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SO026

How do we manage acute behavioural disturbance in the acute medical unit? The Edinburgh Royal Infirmary experience

HOW ARE WE MANAGING ACUTE BEHAVIOURAL DISTURBANCE (ABD) IN THE ACUTE MEDICAL UNIT (AMU) AT THE ROYAL INFIRMARY OF EDINBURGH?

The management of acute behavioural disturbance in the acute medical unit varies considerably, with most cases occurring out of hours and an oral-first approach to sedation being applied inconsistently.

The aim of the audit was to evaluate the recognition and management of acute behavioural disturbance (ABD) in the Acute Medical Unit (AMU) at Edinburgh Royal Infirmary and identify areas for improvement. All Datix incident reports relating to ABD in the AMU between 2020 and 2025 were retrospectively reviewed. Clinical data were obtained from electronic patient records, identifying information was removed before analysis, and statistical analysis was performed using Microsoft Excel; the results reported in the poster are based on the full cohort of 71 cases. According to the management indicators presented in the poster, verbal de-escalation was documented in 65% of cases and senior clinician assessment in 45%, while physical restraint was used in 65%; patient injury, staff injury and referral to intensive care were reported in 8%, 27% and 8% of cases, respectively (the conference abstract reported these rates as 62%, 45%, 71%, 29%, 32% and 10%, respectively). Of the cases, 62% occurred during the out-of-hours period between 20:00 and 08:00, when staffing levels were lower. Sedation practice did not follow an oral-first approach: intramuscular (IM) medication was used in 59% of cases, and 57% of cases receiving IM medication had no documented attempt to administer oral medication or record of refusal. Only 20% of cases received oral medication, and refusal of oral medication was documented in 17%. Medication was used in 65% of cases with a documented de-escalation attempt and in 80% of those without one. There was considerable variation in the time to assessment, the seniority of the managing clinician and the pharmacological approach chosen when verbal strategies failed, with a subgroup requiring emergency department-level intervention. In conclusion, a nurse-led agitation escalation tool is being developed to support timely monitoring and preventive de-escalation before critical deterioration. An updated ABD guideline incorporating Sedation Assessment Tool (SAT) scores and agitation records is planned to standardise senior decision-maker involvement, followed by a post-implementation re-audit.

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