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Cg25 violence: information for the public

Violence: managing
disturbed/violent behaviour

Understanding NICE guidance – information for
service users, their advocates, families and carers,
and the public

Information about NICE Clinical Guideline 25
Violence: Managing disturbed/violent behaviour
Understanding NICE guidance – information for service users, their
advocates, families and carers, and the public

Issue date: February 2005
To order copies
Copies of this booklet can be ordered from the Department of
Health Publications Order Line; telephone 0870 1555 455 and quote
reference number N0829. A version in English and Welsh is also
available, reference number N0830. Mae fersiwn yn Gymraeg ac yn
Saesneg ar gael hefyd, rhif cyfeirnod N0830. The English and bilingual
versions of this booklet are also available from the NICE website
(www.nice.org.uk/CG025publicinfo). The NICE clinical guideline
on which this information is based, ‘Violence: the short-term
management of disturbed/violent behaviour in psychiatric in-patient
settings and emergency departments’, is available from the NICE
website (www.nice.org.uk/CG025NICEguideline). A quick reference
guide for healthcare professionals is also available from the website
(www.nice.org.uk/CG025quickrefguide), and the Department of
Health Publications Order Line (reference number N0828).
National Institute for
Clinical Excellence

MidCity Place71 High HolbornLondonWC1V 6NA Published by the National Institute for Clinical ExcellenceFebruary 2005Artwork by LIMA Graphics Ltd, Frimley, SurreyPrinted by Abba Litho (Sales) Ltd National Institute for Clinical Excellence, February 2005. All rights reserved. This material may be freely reproduced for educational andnot-for-profit purposes within the NHS. No reproduction by or forcommercial organisations is allowed without the express writtenpermission of the National Institute for Clinical Excellence. Contents
About this information
‘Disturbed behaviour’ resulting in violence What you can expect
making your wishes knownExtra information for specific groups Predicting disturbed/violent behaviour
(risk assessments)Things that can make violence more likely Preventing disturbed/violent behaviour
Interventions – stopping a violent incident
intervention, seclusion or rapidtranquillisation has been used If you go into an emergency department
Other points covered by the NICE guideline
Where you can find more information
of this guidelineIf you want to know more about NICE Explanation of technical words used
About this information
This information describes the guidance that the National Institute for Clinical Excellence(called NICE for short) has issued to the NHS on how to manage disturbed/violent behaviourin psychiatric units, wards and emergencydepartments. It is based on ‘Violence: the short-term management of disturbed/violentbehaviour in psychiatric in-patient settings andemergency departments’, which is a clinicalguideline produced by NICE for doctors, nursesand others working in the NHS in England and Wales. A brief description of the type of behaviour covered by the term ‘disturbedbehaviour’ in the context of violence is given on page 5.
Clinical guidelines
Clinical guidelines are recommendations for good practice. The recommendations in NICE guidelines are prepared by groups ofhealthcare professionals, lay representatives with experience or knowledge of the conditionbeing discussed, and scientists. The groups lookat the evidence available on the best way oftreating or managing a condition and makerecommendations based on this evidence. There is more about NICE and the way that theNICE guidelines are developed on the NICEwebsite (www.nice.org.uk). You can downloadthe booklet ‘The guideline development process– an overview for stakeholders, the public andthe NHS’ from the website, or you can order acopy by phoning the Department of HealthPublications Order Line on 0870 1555 455 (quote reference number N0472).
What the recommendations cover
NICE clinical guidelines can look at differentareas of diagnosis, treatment, care, self-help or acombination of these. The areas that a guidelinecovers depend on the topic. They are laid out ina document called the scope at the start ofguideline development.
The recommendations in the NICE guideline on managing disturbed/violent behaviour coverhow the people in the NHS should try to preventviolent situations from happening, and whatthey should do if someone becomes violent.
The information that follows tells you about the NICE guideline. It doesn’t attempt to explainthe possible methods that could be used in detail.
If you have specific questions, talk to one of thehealthcare professionals you see regularly.
How guidelines are used in the NHS
In general, healthcare professionals in the NHS are expected to follow NICE’s clinicalguidelines. But there will be times when therecommendations won’t be suitable for someonebecause of his or her specific medical condition,general health, wishes or a combination ofthese. If you think that the treatment or careyou receive does not match the treatment orcare described on the pages that follow, youshould talk to your doctor, nurse, advocate orother healthcare professionals involved in your care.
‘Disturbed behaviour’ resulting in violence
For some people with mental health problemsthere are times, particularly when they areemotionally distressed, when they maybehave in a way that directly affects otherpeople. There may be a risk that the personwill react in a violent way towards otherpeople, or harm themselves or property. A note on the way this information
has been written

In general, we have tried to make thisinformation more readable for service users by using ‘you’ rather than ‘a service user’. This does not mean that all service users arepotentially disturbed/violent. We have split the information into parts.
• ‘What you can expect’ covers the general points made in the NICE guideline – describing how you should be treated by staff in an in-patient area or emergencydepartment. Also covered is the informationthat you should be given about what is going on, and what the unit or wardshould be like. • ‘Predicting disturbed/violent behaviour’ looks at how staff should judge whetheryou’re going to become disturbed/violent, and what should happen if you need to be searched.
• ‘Preventing disturbed/violent behaviour’ describes what should happen if you start tobehave in a way that could become violent. It also covers observation and what shouldhappen if staff need to observe you as a wayof helping you to stay calm and to watch forsigns of disturbed/violent behaviour.
• ‘Interventions – stopping a violent incident’ covers methods staff may use to stopdisturbed/violent behaviour if talking to you doesn’t help you to calm down. • ‘If you go into an emergency department’ covers specific recommendations NICE aremaking about providing care for people withmental health problems in this setting.
• The final section outlines the other parts of the NICE guideline that aren’t dealt with in this booklet. These are mainlyrecommendations covering staffing issues and training, and the policies and proceduresthat should be in place.
An explanation of technical words used in thisbooklet appears at the end.
What you can expect
Important principles that apply during
your time in the unit, ward or emergency

