Development of a statewide evidence based Guideline – management of patients with acute severe behavioural disturbance in emergency departments

Sarah Marmara1, Dr Sally McCarthy2

1 NSW Ministry of Health Locked bag 961 North Sydney NSW 2059
2 NSW Agency for Clinical Innovation, PO Box 699 Chatswood, NSW 2067

Development of a statewide evidence based Guideline – Management of Patients with Acute Severe Behavioural Disturbance in Emergency Departments

Violence and aggression in emergency departments (EDs) is increasingly common and increasingly reported in the media. The public interest in behaviour related to use of methamphetamines is also increasing. Patients who present to emergency departments with severe behavioural disturbance, whether through voluntary or involuntary presentation, can require significant use of ED resources to safely assess and manage their care. Inconsistent practice can result in poorer outcomes for patients, and potential risks to staff.

In NSW, it became clear that variation existed among EDs in relation to the management of patients presenting with acute severe behavioural disturbance. Based on clinician feedback through the statewide ‘Whole of Health Program’, an evidence based guideline was developed and implemented. The Guideline follows the key principles of: assessment of the patient in a safe environment; use of de-escalation techniques to allow for assessment; ensuring adherence to legal requirements;  sedation of the patient whose behaviour puts them or others at immediate risk of harm; post sedation care of the patient; disposition decisions and transport of the patient from the ED to the most appropriate place for continuation of their care.

Despite its evidence base, controversy surrounds use of the Guideline for certain clinical groups outside ED due to its inclusion of the drug Droperidol. Implementation of the Guideline has influenced clinical practice outside the ED, in particular prompting a review of clinical guidelines by NSW Ambulance for patients with acute severe behavioural disturbance.


Sarah Marmara is the Principal Policy Advisor, Emergency Access at the NSW Ministry of Health. Sarah has 20 years’ experience as an Emergency Nurse in a variety of senior nursing roles including Clinical Nurse Consultant and Nurse Educator. Sarah is passionate about supporting Emergency Department staff to enable the delivery of high quality, safe care for patients as well as ensuring that statewide policy on the delivery of emergency care is sensible and applicable in the clinical environment.