Acute behavioural disturbance

Any person, 16 to 65 years (16 to 55 years, if of Aboriginal and Torres Strait Islander origin) whose behaviour places them or others at immediate risk of harm, necessitating prompt intervention. This may include extreme distress, threatening or aggressive behaviour and serious self-harm.

This protocol is only to be used by nurses who have completed NSW Health Violence Prevention Management Personal Safety.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
Safety	Remove potentially harmful items from the environment such as IV poles, sharps, cords, cardiac leads or oxygen tubing before the patient arrives Allocate patient into an appropriate environment which maximises their wellbeing, comfort and safety Patient should be within sight at all times Consider a low stimulus environment, particularly for patients with a neuro-development disorder, such as autism spectrum disorder, attention deficit hyperactivity disorder or an intellectual disability
Behaviour and characteristics	For patients who have a management plan, use their personalised plan first Continue de-escalation techniques, see focused assessment section
Patient descriptors	Document hair colour, eye colour, clothing and distinguishing features. This will assist police or people searching for the patient in the event they abscond

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Measure SpO2 if signs of hypoxia or respiratory distress Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation Do not disturb patient or escalate behaviour unnecessarily Use hands off approach Assess heart rate and blood pressure if clinically relevant and patient is cooperative Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, and if safe to do so Cardiac monitoring is required if concern for drug ingestion or if altered conscious state Complete 12 lead ECG if suspected drug ingestion or organic cause (when safe to do so)
IVC and/or pathology	IVC is often unsafe Insert IV cannula, if trained, only if required for urgent access (e.g. lifesaving medications) See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

Assessment	Intervention
ACVPU	If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature If suspected drug-induced hyperthermia, or rapidly escalating temperature, over 40°C, actively cool Consider causes for acute behavioural disturbance if febrile, e.g. sepsis and switch to appropriate protocol if required
Skin inspection, including posterior surfaces	Check and document any abnormalities Ensure skin integrity is maintained and neurovascular observations are conducted if mechanical restraint is in situ

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart as required Encourage oral hydration
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment	Intervention
BGL	Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol

Focused assessment

Complete a mental health focused assessment.

Precautions and notes

• People with a mental health condition may have a history of trauma.
• Minimise potential for distress through clear and respectful interactions.
• Restraint poses a risk of traumatising and injuring the patient and staff.
• Restraint removes patient autonomy and should only be used as a safety intervention when attempts to de-escalate have been exhausted.
• Restraint should only be carried out by trained staff using the safest techniques.
• Avoid restraining in the prone position.

Interventions and diagnostics

Specific treatment

Patient search

• A patient search (including their property) should be considered in high-risk patients, consistent with the provision of trauma-informed care and local guidelines.
• NSW Health staff can only search a patient or their property if they have received a patient’s consent or the patient is detained under the Mental Health Act.
• To avoid escalating behaviour, ensure the search is carried out by two staff members in a private and sensitive manner.
• Remove any patient belongings that may be used to harm themselves or others.
• Document patient items that have been removed and place them in a secure location.

Verbal de-escalation

• Attempts must be made to engage, reassure and establish rapport with the patient, providing an opportunity for the patient to de-escalate.
• See mental health focused assessment for verbal de-escalation techniques.
• Seek support from family or carer, as appropriate.

Medication management

• Emergency sedation is to be given only if verbal de-escalation is unsuccessful.
• Emergency sedation aims to achieve an optimal reduction in agitation or behavioural disturbance, thereby allowing a thorough evaluation to take place.
• Give one of:
  • diazepam 10 mg orally once only
  • or olanzapine 5 mg orally once only.
• The sedative effects of antipsychotic drugs occur much sooner than the antipsychotic effects. Avoid benzodiazepines if the patient has had a previous paradoxical reaction or is tolerant to benzodiazepines.

Post-sedation monitoring

• Patients should be visually monitored at all times.

Acute dystonia

• If dystonic reaction, give benzatropine mesilate 2 mg IM/IV once only.

Documentation

• Reasons for sedation (in medical notes)
• Medications used: name, dose and route
• What worked? What was unsuccessful?
• As applicable, additional documentation may be required to address the following:
  • Code response
  • Patient safety, using the local risk incident reporting system IMS+ notification
  • Staff safety and OHS
  • Consent
  • Mental Health Act Restraint Register (NSW).

Alcohol or drug withdrawal

• Consider substance withdrawal (suspected) protocol.

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Analgesia

If pain score 1–6 (mild–moderate), give:

• paracetamol 1000 mg orally once only
• and/or ibuprofen 400 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS protocol.

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg

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Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.

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Pathology

Only collect samples if safe to do so.

• First presentation with acute behavioural disturbance: FBC, UEC, LFT, TSH, glucose
• Female of childbearing age: urine βHCG
• Other presentations, if clinically indicated: urine drug screen

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au