• You should be treated with dignity and respect whatever your cultural background,sex, diagnosis, sexuality, disability, ethnicityor religious or spiritual beliefs. (See alsopage 61 for the recommendations thathave been made to help to ensure this.) • Staff should take the time to listen to you and to take your views on board,whatever your individual background and circumstances. It is important than you feel supported and understood,particularly if you have had any previousexperiences in the mental health systemrelated to your culture or background.
Finding out what’s happening and
making your wishes known

Information you should be given
Every time you’re admitted to a unit or ward,you should be given information on: • the staff member who has been assigned to you and how and when they can be contacted– if possible, you should be able to chooseyour key worker • why you have been admitted – if you’ve been detained (‘sectioned’), you should be told whythis has happened, what powers have beenused to detain you and what they cover, andyour rights of appeal • your rights on agreeing (consenting) to • your right to complain about the care you • how you can get independent advice and someone to speak on your behalf (an advocate) This information should be provided in a waythat is suitable for you. You should have help if needed to understand the information (forexample, if someone’s preferred language isn’t English, they should be able to have an interpreter). The information should berepeated to ensure that you can understand it. Making an advance directive
If you are thought to be at risk of becomingdisturbed/violent, you should be offered thechance to make your needs and wishes known.
This may mean making what is known as an‘advance directive’. This can include informationabout what you do and don’t want to happen if you become disturbed/violent. You shouldhave the chance to review your advancedirective with staff so you can make changes ifyou want. This review should be repeated atintervals so your advance directive is up to date. A record of what you’ve said in your advancedirective should be put into your care plan (seepage 11) and your medical notes. Your care plan
When you’re admitted to a unit or ward, thestaff will need to find out what sort of care willbe best for you, your views and preferences onhow you wish to be treated, whether you haveany particular physical needs and how likely youare to become disturbed/violent. To do this theywill talk to you and ask you some questions, andassess your physical needs. Your care plan will bebased on this, and will set out the details of thecare you should receive and what staff plan todo if you become disturbed/violent. You should be given a copy of your care plan. Acopy will be given to your carer if you agree tothis happening.
Giving medicines
When staff are giving you your medicines, theyshould make sure that the type of medicines youhave remains confidential. If you want to have your medicines reviewed,the person who prescribes them should listen toyour concerns and see if changes can be made. If abuse happens
If you suffer any form of harassment or abusewhile you’re in the unit or on the ward it should be looked into as soon as possible.
There should be a procedure in place that staff should follow.
Extra information for specific groups
If you’re pregnant
If you’re pregnant and there’s a chance youmight become disturbed/violent, your care plan should contain details of special measuresthat should be taken to protect your health and that of your baby if staff need to intervenebecause of your behaviour.
If you’re Black or from a minority ethnic group
Each health trust should have a board memberwho, at a senior level, is responsible for makingsure all individual service users are treatedequally and that staff don’t resort tostereotyping people. If you have a disability
If you have a disability, impairment and/or other problems communicating and there’s achance you might become disturbed/violent,your care plan should say what staff need to do when using de-escalation methods, rapidtranquillisation, physical intervention andseclusion if these are needed (these aredescribed in the section that starts on page 33). If you have an infectious disease
Although all service users have a right to confidentiality about their medicalcircumstances, there are certain times when this may have to be overridden to protectothers. This may be the case if you have aninfectious disease and start behaving in a waythat puts other people at risk of infection. If anyone is hurt during a violent incident where blood is spilt, the skin is broken or there has been direct contact with bodily fluids,steps should be taken to help protect staff and other service users from infection (all bodily fluids should be treated as if they are infected). The unit or ward
General points
Units and wards should be organised so thatyou: • can be yourself socially and spiritually. The particular needs of women, men and people from different cultural groups should be met.
If a person first arrives with a police escort, staff should meet them in a separate area. Facilities and activities
The building should be designed to let everyonemove around and make use of the facilities,regardless of any disabilities or impairments.
Men and women should have separate toilet and washing facilities, day areas and sleepingaccommodation. There should be an activity room,a dayroom with a television, and a quiet area setaside for prayer and reflection. The dayroomshould be open during the night for people whocan’t sleep. Where it’s possible, there should be aprivate area where you can make phone calls, andmeet and talk to your visitors and to staff. Every day, you should get the chance to exercise and take part in group activities andtherapy if you want to. And while you’re in theunit or ward, you should have easy access tofresh air and natural daylight. Where thebuilding design allows it, you should be able to get to an outside area through the unit. All areas should look and smell clean. Areas and rooms for smoking should be fitted out sothat the smell of smoke doesn’t filter through to non-smoking areas. And it should be possibleto control the lighting, temperature and noiselevels throughout the unit or ward to help make sure the environment is comfortable.
Safety and security
Your room, bathroom and toilet should besecure and should have a lock (staff should beable to unlock the door from the outside if theyhave to). The unit or ward should be designed andorganised so staff can see all the exits andentrances. Closed-circuit television (CCTV) andspecial mirrors may be considered necessary forplaces such as corridors, stairs and reception areas(potential blind spots). If there’s an emergencysituation because a person has become disturbed/violent, it should be possible for other people togo into and come out of the area safely. There must be alarms in interview rooms and inreception areas and any places where there areone-to-ones between service users and staff. Andit should be easy to get to the alarms – they mustnot be blocked by furniture, for example. Otheralarms must be in places where there’s a possiblerisk of an incident, and this will depend on theindividual unit and service user. This also appliesto personal alarms, which may be given to someservice users and staff if they have a higher riskof being caught in a difficult situation. Predicting disturbed/
violent behaviour

