Overview of 2019 surveillance methods
NICE's surveillance team checked whether recommendations in violence and aggression: short-term management in mental health, health and community settings (NICE guideline NG10) remain up to date.
The surveillance process consisted of:
Feedback from topic experts via a questionnaire.
A search for new or updated Cochrane reviews and national policy.
Examining related NICE guidance and quality standards and NIHR signals.
A search for ongoing research.
Examining the NICE event tracker for relevant ongoing and published events.
Literature searches to identify relevant evidence.
Assessing the new evidence against current recommendations to determine whether or not to update sections of the guideline, or the whole guideline.
Consulting on the proposal with stakeholders.
For further details about the process and the possible update proposals that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.
We searched for new evidence related to debriefing, methods of restraint and pharmacological management for the indication of rapid tranquilisation.
We found 19 studies published between 4 August 2014 and 28 May 2019.
We also included 9 relevant studies from a total of 11 identified by topic experts.
From all sources, we considered 28 studies to be relevant to the guideline.
See appendix A for details of all evidence considered, and references.
Studies involving debriefing were eligible if they were conducted with patients with mental health conditions who were currently service users within healthcare, including mental healthcare, social care and community settings.
All studies involving physical restraint were included.
Studies involving pharmacological management were eligible if they involved adults (aged 18 and over), children and young people with mental health conditions who are currently service users within healthcare, including mental healthcare, social care and community settings. Studies involving pharmacological management that were not randomised controlled trials, systematic reviews or meta-analyses were not included.
We checked for relevant ongoing research; of the ongoing studies identified, 3 studies were assessed as having the potential to impact on existing recommendations. Therefore, we plan to regularly check whether these studies have published results and include them in the update where possible. These studies are:
We considered the views of topic experts who had been recruited to the NICE Centre for Guidelines Expert Advisers Panel; experts completed a questionnaire about developments in evidence, policy and services related to the guideline.
We sent questionnaires to 17 topic experts and received 7 responses.
Areas raised in topic expert feedback included:
The new scheme of Liberty Protection Safeguards which will replace current Deprivation of Liberty legislation. This is due to publish in 2020 and NICE will track this legislation and the content will be assessed for impact on publication and considered during the update.
The Human Rights Framework for Restraint has been published which considers new equalities issues around the age of service users.
The publication of the Use of Force Act. This act states that a policy must be published regarding the use of force by staff who work in mental health settings.
Revisiting pharmacological interventions.
NICE had also recorded correspondence from stakeholders after the guideline was published and this was considered in this surveillance review:
The current guideline recommends the supine restraint position and not prone restraint but a stakeholder submitted evidence indicating that both approaches appear safe and effective. However, the studies recruited small numbers of healthy volunteers and were not conducted in mental health settings.
The use of post-incident debriefs was queried as the NICE guideline on post-traumatic stress disorder specifically recommends not using psychologically focused debriefing techniques. It is proposed that this area is reconsidered during the update of the guideline.
At consultation, comments were received from NHS England, NHS foundation trusts, private healthcare organisations, royal colleges, charities and NHS bodies. Four of the stakeholders agreed with the original decision to not update the guideline and 4 did not agree. The main reasons for requesting an update involved:
Proactive instead of reactive. There were many comments that the guideline only addresses the immediate short-term management of violence and aggression and not the prevention and longer-term care. It was suggested that the guideline does little to reduce incidents and fails to reflect preventative approaches encouraged in services. The title of the guideline was also queried, as it currently refers to short-term management and it was believed that NICE could add value by considering long-term interventions.
Trauma-informed care. It was suggested that trauma-informed care should be given further consideration within the guideline and consideration should be given to the British Institute of Learning Disabilities Restraint Reduction Network Standards which highlight the importance of trauma-informed care and support.
There were many comments regarding the different drugs that can be used or should not be used for rapid tranquilisation. It was stated that there is variation in practice with different settings using different drugs. It was suggested that recommendations on rapid tranquilisation in the NICE guideline are strengthened by considering the evidence around the safety and efficacy of all drugs used for this indication. The comments noted that some drugs which are currently being used have known safety issues.
Children and young people in mental health settings. There were many comments regarding the care of children and young people in these settings and concern was stated that children and young people, especially those with learning difficulties, should be represented within the guideline.
People with learning difficulties in mental health settings. It was noted that there is a gap within NICE guidelines for populations with learning difficulties who may become violent and/or aggressive in these settings and acknowledging what the best care may be for them. This population was outside of the original scope and therefore no evidence has been considered in this area.
See appendix B for full details of stakeholders' comments and our responses.
See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.
Equality issues were identified during the surveillance process. It was noted that the guideline did not meet the full recommendations within the Human rights framework for restraint in that the age of the service user is not considered alongside other factors when undertaking manual restraint. It was also noted that there was not enough information regarding rapid tranquilisation in pregnant women. Comments were also made during consultation regarding the disproportionate use of certain restraint mechanisms on particular population groups with protected characteristics and that these should be addressed within the guideline.
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