology; 11 261 - 277
Corrigan JD, Mysiw WJ, Gribble M, Chock S (1992). Agitation, cognition and attention during posttraumatic amnesia. Brain Injury; 6 155 - 160
Fleminger S, Greenwood RJ, Oliver DL (2002). Pharmacological management for agitation and
aggression in people with acquired brain injury. In: The Cochrane Library, Issue 2, 2002
Foster HG, Hillibrand M, Chi CC (1989) Efficacy of Carbamazepine in assaultive patients with frontal
lobe dysfunction. Prog Neuropshychopharmacol Biol Psychiatry; 13 (6): 865 - 74
Gervasio AH and Matthies BK (1995). Behavioural management of agitation in the traumatically brain
injured person. Neurorehabilitation; 5 309 - 316
Good practice in consent implementation guide: consent to examination or treatment. Department of
Guidance for Restrictive Physical Interventions (2002). Department of Health
Herbel K, Schermerhorn L, Howard J (1990) Management of agitated head injury patients: A survey of
current techniques. Rehabilitation Nursing: 15 (2) 66 - 69.
Kaschel R, Zaiser-Kaschel H, Shiel A, Mayer K (1995) Reality orientation training in an amnesic: a
controlled single case study. Brain Injury, 9(6), 619 -633
Knoester PD, Jonker DM, Van der Hoeven RT et al (2002). Pharmacokinetics of midazolam
administered as a concentrated intranasal spray. A study in healthy volunteers. Br. J. Clin Pharmacol;
53: 501 -507
La Vigna GW and Donnelan AM (1986) Alternatives to punishment: Solving Behaviour problems with
nonaversive strategies. New York, NY.Irvington Publishers.
Guidelines for the management of behavioural disturbance and cognitive impairments following acute brain injury. HPNC
Page 28 of 40
Making decisions. Helping people who have difficulty deciding themselves. Lord Chancellor’s
Department May 2003
Martin and Pear (1998) Behaviour Modification: What it is and How to do it. Pearson US
Matthies B K, .Kreutzer J S and West D D (1997) Behaviour Management Handbook. A practical
approach to patients with neurological disorders. Therapy Skill Builders; The Psychological Corporation,
Meagher D (2001) Delirium: The role of psychiatry. Advances in Psychiatric Treatment; 7 433 - 443.
Sandel E and Mysiw J (1996). The agitated brain injury patient. Part 1: Definitions, Differential
Diagnosis and Assessment. Arch Phys Med Rehabilitation ; 77 617 - 623.
Sohlberg McKay M. and Mateer A C (2001) Cognitive Rehabilitation. An integrative neuropsychological
approach. The Guilford Press.
Specialist commissioning guidelines for the rehabilitation of patients with brain injury. Definition 7.
Department of Health.
Yuen HK and Benzing P (1996). Guiding of behaviour through redirection. Brain Injury Rehabilitation; 10
(3) 229 - 238.
UKCPA: Detection, prevention and treatment of delirium in critically ill patients. 200?
Guidelines for the management of behavioural disturbance and cognitive impairments following acute brain injury. HPNC
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Appendix A
Sedation Assessment
Richmond Agitation and Sedation Scale
Overtly combative, violent,
immediate danger to staff
Very Agitated
Pulls or removes tube(s) or
catheter(s); aggressive
Frequent non-purposeful
movement, fights ventilator
Anxious, but movements not
aggressive vigourous
Alert and calm
Light sedation
Briefly awakens with eye contact to
voice (≤ 10 seconds)
Moderate sedation
Movement or eye opening to voice
(but no eye contact)
Deep sedation
No response to voice, but
movement or eye opening to
physical stimulation
Not fully awake but has sustained
awakening (eye opening/eye
contact) to voice (≥ 10 seconds)
No response to voice or physical
If RASS is -4 or -5 then stop and reassess patient at later time
If RASS is above -4 (-3 through to +4) then consider withdrawal syndrome and follow
Guidelines for the management of behavioural disturbance and cognitive
impairments following acute brain injury.