It’s important that the risk of violence inpsychiatric units is as low as possible. To makethis happen, staff need to be aware of all of thepossible risks and these need to be managedeffectively (a full ‘risk management strategy’should be in place). Assessing the risk of violence
(risk assessments)

Staff need to be aware of how likely you are to become disturbed/violent, and the likelihoodof this in a given situation. This is done throughsomething called a risk assessment. Staff look at the individual service user and the possiblesurroundings and situations that they may findthemselves in, and work out the likelihood of a violent incident happening. The risk assessment should not be biased in anyway, and should not be affected by staff’s ownfeelings or opinions, for example on race orculture. Although some types of behaviour mayseem unfamiliar to some staff members, theyshouldn’t be mistaken for aggression. Carrying out risk assessments is an importantpart of working with people with mental health problems, and the results should help the staff when they’re preparing your care plan(see page 11). The risk assessments themselvesshould involve a team of different types ofhealthcare professionals. Since the things that affect the risk ofdisturbed/violent behaviour change, riskassessments should be carried out on an ongoing basis. The results of the assessmentshould be passed on to all the places whereyou receive treatment and care, though patientconfidentiality should be respected. Talking to you as part of the risk assessment
To help staff judge how likely you are to become disturbed/violent, one or more membersof staff should talk to you, and possibly yourcarers, in an interview. Staff doing interviewsshould always talk to you and treat you in asensitive way. If you’ve become disturbed/violentbefore, you should be asked: • what sets off this type of behaviour (the things that do this are sometimes called trigger factors) • whether there are any warning signs that you’re going to become disturbed/violent • whether there’s anything else that could be • what you think would be the best way of managing you if any of the things youmention happen while you’re in the unit oron the ward. From the results of the risk assessment, staffshould judge whether your care plan needs toinclude specific descriptions of how you should betreated if you become disturbed/violent. Staffshould give you feedback on your risk assessment.
Things that can make violence
more likely

Staff should know about the things that canstart off a violent incident. Generally, these canbe grouped into people’s attitudes, situationsthat a service user is in, the organisation of theunit and other things affecting a service user,and their environment.
The NICE guideline lists some of the things thatcan make a person more likely to become violent(called risk factors). These will vary betweenservice users but may include: • things about the person’s background (such as having been violent before, or having hadviolent feelings before) • things about their mental health symptoms • things about their situation (such as having Some things that can be warning signs fordisturbed/violent behaviour are listed in the box on pages 21 and 22. They will vary fromperson to person. If there’s a risk that you could become disturbed/violent, you should beencouraged to recognise your own particularearly warning signs – a note of these should beincluded in your care plan (you should have acopy of this). Some potential warning signs for violence
• The person is more restless than usual, or is restless for longer than normal, or theirbody is tense or they are pacing around • The person is breathing more quickly, their heart is beating more quickly, their musclesare twitching and/or their pupils are largerthan normal • The person is talking more loudly than normal and/or they are making unexpectedand unpredictable movements • The person’s face is tense and angry • The person holds eye contact for longer • The person is unhappy, refuses to talk, or is • The person isn’t thinking clearly or can’t • The person thinks something is happening that isn’t, and what they think is happeninghas an element of violence attached • The person says threatening things or • The person is acting in a way that’s similar to how they acted before an earlierepisode of violence • The person says they feel angry or violent • The person is blocking or has blocked the Searches
Searching service users and visitors is animportant part of running a safe unit. Butsearching has to be carried out sensitively andlegally and only when it’s really needed. Consenting (agreeing) to a search
The sort of search that is carried out shoulddepend on the reason for the search and theperson involved. Staff should always ask for your consent (agreement) to be searched,though in some circumstances the search will go ahead even if you don’t consent. If youhaven’t consented but the search has goneahead, there should be a review of whathappened before and during the search. As part of this, you should be seen by an advocateor a hospital manager so your views can beincluded in the review. The search
The type of personal search that’s done shoulddepend on the reasons for the search – a ‘rubdown’ search shouldn’t be done unless there are reasons for doing it. Staff should payattention to the dignity and privacy of theperson being searched. Women should besearched by female staff and men by male staff. If you’re being searched, you should betold what is happening and why. If a search is needed but the person doesn’t let staff near them to carry it out, the healthteam will decide whether the person needs to be physically held while the search is beingdone. The policy on searching should describethe options for staff if the decision is made notto go ahead with the search. Keeping a record of the search
Every time a search is carried out, a detailedrecord should be made of what happened andwhy the search was needed. The results of thesearch should be added into other records andnotes as appropriate (for example, if somethingis found that shows you may have been planningto harm yourself or others, this will affect yourrisk assessment). After a search, help and advice should beavailable for you and everyone else involved.
Preventing disturbed/
violent behaviour

If you become angry or show signs ofdisturbed/violent behaviour, staff must respondin a reasonable way that’s right for theindividual situation you’re in. To help with this,staff should learn to recognise what generallyupsets and calms people. And they should alsomake themselves aware of what specific thingsupset and calm you. To do this, they shouldlisten to what you say is upsetting, and thisshould be noted in your care plan. Staff shouldbe aware of what they do and say and the effect that things like making eye contact andstanding in certain ways can have on people.
They should learn to check these things andmake sure that they aren’t doing or sayingsomething that could make a situation worse.
If you start to show signs of behaving in adisturbed/violent way, staff should make everyeffort to try to help you calm down in an openarea (that is, you shouldn’t be moved unless it’snecessary). However, sometimes staff may askyou to move to a safe area or room designed tohelp people calm down (the seclusion room, inunits where seclusion is used, shouldn’t be usedfor this purpose – see page 38 for moreinformation on seclusion).
At the first signs of agitation, or
disturbed/violent behaviour

