Consensus on acute behavioural disturbance in the UK: a multidisciplinary modified Delphi study to determine what it is and how it should be managed

Derived Delphi consensus statement

• Regarding recognition of acute behavioural disturbance (ABD) by first responders
• All first responders should understand that ABD does not denote a specific diagnosis.
• For first responders, the triad of being hot to touch (tactile hyperthermia), exhibiting constant or near-constant activity, and extreme agitation or aggression should be the focus of recognition, as the majority of other described signs and symptoms arise as a consequence of these.
• The triad in (2) includes features which are less vulnerable to racial and gender stereotyping.
• Features for recognition of ABD may be different depending on professional role (eg, call handler scripts can identify features to prompt responding officers to consider signs of ABD).
• Individual features are insufficient for recognition of ABD. The person should be exhibiting more than one consensus feature. However, the presence of all consensus features is not required.
• The person is sweating profusely.
• The person is exhibiting constant (or near-constant) physical activity.
• The person is unable to sit or stand still.
• The person is exhibiting extreme agitation.
• The person is exhibiting extreme aggression.
• The person’s presentation of aggression or hostility may appear atypical.
• The person appears disoriented (to place/person/time).
• The person is exhibiting bizarre behaviour.
• The person does not respond to other people present.
• The person is exhibiting exceptional strength.
• The person is constantly resisting restraint, or is restrained for 15min without resolution or de-escalation.
• The person does not become calmer with verbal de-escalation or restraint.
• The person has a raised heart rate.
• The person’s behaviour is not explained by other factors.
• Phrases such as ‘superhuman strength’ should not be used.
• Attraction to mirrors or glass.
• Destruction of mirrors or glass.
• All first responders should understand that patients presenting with rapid physical deterioration and agitated behaviour should have a focus on management of their physical health.
• People recognised as presenting with ABD should have a focus on physical health monitoring for evidence of deterioration, use of de-escalation techniques and early transportation to a healthcare facility if there is evidence of deterioration.
• Police officers should have a high index of suspicion for recognising ABD, and therefore a low threshold to divert to a healthcare provider rather than a custody setting.
• Live feed from a police officer’s body-worn video to specifically trained individuals in force control rooms may be helpful.
• All police custody staff should be trained to recognise a patient who is at high risk of deteriorating early.
• In settings with healthcare provision (custody suites, ambulance services or EDs)
• Clinical staff have additional skills, training and potential opportunities to undertake patient assessment which may lead to a better understanding of the cause of the presentation of ABD, or negate the need to use the term.
• Healthcare professionals have a responsibility to differentiate the cause of the patient’s presentation.
• Have plans regarding the management of patients presenting with ABD until emergency care has arrived, including de-escalation.
• Have access to readily available emergency equipment in environments which may be required to care for people presenting with ABD.
• Be aware that restraint may worsen a patient’s condition.
• Understand that the combination of physical health deterioration and behavioural disorganisation is likely to need emergency medical care.
• Observable features leading to recognition of a presentation of ABD should have more detail for healthcare staff.
• The triad of being hot to touch (tactile hyperthermia), exhibiting constant or near-constant activity, and extreme agitation or aggression should be the focus of recognition, as the majority of other described signs and symptoms arise as a consequence of these.
• Individual features are insufficient for recognition of ABD. The person should be exhibiting more than one consensus feature.
• Hot to touch/sweating/hyperthermia/removal of clothing.
• Constant or near-constant physical activity.
• Hypervigilance/fearfulness/panic/paranoia.
• Being unable to obtain observations due to agitation—BP, pulse, pulse oximetry, pupil size.
• Evidence of autonomic dysfunction.
• Does not appear to tire, agitated and not interacting, or psychomotor agitation.
• Exhibiting exceptional strength.
• Does not understand verbal commands.
• Psychological distress with the potential to harm themselves or another person.
• Disinhibited or violent behaviour.
• Aggression with no identifiable reason.
• Features of psychosis (eg, hallucinations).
• Exhibiting behaviour reported to not be normal for them.
• The features had a sudden onset.
• Failure of de-escalation techniques.
• Constant resistance to restraint, or restraint for 15 min without resolution or de-escalation.
• Sustained non-compliance with police or ambulance staff.
• Hypoglycaemia has been excluded.
• Likely to have ingested stimulant drugs.