Guidelines for the management of behavioural disturbance and cognitive impairments following acute brain injury. HPNC
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Appendix B
Withdrawal Syndrome
It is very common for the patient recovering from brain trauma and/or brain surgery to become agitated and can be
aggressive. The UKCPA guidelines for the Detection, Prevention and Treatment of Delirium in Critically Ill Patients
(2006) highlight some of the affects of the drug therapy that is commonly prescribed in ITU which may contribute to
the development of delirium. A summary of the common ones used in the neurosciences ITU are shown below, for
the complete list and details see the full UKCPA guidelines. Prompt cessation of medication that is no
longer required can help minimise the occurrence of delirium.
Drugs that have been shown to be deleriogenic:
It is important to try and establish a day night cycle but some of the commonly used drugs in ITU can affect sleep.
A summary of the common ones used in the neurosciences ITU are shown below, for the complete list and details
of the sleep disorder see the full UKCPA guidelines.
Norepinephrine/ Epinephrine
Phenytoin •
A change in rapid eye movement (REM) sleep is one area that can be disrupted by drug therapy. Patients who
have had significant suppression of REM sleep by pharmacological agents are at risk of REM rebound upon
withdrawal of the drug. REM rebound is characterised by tachycardia,
hypertension, apnoeas, ventilatory depression and nightmares. Critically ill patients weaning from mechanical
ventilation may be particularly prone to the adverse effects of REM rebound.
When patients are weaning from mechanical ventilation it is also important to consider the acute withdrawal effects
of commonly used drugs such as benzodiazepines and opioids. Avoid abrupt discontinuation of drugs known to
suppress REM sleep where possible.
Symptoms of benzodiazepine withdrawal
Psychiatric symptoms
Acute anxiety states
Perceptual disorders
Somatic symptoms
Muscle pains
Blurred vision
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Consider the following to try and minimise withdrawal effects:
Continue or re-commence any antipsychotics or long term antidepressants that the patient may have been
taking previously particularly if the patient has a long psychiatric history.
Other factors exacerbating withdrawal syndromes (e.g. alcohol,
nicotine) and treat if appropriate.
Withdrawal can be achieved by reducing the administration of benzodiazepine over a period of many days to
weeks. This can be facilitated by changing to a longer acting agent such as lorazepam, whichhas the additional
advantage of allowing enteral administration or sublingual administration.
Adaptation of protocols to individual circumstances is required due to wide variation in response
between patients.
Example withdrawal regime using lorazepam which may be a useful guide
Calculate the daily infused dose of midazolam and divide by 12 to give an approximate total daily dose of
 Prescribe one quarter of the daily dose of lorazepam at a frequency of six hourly, rounding down to a
convenient dosage unit
 After the second oral dose of lorazepam, reduce the midazolam infusion by 50%
 After the third oral dose of lorazepam, reduce the midazolam infusion by a further 50%
After the fourth oral dose of lorazepam, discontinue the midazolam infusion
Reduce daily lorazepam intake by 500micrograms-1mg a day until weaned completely.
Alternatively prescribe small doses of lorazepam (e.g. 500micrograms), which can be given as often as needed
during the first few days after the benzodiazepine infusion has been stopped. This can be used to calculate a
regular baseline dose which can then be tailed off over several days to weeks.
Benzodiazepine withdrawal in head injured patients
Head injured can be very difficult to manage for the following reasons:  Patients can be heavily sedated +/- paralysed for a long period of time (sometimes weeks) to maintain
stable ICPs and CPPs.
 Large doses of hypnotics are required to achieve the desired level of sedation. Tolerance can quickly
occurs, resulting in rapid dose escalation followed by a pronounced withdrawal syndrome.
 Once the neurological parameters are stable, there is often pressure to completely stop sedation to
facilitate neurological assessment.
 It can be difficult to assess which symptoms are due to drug withdrawal and which are due to the
sequelae of the patients’ original injury.
Use the minimum amount of sedative agents as possible, and wean slowly
Opioid withdrawal
Opioid withdrawal reactions can occur as a result of prolonged opioid infusions whilst critically ill, or because of
a prior history of opioid use or abuse.
Signs and Symptoms
Feeling hot and cold
Abdominal cramps
Example withdrawal regime (opioid infusion tailing): -
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Calculate the daily infused quantity of opioid (day 0).
Reduce the infusion rate by 20% on day 1.
Reduce the infusion rate by 10% of the original dose on a daily basis until weaned completely.
Pragmatic rounding off of doses will be required to allow appropriate prescribing and administration.