If possible, staff should first try to get you to calm down using what are known as de-escalation methods. The next sections cover how staff should treat you in thesecircumstances.
At the start of a situation where you couldbecome disturbed/violent, one member of staff should take control. This person shouldexplain to you and anyone else in yourimmediate area what they plan to do. They’llorganise the people around them – for example,getting other service users to leave the area,getting help from other staff, and letting youknow that you have some choices about whathappens next. All the time, this person should be talking to you and trying to reach anagreement with you to help calm you down.
They shouldn’t say anything you could take as a threat.
When trying to calm down the situation the staffmember should: • ask you about what has happened (the facts) and what has made you angry (questionsabout facts rather than feelings can help tocalm things down) • encourage you to think through what has • give you some realistic choices about what can • show that they’re concerned through their • listen carefully to what you say, and be understanding about the things that haveupset you (you shouldn’t be patronised).
If there are potential weapons around, youshould be moved to a safer place if possible. If you have a weapon, you should be asked toput the weapon down somewhere (rather thanbeing asked to hand it over). Observation
Observation is a way that staff can help someone who’s showing signs of becomingdisturbed/violent. Its main aim is to help theservice user and staff member connect (‘engage’)in a positive and trusting way, to help reduce the risk of disturbed/violent behaviour. It’s alsoused to help prevent a person from harmingthemselves. There are four levels of observation that can be used, depending on the likelihood of violence – these are described below. It’snormally a qualified nurse who carries outobservation, though they may ask other staff to do specific tasks connected with theobservation. If this happens, it’s still theresponsibility of the nurse to make sure that the observation is done properly. All staffinvolved should be aware that service userssometimes find observation difficult to cope with – staff should be sensitive to your feelingsat all times so they don’t provoke a situationthat might not otherwise happen.
General observation: staff should know
where you are, but they don’t have to be able
to see you all the time. At least once during
their shift, a nurse should check on how you
are, and whether your mood or behaviour
shows any signs that you are becoming
disturbed/violent – a record should be kept
of this in your notes. Most service users are
observed in this way.
Intermittent observation: staff should check
on where you are every 15 to 30 minutes
(the exact times should be specified in your
notes). As far as possible, this should be done
without disturbing you or making you feel
you’re being checked on. This type of
observation should be used if you might
possibly become disturbed/violent as long as
there’s no sign that this is going to happen
immediately. It should also be used if, for a
time, there was a risk that you could harm
yourself or other people, but this is getting
less likely.
Within eyesight: staff should keep you within
eyesight at all times of the day and night. They
should be able to easily reach you at all times,
too, just in case something happens. If necessary,
anything that you could use to harm yourself or
others should be removed. Staff may need to
search you and your belongings, though they
should do this in a sensitive way and should
keep your legal rights in mind. This type of
observation should be used if there’s a risk you
could try to hurt yourself or another person at
any time.
Within arms length: when you’re having this
level of observation, one or more members of
staff should stay close to you. Your privacy and
dignity should be respected as far as possible,
though. You should be asked your opinions on
different aspects of being under this level of
observation (for example, would you prefer
to be observed by staff of the same sex as
yourself). Details of how the observation should
be done and any special considerations should
be written in your care plan. This type of
observation should be used if you’re likely
to hurt yourself or another person if you
get the chance.
How staff should behave
Nurses and other staff involved in yourobservation should have been briefed on yourprevious medical history, and should know aboutany particular needs you have or areas whereparticular care should be taken. They should tryto engage positively with you, listen to whatyou’re saying, and value you as a person. Thesame member of staff shouldn’t observe you formore than 2 hours if you are being observed athigher than the general level.
Deciding which level is needed
You should be observed using the lowest level of observation possible, given the circumstances(and you should only go to a higher level if staffhaven’t been able to engage with you and helpyou feel more calm). A balance should be struckbetween your dignity and privacy and the safetyof yourself and those around you. Decisions about your level of observation shouldtake into account your current behaviour, themedicines you’re on, and the current risk thatyou’ll become disturbed/violent. The sameapplies to decisions about how often a checkshould be made on how you’re getting on, andwho should be responsible for doing this check.
Your views should also be taken into account as far as possible. Your psychiatrist or the doctoron call should be told of any decisions aboutincreasing your level of observation as soon aspossible, and decisions should be written in yournotes, together with the reasons for usingobservation. Your level of observation should be reviewed by staff at least every shift.
Some of the signs that a person may need ahigher level of observation are described in theNICE guideline. Keeping you informed
If your observation level is increased above thegeneral level, you should be given informationabout why this has happened, the aim of thechange, and when you are calmer how long theobservation is likely to last. Where it’s possible,you should be involved in the handover betweenstaff at the end of observation shifts so youknow what is being said about you.
Your nearest family, friend or carer should betold about the observation that you’re going tobe under, if you agree to them knowing. Interventions – stopping a
violent incident

If de-escalation methods haven’t helped to calm you, staff may need to do something elseto stop the situation getting out of control.
Depending on the situation, you may bephysically held for a short time (physicalintervention) so that you can’t hurt yourself oranyone around you, or you may be moved to the safety of a seclusion room. Sometimesmedicines may be given to help calm you (this is called rapid tranquillisation).
Important note
Physical intervention, seclusion and medicinesare ways of managing and calming a persondown if they have become violent so that asituation does not get out of control. Theyshould only be used once all the other waysof trying to calm the person have been tried.
Whilst using these methods staff shouldcontinue to use calming (de-escalation)techniques.
When deciding what to do, staff should think about the service user’s needs andsafety. If the service user has made anadvance directive that covers the situation,this should be taken into account whereverpossible. Staff should follow the guidance set out in the Mental Health Act Code ofPractice (chapter 19) – if they take a differentapproach, they should record what they aredoing, and give good reasons for doing it. When deciding what to do, staff should bearin mind the effects of the situation on otherservice users, staff and visitors. They mustavoid using excessive force to manage thesituation and help you to calm down. The box below has some general points on whatshould happen if physical intervention, seclusionor rapid tranquillisation is used.
If a physical intervention, seclusion or rapid
tranquillisation is used