• An ongoing need for sedation at higher doses than would typically be expected.
• Difficult to palpate a radial pulse.
• When professionals believe the ABD criteria are met, the person should always be moved to an ED for assessment, as an emergency.
• Regarding the applicability of ABD guidelines
• It is not helpful for healthcare staff to have separate guidance for ‘agitation’ and ‘ABD’. Rather, a history should be taken and assessment of the level of agitation should be made. Treatment should be based on the level of agitation and clinical risk. However, this should not be understood to mean that there is no role for the application of guidance currently provided for presentations of ABD.
• The consensus group do not agree that there is no definition of ABD. The features of concern can be described.
• As ABD is not a diagnosis, national guidance should be directed towards the safe care of any acutely distressed person.
• Evidence of rapid and significant physical or physiological deterioration along with agitation or confusion should lead to urgent clinical assessment and management. Other descriptors are not specific.
• No single sign or symptom should be used in isolation to identify this presentation. The clinical history and preceding events should be used to build a clinical picture.
• The person does not need to be exhibiting all consensus features, and assessment should not be limited to ‘objective measures’ such as vital signs and blood tests.
• Regardless of the terminology used, restraint and sedation should always be a last resort. The first response to any acutely distressed or agitated person should be non-physical approaches, including de-escalation.
• It is hoped that a focus on appropriate recognition of ABD will prevent guidelines for ABD being applied to all agitated people.
• ABD is not a diagnosis, and recognition of a presentation of ABD does not stop other clinical guidelines becoming relevant.
• If a likely diagnosis or condition is present, then that should be treated, but there may be a role for using ABD guidance in conjunction with other relevant clinical guidelines.
• The decision to move to alternative clinical guidance is not the exclusive domain of emergency departments.
• If the person’s baseline state cannot be determined from them sharing their personal experience, collateral history or medical records, the default should be to assume the abnormal behaviour is acute.
• It is identified that the patient is struggling to breathe.
• The person is able to communicate their experiences.
• The person responds to verbal de-escalation.
• The person engages in >60 s of consistent verbal communication, or focuses aggression at an individual, demonstrating perception of environment and persons around them.
• Signs or symptoms of physiological disturbance are not identified on healthcare staff assessment.
• Additional information becomes available (eg, psychiatric history identifies known schizophrenia) to which the person’s presentation can be attributed appropriately.
• Regarding patients who are breathing and conscious with a suspected presentation of ABD
• There is a triad of tactile hyperthermia, extreme agitation or aggression, and constant or near-constant activity.
• The person is restrained for 15 min without resolution or de-escalation.
• There is sudden cessation of resistance, or the person suddenly becomes quiescent.
• There is a history of syncope or pre-syncope, seizures or chest pain.
• Constant or near-constant activity.
• Persistent or extreme agitation or aggression.
• Tactile hyperthermia or sweating profusely.
• A sudden change in rate or depth of breathing.
• The person is requiring medication for agitation.
• The person cannot be calmed with de-escalation techniques.
• Continued use of force with a high degree of resistance.
• Clear indications of key drug use (eg, cocaine, other stimulants, phencyclidine, lysergic acid diethylamide).
• There is an inability to safely manage the risk to self or others.
• The person is a risk to themselves or others.
• Hyperkalaemia, raised lactate or acute kidney injury are identified on blood tests.
• A cause for the person’s presentation cannot be identified.
• An abnormality identified in primary survey.
• Abnormal vital signs, blood glucose or ECG.
• Bizarre behaviour or thoughts.
• Significant physical injuries.
• All people presenting with ABD require an emergency response.
• The same criteria should be used as for anyone with acute agitation.
• A person presenting with ABD cannot wait 2 hours for assessment.
• If a person initially presented with high-risk features but has subsequently improved, then non-emergency healthcare response may become appropriate.
• If a person’s behaviour has returned to normal and the features identified in (37.f) are excluded on clinical examination, a subsequent non-urgent response is possible.
• Regarding observation in police custody
• Observation in police custody would only be safe following diagnosis of the cause of the ABD and return of temperature, pulse, RR and other clinical parameters to acceptable levels having been monitored in a setting with full resuscitation facilities.
• The person should have decreasing levels of agitation, and this should be manageable with simple measures.
• The person should be coherent and able to converse giving rational responses.