Clinical Practice Guidelines

Acute behavioural disturbance: code grey


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Key Points

    • The procedure should emphasise safety and non-restraint strategies in the first instance.
    • The Code Grey team should perform this procedure.
    • Any physical restraint is a last resort, and should only be used to facilitate rapidly effective pharmacological treatment.

    Background

    Principles

    • A key principle of medical ethics is that a child's autonomy should be respected.
    • Physical restraint is only used for safety and/or treatment.
    • As physical restraint and sedation deprives the child of autonomy, it should only be contemplated as a last resort. A child who is 'acting out' and who does not need acute medical or psychiatric care should be discharged from the hospital to a safe environment rather than be restrained.
    • When physical restraint is required a coordinated team approach is essential, with roles clearly defined and swift action taken. Staff members should never attempt to restrain the child without the Code Grey response team resource on hand.
    • Unless contraindicated, sedation should usually accompany physical restraint.

    Alternative means of calming a child

    • Crisis prevention.  Anticipate and identify early irritable behaviour (and past history).  Involve mental health expertise early for assistance (intake worker; after hours - on call psychiatry registrar).
    • Provide a safe 'containing' environment.  This includes a confident reassuring approach by staff without added stimuli.
    • Listen and talk simply and in a calm manner.
    • Offer planned 'collaborative' sedation (e.g. ask the child if they would take some oral medication to regain some control of their behaviour).
    • See Acute behavioural disturbance:  Assessment and verbal de-escalation CPG

    Indications for restraint

    • Other methods to control the behaviour have failed, such as de-escalation techniques; and
    • The child displays aggressive or combative behaviour which arises from a medical or psychiatric condition (including intoxication); and
    • The child requires urgent medical or psychiatric care; and
    • The behaviour involves a proximate risk of harm to the child or others, or risk of significant destruction of property.

    Cautions and contraindications to physical restraint and emergency sedation:

    • A child who is 'acting out' and who does not need acute medical or psychiatric care should be discharged from the hospital to a safe environment (home, police, DHS) rather than be restrained.
    • Be aware of previous medications and possible substance use.
    • Safe containment is possible via alternative means (including voluntary, collaborative oral sedation).
    • Inadequate personnel/unsafe setting/inadequate equipment.
    • Situation judged as too dangerous e.g. the child has a weapon (call a Code Black)

    Emergency chemical restraint

    See Acute Behavioural Disturbance: acute management

    Procedure

    1. The Code Grey team should perform this procedure.
    2. Team leader will designate roles before approaching child.
    3. All members should ensure own safety, with gloves and goggles.
    4. Draw up medication (See Acute behavioural disturbance: acute management CPG)
    5. Secure the child quickly and calmly using the least possible force. At least 5 people are required.
    6. The child should be initially held supine. In highly agitated children, a face down technique may be used at the discretion of the team leader, but be aware of the increased risk of asphyxiation.
    7. Administer the drugs by intramuscular injection into the lateral thigh (Other options - ventrogluteal or dorsogluteal). Beware of the risk of needle stick injury.  Further titrated doses of medication may be required depending on clinical response (If medication can be given IV this may be an option if the child is safe to cannulate)
    8. Post sedation care (See below)
    9. A Child who has needed emergency restraint & sedation may also require mechanical restraint, although chemical restraint is preferred. Mechanical restraint should be provided by trained personnel only.

    Figure: Code grey procedure

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    Post-sedation monitoring

    See Acute behavioural disturbance: acute management CPG

    Explain the procedure to the parents/carers if possible

    Complications of emergency restraint include

    • Complications from medications (above)
    • Injury to the child or staff
    • Traumatic asphyxiation

    Complications of mechanical restraints include

    • Escape from mechanical restraints
    • Pressure effects of mechanical restraints
    • Complications of being held supine, such as inability to clear vomitus from airway

    Ongoing care

    • Following restraint, the child must undergo a detailed medical and mental health assessment to guide subsequent management.
    • In some cases recommendation and transfer to an inpatient mental health facility may be required (Section 9 of the Victorian Mental Health Act, 1986).
    • The need for restraint and sedation should be reviewed on an ongoing basis and the child should be cared for in the least restrictive modality so as to provide safety.
    • In most cases, mechanical restraints should be removed once control is gained and this should be done in a stepwise fashion (one limb at a time).
    • As the sedation wears off, the child's risk status should be carefully monitored throughout the entire process.  Adjuncts to safe care may include the use of the Emergency Behavioural Assessment Room (EBAR), further sedation (oral, IV, IM) or possible use of mechanical restraints.

    Documentation

    Document fully in the child's medical record and medication chart when appropriate:

    • The indication for restraint, noting times
    • The child's response to sedation and complications thereof
    • On-going observations documented at least 15 minutely, including limb observations if mechanically restrained
    • There may be a specific code grey reporting form

    Defusing and debriefing

    • The need to physically restrain an aggressive child can be extremely distressing for staff involved.  A critical incident stress debriefing session may be required. It is ideally chaired by an objective facilitator who was not involved in the restraint process.  See your health service’s Human Resources Employee Assistance Program (EAP).
    • An operational debriefing may also be useful as a quality improvement tool.

    Consider consultation with local paediatric team when:

    • Children who require ongoing observation or stabilisation of an underlying medical cause e.g. resolution of drug toxicity.
    • Have a low threshold for involving local mental health clinicians in the ongoing care of behaviourally disturbed children.

    Consider transfer when:

    Once the behavioural disturbance is controlled, some children will require transfer to a tertiary psychiatric centre. This can be facilitated following an assessment by local mental health clinicians.

    Complications from chemical sedation - respiratory depression, hypotension, extrapyramidal reactions.

    Child requiring care beyond the comfort level of the hospital.

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Information specific to RCH

    If IM or IV medication is required the Code Grey team will provide assistance.

    RCH intranet links
    Code Grey Procedure
    Code Black Procedure
    Emergency Behavioural Assessment Room (EBAR)
    Human Resources Employee Assistance Program (EAP)

    Last Updated July 2017