• Staff should take steps to make sure you don’t feel humiliated during the process ofcalming you down • As soon as it’s possible, staff should explain • You should be given the chance to write up your account of what happened in yournotes Access to a doctor and emergency

If staff are using physical intervention, seclusionor rapid tranquillisation and need medical adviceor help, they should be able to alert a doctor. He or she should be on hand to help as quicklyas possible. Staff involved in using these methods should be trained in emergency resuscitationprocedures. Staff should be able to getemergency equipment to an incident within 3 minutes in units, wards and departmentswhere physical intervention, seclusion or rapidtranquillisation might be used. Physical intervention
A physical intervention is a way of holdingsomeone so that they can’t move easily. Staffshouldn’t use this unless it’s absolutely necessary.
If it is used, it should be done for the shortesttime possible either to allow the immediatedanger to pass or to organise an alternative such as rapid tranquillisation (whichever issooner in the particular situation). Staff should never directly press on your neck,chest, abdomen, back or pelvic area duringphysical intervention. One person should beresponsible for protecting and supporting yourhead and neck the whole time. This personshould also watch what the other members ofstaff are doing to make sure that the physicalintervention is being done safely (for example,they should make sure you can breatheproperly), using recommended techniques. Staff should be keeping a check on how you are (physically and mentally) the whole time.
Whatever technique is used, the force used mustbe just enough to control you and it should beused for the shortest possible time.
Staff should make every effort not to usetechniques that cause pain, but very occasionallythey may be needed if staff, service users orothers need to be rescued immediately. Staff shouldn’t normally use equipment torestrain you. If equipment is used, there should be a valid reason for it and the decisionshould be made by a group of healthcareprofessionals with different areas of expertisebefore it is used.
Seclusion is a way of putting someone in a safeenvironment to calm down. If seclusion is usedfor you, it should be done for the shortest timepossible, and staff should make scheduledregular checks on you. Every 2 hours (or moreoften), staff should review whether you’vecalmed down enough that you can come out ofthe seclusion room. Staff should tell you thatthese reviews will happen. You will be observedby a member of staff at all times from outsidethe room (see also Observation, pages 28–30).
Your clothes shouldn’t be removed when you’rein seclusion (the possible exception is if you’rewearing something that could be used to harmyourself or another person). You should also beallowed to keep things that are important toyou because of your religion or culture (forexample, some items of jewellery), again as long as they couldn’t be used to cause harm. The seclusion room
If the unit or ward uses seclusion, it should havea seclusion room that’s designed so a person in it can be seen clearly. The room should be wellinsulated and ventilated, and safe, and thereshould be access to toilet/washing facilities. Rapid tranquillisation
In some circumstances, one or more medicinesmay be used to calm you down. This is calledrapid tranquillisation. Any medicine given to help you calm down in the short term should bethought of as being part of rapid tranquillisation. Giving the medicines
Some of the medicines used for rapidtranquillisation are taken by mouth (orally), but others are injected. Usually, you should beoffered the medicine orally. If injections areneeded, they should be given into a musclerather than directly into the blood (via a vein), if possible, because it’s generally safer to injectinto a muscle. If injections are used, you shouldbe switched to oral medicines as soon aspossible. Staff should allow the medicine time to work before deciding to try another dose. The team of healthcare professionals involved in rapid tranquillisation should include apharmacist who has specialist knowledge and experience in preparing medicines forpeople with mental health problems. Thepharmacist has a responsibility to monitor howthe medicines are used and to make sure thatthey’re being given safely and correctly. The medicines that should be used
The best type of medicine to use for rapidtranquillisation depends on your particularcircumstances. Staff shouldn’t use two of thesame type of medicine at the same time (forexample, two antipsychotics). In all situations,the person who prescribes the medicine and theperson who gives it to you should try to get yourconsent (agreement) to have the medicine.
There are some circumstances where staff should take extreme care if they use rapidtranquillisation, and these are shown in the box on page 41. After you’ve had the medicines, you should be able to understand and respond to what isbeing said to you. This is important becausethere are some risks with the medicines used – if they aren’t used properly, you may becomeunconscious or drowsy, or stop breathingproperly. Some of the possible problems areshown in the box on pages 42 and 43. If youcan’t respond to what’s being said to you, youshould get the same kind of general care that a person would have if they were under ageneral anaesthetic. Rapid tranquillisation should be used with
extra care in these people, if it’s used at all

• The person was born with a specific heart condition that affects their heartbeat (they have what’s known as a prolongedQTc syndrome) • The person is taking another medicine that affects their heartbeat in a specific way • There’s something that might change the way the person’s body copes with the medicine – for example, they may bevery cold (have hypothermia), have a hightemperature (hyperthermia), be stressed or very emotional, or have just donesomething that will have made their heartbeat very quickly (such as hard exercising) Possible problems with the different
medicines used for rapid tranquillisation