Alcohol withdrawal
Alcohol dependence is relatively common and patients presenting to critical care may experience alcohol
withdrawal syndromes. Symptoms of alcohol withdrawal delirium can occur rapidly after cessation of alcohol
intake, but typically take two to three days to develop and last for a further two to three days or occasionally
Symptoms of alcohol withdrawal include autonomic hyperactivity (e.g. sweating, pulse rate > 100/min),
increased hand tremor, insomnia, nausea, vomiting, transient visual, tactile or auditory hallucinations, anxiety,
psychomotor agitation, seizures. The alcohol withdrawal delirium can present in a similar way to the individual
recovering from a neurological insult. Alcohol dependence can be particularly common in patients who sustain
head trauma. The common features of alcohol withdrawal delirium include a reduced clarity of awareness of
environment, with reduced ability to focus, sustain or shift attention and cognitive deficits. Treatment should be
primarily with sedative hypnotics but careful assessment is necessary to distinguish between alcohol
withdrawal delirium and the effects of the neurological insult or whether there is a combination of factors. For
more information on drugs and dosage see the full UKPA guidelines.
Nicotine withdrawal
Signs and Symptoms
Depressed mood
Slowed cognition
Sleep disruption
Difficulty concentrating
Increased appetite
Increased sensitivity to pain
Nicotine replacement
The evidence base for the use of nicotine replacement therapy on the critical care unit is extremely limited.
Given the clear somatic symptoms experienced by patients with a strong history of smoking in the
context of a poor evidence base, it is prudent to consider nicotine replacement therapy after all other potential
factors have been either identified and treated or discounted, and where the thrombosis risk is
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Appendix C
Sections 5(2) and 5(4) of the Mental Health Act 1983
Under section 5(1) of the Act, if the registered medical practitioner (RMP) in charge of a patient’s care
considers the patient may be liable for admission for assessment or treatment (ie under Section 2 or 3 of
the Act), an application for admission, under one of these sections, should be made in the usual way.
Section 5(2)
This provides interim measures to keep the patient in hospital against their will for sufficient time to enable
the paperwork for the application for admission to hospital under the Mental Health Act 1983 to be
A patient can be held on an emergency holding order (section 5.2) if the medical practitioner responsible
for the patient (the RMP) is of the view that an application may need to be made to detain the patient under
Section 2 or Section 3 of the Mental Health Act.
The medical practitioner must state his reasons in his report under section 5.2 for believing that an
application under section 2 or 3 ought to be made.
The RMP should provide this report to the hospital managers. From the time of furnishing this report, the
patient may be detained for up to 72 hours, pending completion of the paperwork to effect detention under
either Section 2 or Section 3 of the Act.
As soon as the power is invoked, arrangements should be made for the patient to be assessed by a
psychiatrist. The practice of using consecutive Section 5(2) applications, where the initial 72 hour
period has not allowed enough time to complete the assessments, is likely to be unlawful and is to
be discouraged.
The report to be furnished under Section 5.2 can be completed by the medical practitioner responsible for
the patient but a psychiatrist should see the patient as soon as possible thereafter, to determine whether
he is liable to be detained further.
The purpose of section 5.2 is to allow time to make an application under section 2 or 3 of the Mental Health
Act, where it is considered likely that the patient will discharge himself prior to an application being made.
The section cannot just be used to detain a patient who is absconding from the ward in hospital or who
repeatedly absconds.
It is a misuse of section 5.2 if it is used as a means of restraining the patient from leaving the hospital in
circumstances where the medical practitioner does not consider that an application ought to be made
under section 2 or 3.
The holding power will automatically lapse when either the patient is detained under the Mental Health Act,
or, following assessment, it is determined that he does not require to be detained under the Mental Health
Section 5(3)
This section allows the RMP to nominate one (but not more than one) RMP on the staff of the hospital to
act for him, as his “deputy” in relation to the powers under Section 5(2) above, in his absence.
Section 5(4)
This section allows nurses of a prescribed class to invoke a “holding power” for up to six hours in respect of inpatients who are receiving treatment for their mental disorder on an “informal” basis.
This can only be invoked where it appears to the nurse that the patient is
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1) suffering from a mental disorder “to such a degree that it is necessary for his health or safety or for the
protection of others for him to be immediately restrained from leaving hospital”; and
2) it is not possible to secure the immediate attendance of a practitioner for the purpose of providing a report
under Section 5(2)
The nurse must record the fact that the two conditions above are met, and at that point the “holding power”
becomes active and the six hours time limit runs from the point in time when this information is recorded. The
holding power will lapse upon arrival of the medical practitioner who is to consider whether it is appropriate to
provide a report under Section 5(2).
