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BOC Management in Western Health Emergency Departments

This document is a summarised version of DG-GC6-Pharmacological Management of Acute Behavioural Disturbance in the Emergency DepartmentDP-EP4-Prevention and Management of Patients with Behaviours of Concern in the Emergency Department and DP_RS5-Emergency Department Behavioural Assessment Spaces. The summary has been created to be Emergency Department specific, and has been endorsed by the ED Leadership Team. Staff should review this document if they require further information.


The safety of staff and patients is paramount in the Emergency Department.  Patients with behavioural disturbance pose risks of occupational violence and aggression (OVA) to themselves and others, including staff, other patients and visitors.


This QRG applies to all presentations to the Emergency Department of patients displaying Behaviours of Concern.


It is the responsibility of the Nurse Unit Managers and Directors of the Emergency Departments of each site to ensure the relevant staff are familiar with this QRG and associated PPGs.

Guideline Details

Prediction of “Behaviours of Concern” (BOC) and prevention of escalation through awareness of the following key concepts are critical to risk reduction such as risk/hazard identification, risk assessment and control measures to reduce/minimise the risk.

Process Details

  • All patients should have a risk assessment performed using the BOC Chart at the same time as other vital signs
  • BOC of 1 or more should be escalated to the NIC and Senior Medical Officer
  • Specific procedures exist for:
    • Section-351 patients
    • Patient searches
    • Smoking
    • Absconding
    • Patients outside ED doors
    • Refusal to treat
    • Security Responses

Key Components

Risk Identification

  1. Alerts – EDIS, EMR, IPM
  2. Risk factors – previous violence, intoxication, acute mental health conditions, forensic history
  3. Behaviour management plans

Risk Assessment

All patients should have a risk assessment performed using the BOC Chart at the same time as other vital signs.

    • A score is generated which indicates level of risk:
      • Score = 0 Low
      • Score 1-2 Moderate
      • Score >2 High
Figure 1: Behaviours of Concern Observation Chart as per Adult Observation Chart.

BOC of 1 or more should be escalated to the NIC and Senior Medical Officer.

All patients should be assessed for organic causes of behavioural disturbance.

Risk Management

The Management Matrix collocated with the “BOC Chart” should guide all management


Non-pharmacological management:

  • De-escalation
  • Reducing environmental triggers
  • Physical and mechanical restraint
  • Additional staffing e.g. specials


Pharmacological management

According to the Pharmacological Management of Acute Behavioural Disturbance in the Emergency Department Guideline (Emergency Department DG-GC6)


Behaviour Assessment Unit (BAU; SHED specific)

The operational and functional purpose of BAU is to manage and assist patients that present at high risk of self-harm or causing harm to others, including highly agitated and/or aggressive patients.

The BAU provides a dedicated space within which a multidisciplinary team can work. The environment is designed to be low stimuli and have increased privacy, improving the patient experience.

BAU will operate 24/7, 365 days. It will be staffed with nursing, medical and mental health clinicians.


Behaviour Assessment Room (BAR)

The purpose of using the BAR is to provide a safe environment to manage behaviours of concern in a location which maintains privacy for the patient, and limits distress for other patients and relatives. There are two BARs that form part of the overall BAU with nursing and medical support.

The decision to utilise the BAR is made by the Senior Medical Officer, in collaboration with the Nurse in Charge and Team Leader of Resus/BAU of the shift and where appropriate, in consultation with specialist services (e.g. Mental Health clinicians and security).

This decision will be based on the risk of violence, considering the following:

    • Absolute indication:
      • BOC score >2;
      • Arrival with police escort under Section-351 of the Mental Health Act.
    • Relative indications as deemed necessary:
      • BOC score 1-2;
      • Arrival with ambulance with pre-notification of behaviours of concern.

The use of this space is outlined in more detail in Emergency Department Behavioural Assessment Spaces (Emergency Department DP-SE1.3.1)


Security responses

Security are in attendance in ED 24 hours a day and should be proactively engaged through:

  • Planned Code Grays (BOC Call)
  • Unplanned Code Grays
  • Duress activation
  • Code Blacks


  • Clinicians in clinical notes and observation charts
  • Security in Riskman

Disposition considerations

  • Cause of behaviours
  • Likely persistence of behaviours
  • Need for admission, either for cause of behaviours or other illness
  • Management required for behaviours
  • Safety of staff and other patients

Paediatric management

Applies the same principles with additional consideration to:

  • Care-giver’s role in consent and escalation/de-escalation
  • Developmental age of the child
  • Disposition complexity

Staff Support

  • All incidents of BOC requiring security attendance will be investigation by ED managers
  • Staff should seek support through their managers, OHS and EAP