Benzodiazepines (for example, lorazepam)• Passing out (losing consciousness) working properly if the person is alsotaking the medicine clozapine) Antipsychotics (for example, haloperidol)• Passing out (losing consciousness) • Restlessness (the medical name is akathisia) • Neuroleptic malignant syndrome: this is rare but serious – the person becomes veryill, with symptoms that include a very hightemperature, losing consciousness,sweating, and a fast heart rate Antihistamines (for example, promethazine)• Becoming too drowsy • Side effects such as dry mouth or blurred If you have psychosis
Psychosis is the medical word used to describemental health problems that stop the personfrom thinking clearly, understanding what’s realand what’s not, and acting in a normal way. If you have psychosis, the first medicines thatshould be considered for you are an oralantipsychotic medicine and oral lorazepam.
Lorazepam is a type of medicine known as abenzodiazepine, which makes people feelcalmer. It is used to bring about an early calmingresponse giving time for a lower dose of theantipsychotic to take effect. Antipsychotic medicines should be given at thedose that’s right for you – this will depend onthings like your age and whether you are takingother medicines or have other medicalconditions. If injections are needed: if you refuse to take
a medicine by mouth or the staff have good
reason to judge that oral medicines won’t calm
you down quickly (for example, if they haven’t
worked in the past for you, or you’re extremely
disturbed), you should normally be given
injections of haloperidol (an antipsychotic)
and lorazepam.
If you’re less severely disturbed, staff may giveyou an injection of a medicine called olanzapine(staff should be aware that there is a particularrisk if this drug is used outside of the maker'sinstructions). If you’re given an injection ofolanzapine, you shouldn’t have an injection oflorazepam until at least an hour later if you haveit at all. Oral lorazepam should be used only withcaution if you have had an olanzapine injection. If you’re given a haloperidol injection: staff
should give you another medicine called an
antimuscarinic to prevent any side effects such
as spasms. This will be given by injection.
Injections into the blood: benzodiazepines and
haloperidol should not normally be injected
straight into the blood for rapid tranquillisation.
But if there’s an occasion when the situation
means you need to be calmed down very quickly,
and senior staff think it’s the right thing, these
medicines can be injected in this way (injecting
them into the blood means that they work more
quickly, but it also increases the risk of problems).
A person who has had an injection into the
blood should not be left on their own at all. And
these injections should only be given where the
staff have had the right training and the right
emergency equipment is available (staff should
be trained to recognise the signs that the person
is having problems breathing or with their heart).
If medicines are injected into the blood, a record should be kept of why and when this was done (records should also be kept for anymedications given). The decision to give this type of injection should be made by a seniorstaff member, not a junior one on their own. In very exceptional circumstances, haloperidolplus a drug called promethazine, or one calledmidazolam (given on its own) could be injectedinto a muscle rather than injecting medicinesinto the blood. Junior staff should discuss this with a senior on-call psychiatrist. If there’s no psychosisIf there’s no psychosis, lorazepam shouldnormally be used (normally it’s taken by mouth,but sometimes it’s injected into a muscle). Zuclopenthixol acetateZuclopenthixol acetate (also known as‘acuphase’) is an antipsychotic medicine, but it should not usually be used for rapidtranquillisation because it takes a long time to work and then it takes a long time for itseffects to wear off. But it may be an option if: • it’s clear that you’re going to be • you’ve had it before and it has calmed you • you’ve had repeated injections of it in the • you’ve made an advance directive that says you’d prefer to have zuclopenthixol acetate.
Zuclopenthixol acetate should never be given to someone who hasn’t had an antipsychoticmedicine before. Medicines that shouldn’t be used for rapid

The following medicines shouldn’t be used forrapid tranquillisation: • chlorpromazine by mouth or by injection into • long-acting antipsychotics that are injected If someone has dementia (where the person’smental abilities are worsening and this affectstheir normal activities), staff shouldn’t useolanzapine or risperidone to calm them down if they become disturbed/violent. After rapid tranquillisation has been given
Staff should keep a close check on you if you’vehad medicines for rapid tranquillisation. Theyshould check your ‘vital signs’ regularly – these arethe things that show if a person is all right (forexample, the breathing rate and pulse rate). Theyshould also keep a record of your blood pressure,pulse, temperature and breathing rate, and howhydrated you are – this should carry on until youbecome active again (a team of healthcareprofessionals should decide how often thesethings should be checked). A piece of equipmentcalled a pulse oximeter may be used. This clipsover a finger or toe and measures the amount ofoxygen in a person’s blood and their heart rate. Sometimes, you may need to be checked moreoften and more closely than normal, and arecord of what happens needs to be kept in yourcare plan. Staff should pay special attention toyour breathing and how drowsy you are if: • you appear to be or are asleep or have been • the medicine was injected into the blood • more medicine was used than is generally recommended (there may be special reasonsfor doing this) • it’s more likely than usual that you could • you have been using illegal drugs or other substances, or have been drinking alcohol • you have a medical problem or are taking a medicine that may mean special care is needed.
If you’re moved to another unit: if you go to
another unit or ward, staff should let the new
place know all the details of the medicines
you’ve had, with information on how well
they worked and whether there were any side
effects. The new unit or ward should get your
advance directive if you have made one and,
if possible, any notes you’ve written about
your experience of having rapid tranquillisation.
When you leave the unit or ward, this
information should be filed with your medical
records and your doctor should review it
Using rapid tranquillisation and seclusion

If it’s absolutely necessary to use rapidtranquillisation and seclusion together, youshould be watched all the time while you’re inthe seclusion room. The person who watches you should have been trained to look out forany signs of possible side effects of themedicines used.
Once the rapid tranquillisation has worked, you should be taken out of the seclusion room.
What should happen after physical
intervention, seclusion or rapid
tranquillisation has been used