In other words, the nurse’s holding power only lasts until the doctor arrives to take over. If the doctor has not
arrived by the end of the six hour period, the holding power will automatically lapse.
A nurse invoking this provision is entitled to “use the minimum force necessary” to prevent the patient from leaving
the hospital, (Code of Practice para 9.6)
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Appendix D
Identify Need for Authorisation of Deprivation of Liberty Safeguard
in the Agitated, Confused Acute Brain Injury Patient:
Agitated / confused brain
injury patient identified
Is he/she attempting
to leave the hospital and/or
refusing treatment/care?
Continue to monitor
Note at this stage if a person lacks
capacity and it is believed that the
person is at risk of serious harm if
he leaves hospital and/or refuses
care/treatment then according to
Section 6 of the mental capacity act
you can use reasonable and
proportionate restraint if it is in the
patient’s best interest. Section 6
states that someone is using
restraint if they: use force or
threaten to use force to make
someone do something that they are
resisting, or restrict a person’s
freedom of movement whether they
are resisting or not.
For more information see Mental
Capacity Act Sections 4, 5 &6
Refer to Trust Mental Capacity Act
Policy TP199
Explain reasons for remaining in hospital and for
treatment (ensure information is presented in a
way that is easy to understand using appropriate
aids if necessary). Implement environmental
strategies; communication strategies and/or
behavioural strategies. Discuss with family/carers.
Commence managing agitation following acute
brain injury pathway.
Refer to managing agitation
guidelines and flowchart
Despite the above
measures is the patient still
attempting to leave, refusing
treatment and care and requiring
consistent one to one care that
could be considered a deprivation
of liberty?
Continue to monitor
Assessing capacity:
Does the patient have an impairment of
the mind or brain, or is there some sort of
disturbance affecting the way their mind or
brain works? (It doesn’t matter whether the
impairment or disturbance is temporary or
permanenet) If so, does the impairment or
disturbance mean that the person is
unable to make the decision in question at
the time it needs to be made?
A person is unable to make a decision if
they cannot:
A. understand the relevant information
B. retain that information
C. use/weigh that information in reaching
a decision
D. communicate the decision
For everybody in a hospital who lacks
capacity, the following questions should be
Following assessment
is it believed that the patient does
not have the capacity to make
decisions regarding treatment/
Is it believed that
this is not a mental health
Refer to psychiatry for mental health
Review management plan with
MDT, patient and patients family/
carer. Make decision based on
patient’s/ family/carers views and in
best interest of patient. Document
the decision process in the medical
Is it in the best
interests of the patient to
detain in hospital to avoid
serious harm?
Does the care or treatment being provided
take away the person’s freedom to do
what they want to such an extent that it
amounts to a deprivation of their liberty?
Do you believe that the care or treatment
being provided is in the person’s best
Discuss with MDT and family. If the patient
can be detained under the MCA then
document decision process in medical notes.
If it is believed that the restrictions in place to
detain the patient amount to a deprivation of
liberty then consider applying for an urgent
authorisation of deprivation of liberty
safeguard and a standard authorisation of
deprivation of liberty safeguard. Follow
Authorisation of Deprivation of Liberty
flowchart and complete Deprivation of Liberty
safeguard checklist.
Documentation for deprivation of
liberty can be found on the DoH
website or on the HWP network in
the data folder.
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Application for an Authorisation of Deprivation of Liberty Safeguard
Before applying for an authorisation you should always think about providing care or treatment in ways which
avoid depriving someone of their liberty.
It is also important to understand that an MCA DOLS authorisation does not, in itself, authorise care or treatment.
Any care or treatment still needs to be carried out under the wider “best interests” provision of MCA
The MCA DOLS should be used for people who lack the capacity to make their own decisions and where personal
freedoms needs to be restricted in the patient’s best interests, to the extent that it amounts to a deprivation of liberty.
Agitated confused brain injury
patient identified who requires an
authorisation of DOLS
Assessments should include best
interests, capacity and mental health
Refer to Trust Mental Capacity Act Policy
TCP199 available on the intranet.
