Reviewed and revised 24 July 2014 – based on a clinical update written by James Hayes


Priorities in a behavioural emergency:

  • Determine if safe for medical intervention
  • Determine cause – usually delirium with an underlying medical cause, substance abuse or withdrawal or psychiatric disorders
  • If the behavioural disturbance is not due to the above causes or medical intervention is unsafe (e.g. likelihood of extreme violence or weapons present) then security staff or police are required to disarm and restrain the patient
  • Otherwise, provide appropriate medical and/or psychiatric management (see below)


Patients may be brought to hospital by police under restraint (e.g. handcuffs)

  • police officers and handcuffs should remain in place during initial assessment
  • handcuffs can be removed once the patient has been assessed and it is deemed safe to do so
  • before removal of handcuffs medication may need to be given for the patient’s own protection or that of the staff


  • A duress system must be present in the ED
  • Assessment areas should be free of easily accessible dangerous objects and should have more than one exit
  • Hospitals should have established “CODE” protocols for responding to violent patients (e.g. ‘CODE BLACK’ or ‘CODE GREY’ are commonly used)


Initial steps

  • Recognition of warning signs of potential violence before escalation occurs
  • Prioritise assessment of escalating patients (delays can worsen the situation)
  • Always ensure safety of self, staff and others present (e.g. other patients, family members), and the patient
  • Ensure patient cannot obstruct exit route
  • Avoid excessive stimulation
  • Avoid aggressive postures and prolonged eye contact
  • Request aid (e.g. security staff) early if the situation is deteriorating or is expected to deteriorate

Verbal de-escalation

  • Adopt a calm, empathetic non-judgemental approach showing appropriate concern
  • Set boundaries
  • Give the patient time to state their concerns, avoid giving opinions on issues and grievances beyond your control
  • Explain that you want to help the patient
  • State your role and use both your own name and the patient’s name (personalize the interaction)
  • Identify and manage the trigger for the escalation in behaviour (if possible)
  • Identifying unmet needs that are easily corrected (e.g. inadequate pain control, communication failures or social concerns)
  • Recruit trusted others to help (e.g. family, friends, case managers)

Early negotiation

  • Offer verbal support
  • Provide food, drinks or other assistance as required (e.g. seating, access to a telephone, address physical needs)
  • Offer oral medication to alleviate patient stress
  • Allows assessment of:
    1. the patient’s responsiveness to verbal de-escalation
    2. immediacy of risk of self-harm or harm to others
    3. possible psychotic symptoms
  • May allow a cooperative approach to clinical intervention if it is deemed necessary (e.g. physical restraint and or pharmacological treatment)

Show of force

  • involves security staff in view providing back up to the clinician while trying to negotiate with the patient
  • used when verbal de-escalation is ineffective or inappropriate
  • may persuade the patient to cooperate with an appropriate clinical intervention, otherwise physical restraint and/or chemical restraint will be required to ensure safety of the patient, staff and others present

References and Links

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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