If rapid tranquillisation, physical intervention or seclusion has been used, your care planshould be checked and changed if necessary.
After the incident, you should be helped to get back into normal life in the unit or ward. A review of what happened should be carriedout as soon as possible afterwards (in any event,within 72 hours of the incident ending). Thisreview is not about finding fault – it is to seehow things went and what can be learnt toprevent it happening again or how to manage it better. It is also an opportunity to strengthenpossibly damaged relationships between you(and your family or carers) and staff. Normally,the review should be led by someone whowasn’t involved in the incident, and thefollowing people should be considered forinvolvement in the review: • your family or carers, if this is appropriate • other service users who saw what happened • an independent advocate (a person who can • someone with specialist knowledge of how violent incidents can be managed safely.
• what each person did during the incident • how each person felt during the incident, how they feel now, how they may feel, and whatcan be done about any concerns they mayhave (you should get the support you need to deal with any problems). Staff should make every effort to check youunderstand why the incident was handled in theway it was. These efforts should be described inyour notes. If you go into an emergency

A lot of the information on the previous pagesapplies to emergency departments as well aspsychiatric units (emergency departments arealso known as ‘accident and emergency’ or‘casualty’ departments). This is because staff in hospital emergency departments often seepeople with mental health problems. As well as the information that applies generally,NICE has also made some recommendationsspecifically for emergency departments, andthese are described below.
You should be able to understand what peopleare saying to you in the emergency department.
For example, interpreters should be available if your preferred language isn’t English. Allpeople should be given the help they need tounderstand what’s going on; for example, if you are deaf you may need an interpreter who can sign. Finding out what’s wrong
If you’ve gone into an emergency department of a hospital and you’re showing signs of mental health problems, staff should talk to youin a special interview room to try to find outwhat’s wrong. Usually there should be at leasttwo members of staff in the room. The roomitself should be close to or part of the mainemergency reception area. It should be bigenough for six people to sit comfortably, and it should have safety features so that staff cancall for help if they need to. There shouldn’tbe anything that could be used as a weapon inthe room. If rapid tranquillisation is needed
Staff in an emergency department may decide to use rapid tranquillisation if you’re showingdisturbed/violent behaviour. Normally, thedecision to use it should be made by someonesenior. As soon as they are able, staff shouldmake contact with mental healthcareprofessionals. Lorazepam should usually be used if the staff are not sure about your medical history (forexample, whether you have heart problems, or what medicines you’re taking) or if it’spossible that you have used illegal drugs orsubstances, or are drunk. If staff are sure thatyou have had an antipsychotic before and it has worked, lorazepam with haloperidol could be used. Other points covered by the
NICE guideline

All the information covered so far is taken from the NICE guideline called ‘Violence: theshort-term management of disturbed/violentbehaviour in psychiatric in-patient settings andemergency departments’. The guideline alsocontains other recommendations includingtraining for staff, how the unit or ward shouldbe staffed and organised, and the policies thatshould be in place. The next sections list theareas covered in the guideline, but don’t usuallygive any detail of what the guideline says(though more information is included where the information directly affects service users). If you want to find out more about any of these areas, please see the NICE guideline on the NICE website (www.nice.org.uk).
Training for staff
Not all staff in units or wards need all thetraining listed below. Sometimes certain staffmembers will have training in a particular area –more information is given in the NICE guideline.
In most instances, staff who get initial trainingshould continue to receive training in theseareas so their knowledge stays up to date. The training that staff receive should bemonitored and, every year, there should be a review of the training strategy so that staff get the training they need. The NICE guidelinehas recommendations on training in thefollowing areas.
• Understanding groups and individuals in society – staff should be trained to understandthe needs of particular groups to avoidstereotyping service users and to help themunderstand better the individuals they may becaring for. If there are groups such as migrantworkers or asylum seekers living in the area,staff should also have training to help themcare for people from these groups who havemental health problems. Service users andservice user groups should be givenopportunities to be actively involved intraining and setting the training agenda forstaff so that staff become aware of thespecific needs of different groups (for example, women, service users with impairedsight or hearing, Black and minority ethnicservice users, physically disabled or impairedservice users, those with cognitive impairment,and those with communication difficulties).
• Recognising the signs that a person is becoming disturbed/violent and what thingsmay worsen a situation.
• Interventions (carrying out seclusion, the safe use of physical intervention, how themedicines used for rapid tranquillisation work,what can affect the way they work, and theproblems that could happen during rapidtranquillisation. • What to do in medical emergencies – training • Using a pulse oximeter (for staff involved in rapid tranquillisation – see page 49).
• How to write up what’s happened during an Policies and procedures
There should be a procedure for assessing therisk of disturbed/violent behaviour and policieson the following in place.
• Complaining about the care you receive.
• Searching (among other things, the policy should describe the legal position forsomeone if they don’t or aren’t able toconsent to the search, or if they’re in the unit because the Mental Health Act has been used to detain them). • Preventing and dealing with all forms of • Managing the risk of HIV, hepatitis or another • Alarms in the unit or ward and personal • Action plans on what to do in emergency situations (these should be developed locallyand aren’t covered by the NICE guideline).
There are also national directives to reportphysical assaults. Responsibility for ensuring equality
in care

Health trusts should have a board member whois responsible for making sure that all serviceusers receive equal treatment and care during an incident of disturbed/violent behaviour,regardless of the person’s ethnic origin orbackground. This board member’s responsibilitiesshould include: • training staff on equality and cultural and • monitoring how many people from different • asking local Black and minority ethnic groups for their views and involving them indeveloping services.
There should be procedures for service userswith disabilities, including those with physical or sensory impairment and/or othercommunication difficulties. Where you can find more

If you need further information about anyaspects of mental health or the care that you or someone you care for is receiving, please askyour doctor, nurse or other health professional.
You can discuss this information with them ifyou wish, especially if you aren’t sure aboutanything. They will be able to explain things to you. NHS Direct may also be helpful – phone 0845 46 47 or visit the NHS Direct website (www.nhsdirect.nhs.uk orwww.nhsdirectwales.nhs.uk) If you want to read the other versions
of this guideline