Decisions must be made in accordance
with section 4, Best Interests, Section 5
Acts in connection with care or treatment
and Section 6, Limitations of the MCA.
Following all
the relevant assessments has the
MDT in collaboration with the family/carer/
IMCA agreed that an authorisation of
DoLS is required?
Is the need to deprive the
person of their liberty urgent?
The six assessments required for a
standard authorisation include:
Age assessment
No refusals assessment
Mental Capacity Assessment
Eligibility assessment
Best interests assessment
More details can be found in the
Deprivation of Liberty Safeguards
Code of Practice
A managing authority (The Trust) can give an urgent
authorisation for deprivation of liberty if the need to
deprive the person of their liberty is so urgent that there
is not time for the standard authorisation to be
processed or the standard authorisation is being
processed but the need to deprive the person of their
liberty becomes so urgent that it needs to commence
before the request is dealt with. All steps taken to
involve family/carers/IMCA should be documented in
the medical notes. The ultimate decision will need to be
based on a judgement of what is in the patient’s best
interests and all relevant information that indicates how
the decision was made should be documented in the
medical notes. An urgent authorisation should only be
applied for if there is a reasonable expectation that the
six qualifying requirements for a standard authorisation
are likely to be met. The decision for an urgent DoLS
should be made at a senior level within the Trust.
Complete the urgent authorisation form 1 and the
standard authorisation form 4. These forms should be
sent to the relevant PCT (See details below). A copy of
the documentation should be filed in the patient’s
medical records and a copy sent to The Trust Medicolegal Services Manager.
Urgent authorisation lasts for a maximum of 7 days.
During this time the assessments for a standard
authorisation should be carried out by the supervisory
body (PCT)
Review case with MDT and
family and plan management
without DoLS
Complete the standard
authorisation form 4
This form should be sent to
the relevant PCT (See details
below). A copy of the
documentation should be filed
in the patient’s medical
records and a copy sent to
The Trust Medico-legal
Services Manager.
The supervisory body (PCT)
will commission the
assessments which are used
to authorise a deprivation of
Form 1 Urgent Authorisation & Form 4
Starndard Authorisation are available on
the DoH website
The Trust Intranet: go to working here,
then learning zone, then clinical training,
then mental capacity act.
or HWP network in the data folder
Urgent authorisations can never be
made without a simultaneous
application for a standard
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Affix patient label or enter details:
Trust ID No.:
Deprivation of Liberty Safeguard Checklist
For more information please refer to the Trust Mental Capacity
Act Policy available on the Trust intranet
First name:
Has the Matron (or Clinical Site Manager in the absence of the Matron) been
informed about the possible need to apply for a DoLS under the MCA or to
section the patient under the MHA?
Does the patient have a previous mental health history or is it believed that this is
a mental health issue now?
If yes arrange assessment by mental health team regarding the appropriateness
of detaining the patient under the mental health act.
Has the patient been assessed as lacking capacity and details documented in
medical notes?
Note: This must be assessed specifically in relation to the care or treatment that
is deemed to be in their best interest but is causing disagreement or resistance by
the patient to an extent that we feel the need to deprive this person of their liberty.
In the opinion of the MDT is it believed that the person’s liberty is being deprived
beyond that which is supported by the MCA?
Has the decision to apply for an authorisation of DoLS been discussed with the
MDT and with the family or significant others?
If there are any concerns or queries regarding the process please contact the
relevant PCT to discuss (see details below)
If indicated has an Urgent Authorisation for DoLS form been completed? This
must be sent in with a Standard Authorisation for DoLS.
Has a Standard Authorisation for DoLS form been completed?
Have the forms been faxed to the relevant PCT (see details below)
Has a copy of the documentation been filed in the patient’s medical notes?
Has a copy of the documentation been sent to the Trust Medico-legal Services
Has the patient and family/carer been given the relevant information and
Please note an authorisation for a deprivation of liberty does not, in itself, authorise care or treatment.
Print Name………………………………………. Signature ………………………………………………
Brighton & Hove DoLS Office
Tel: 01273 295555
Fax: 01273 296372
West Sussex DoLS Office
Tel: 01903 738900
Fax: 01903 738956
East Sussex DoLS Office
Tel: 01273 336820
Fax: 01273 482776
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Appendix E
Impact Assessment
Please add the full policy title, the TCP number
The date of the next review and page X of Y