Suicide is the most common cause of death for young people in the UK and around 50% of completed suicides in young people have previous self-harm as a theme. Hence, robust management of young people presenting with self-harm to the emergency department is crucial. Guidelines published by the National Institute for Health and Care Excellence (NICE) and the Royal College of Psychiatrists advise an overnight admission for under-16s with self-harm, which is a challenge during winter pressures or bed shortages. In this editorial we discuss the difficulties faced when navigating NICE 2004 guidance documents with the realities of the coalface and consider the prospects for current practice and the future with the NICE 2022 guidance.

Aims and method: NICE guidelines provide a framework for decision making with regard to the management of disturbed or violent behaviour in inpatient mental health settings, although also point to the fact that there is a limited evidence base for the use of more high risk interventions such as rapid tranquillisation, restraint, and seclusion. The current study sought to elicit the views of a team of PICU staff regarding their preference for management strategies for such behaviour.

Results: Forty-three staff assigned ranks to five intervention options: restraint to administer medication, restraint without medication, seclusion, individual counselling, and offering PRN medication. The results revealed a clear preference for individual counselling as the first choice of intervention, and offering PRN medication as a second choice. The three remaining options could not be statistically separated.

Clinical implications: The results indicate that respondents viewed the choice of intervention beyond counselling and the offer of PRN medication as an issue of clinical judgement, dependent on a range of factors relevant to the presenting clinical situation. As such they offer support for the current NICE guidelines. The results are discussed with reference to the NICE guidelines, and areas for further study are highlighted.

Background: PICUs traditionally manage patients who can display disturbed behaviour. Recent guidance has advocated patient engagement in outlining preferences regarding management strategies should they display such behaviour.

Aim: To audit the use, within one PICU, of a mechanism that formally records individual patient preference in management of episodes of acute disturbed behaviour.

Method: Two sets of fifteen retrospective case note analyses in an audit cycle.

Results: Initial findings revealed that advance statements were completed by eight of the fifteen patients admitted (53%). Patients’ wishes were followed for two thirds of patients following incidents needing interventions. Following changes to practice, although only minimal improvement occurred in patients completing advance statements, they were completed sooner after admission and, despite more incidents needing interventions, patients’ wishes following episodes of disturbed behaviour were followed in two thirds of those who completed an advance statement.

Conclusion: Use of advance statements regarding management of disturbed behaviour can be introduced in PICUs and this should be advocated.