There are four versions of this guideline: • the full guideline, which contains all the details of the guideline recommendations andhow they were developed, and informationabout the evidence on which they werebased • a version called the NICE guideline, which lists • the quick reference guide, which is a summary of the main recommendations for in-patienthealthcare professionals and emergencydepartment staff.
All versions of the guideline are available from the NICE website (www.nice.org.uk). This version and the quick reference guide arealso available from the Department of HealthPublications Order Line – phone 0870 1555 455and give the reference number(s) of the bookletsyou want (N0829 for this version, N0830 for thisversion in English and Welsh, and N0828 for thequick reference guide).
If you want to know more about NICE
For further information about the NationalInstitute for Clinical Excellence (NICE) you canvisit the NICE website at www.nice.org.uk. At the NICE website you can also findinformation for the public about NICE guidanceon schizophrenia. This can also be ordered fromthe Department of Health Publications OrderLine (phone 0870 1555 455) and quote referenceN0177 for a version in English, and N0178 for a version in English and Welsh.
Explanation of technical
words used

Advance directive: a document that contains
the instructions of a person with mental health
problems setting out their requests in the event
of a relapse, or an incident of disturbed/violent
behaviour etc. It sets out the treatment that
they do not want to receive and any treatment
preferences that they may have in the event
that they become violent. It also contains
people who they wish to be contacted and
any other personal arrangement that they
wish to be made.
Advocate: an independent person whose job
it is to support service users and to help them
address their needs. They are often available to
attend meetings with healthcare professionals
to ensure that the service user’s views are put
forward and that the service user understands
the discussion.
Antipsychotic: medicines that block the effects
of the excess dopamine (a chemical in the brain)
that cause psychosis.
Benzodiazepine: a type of medication used to
make people sleep and also to make people
feel calmer.
Care plan: this document is a key part of your
care and treatment. You will usually have a
general care plan drawn up when first coming
into contact with services and also a specific care
plan for your time as an in-patient. It sets out in
detail areas such as: your current living and
family situations, occupation, diagnosis, records
of assessments, treatment options, who your
care-coordinator is (this is the person who
oversees your care and with whom you can
discuss your treatment etc), the name of a
specific keyworker for your stay as an in-patient,
other staff members or services who are
involved in your care (for example, social
services), and details of regular reviews. Your
care plan should be where details of your
advance directive are kept.
CCTV: video surveillance equipment that is
used to help staff ensure that all areas of the
environment are safe.
De-escalation: a way of trying to help someone
who is distressed or disturbed to calm down.
This involves talking through what the problems
or difficulties may be, and may involve going to
a quiet area with a staff member. The staff
member should also talk to the person about
possible ways of helping these problems or
Intervention: activities used to prevent violence
from happening and/or to manage violent
situations when they occur. The interventions
used include: calming techniques (de-escalation);
being observed (observation and engagement);
using medication (rapid tranquillisation); being
taken to a room (seclusion); or being physically
held (physical intervention).
Key worker: the member of the mental health
team who has a specific responsibility for the
service user and is usually the first person to
contact in an emergency.
Observation: an intervention that is used when
there is a risk that disturbed/violent behaviour
might occur. There are different types of
observation/engagement, depending on the
situation. During this intervention a healthcare
professional will closely watch the service user,
and will talk to the service user about the risk
of disturbed/violent behaviour. The level of risk
will be used to decide whether the healthcare
professional should check on the service user at
regular intervals, or whether they should be
constantly present.
Post-incident review: A review carried out within
72 hours of an incident to see what happened,
what can be learnt to prevent it happening
again or how to manage it better. It is not
about blaming anyone.
Psychosis: the medical word used to describe
mental health problems that stop the person
from thinking clearly, understanding what’s real
and what’s not, and acting in a normal way. It
happens when cells in the brain release too
much of a chemical called dopamine. The
excessive amounts of dopamine overstimulate
the brain, which gives rise to the symptoms
of psychosis.
‘Rub down’ search: a search that can include
searching pockets, head, hair, around and inside
ears, nose and mouth, and under the tongue.
The search is done around the collar and tops of
the shoulder, and using flat open hands a nurse
will check the arms, the front of the body from
the neck to the waist, the sides from the armpits
to the waist and the front of the waistband. It
also includes the back of the collar to the waist,
the back of the waistband and the seat of the
trousers, the back and sides of each leg from
the crotch to the ankle, and the front of the
abdomen and the sides of each leg.
Seclusion room: a room for the specific purpose
of separating a service user from other people if
he or she is acting in a violent way. It must meet
the requirements laid down in the Mental
Health Act Code of Practice.
Special needs: needs that relate to service
users with communication difficulties, or
who may be deaf or blind, or who have
particular vulnerabilities.
Violence: the use of physical force that is
intended to hurt or injure another person.
National Institute for
Clinical Excellence

Source: http://www.gain-ni.org/flowcharts/downloads/violence_nice_guideline_25.pdf


MEN has many complications and diseases associated with it. Zollinger-Ellison Syndrome (ZES) is relatively common to people with MEN 1. The syndrome was first described by the Norwegian doctor Roar Strøm in 1952. Therefore the syndrome sometimes also is called Strøm-Zollinger–Ellison syndrome in the literature. The syndrome was later described in 1955 by Robert Zollinger and Edwin Ellison,


Rifaximin versus Other Antibiotics in the Primary Treatmentand Retreatment of Bacterial Overgrowth in IBSJanet Yang Æ Hyo-Rang Lee Æ Kimberly Low ÆSoumya Chatterjee Æ Mark PimentelReceived: 13 November 2006 / Accepted: 5 April 2007 / Published online: 23 May 2007 Ó Springer Science+Business Media, LLC 2007Previous studies demonstrate improvement inantibiotics in the treatment and retreat

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