**Background:** Patients with cognitive impairment exhibiting agitation and aggression present significant management challenges in acute hospitals. The Clinical Aggression Response Team (C-ART) is dispatched when patient behaviours place themselves or others at risk. This study aimed to describe patient characteristics receiving C-ART calls, audit practice against local and national guidelines, develop interventions to address shortfalls, and re-evaluate adherence post-intervention.
**Methods:** A retrospective pre-post intervention audit using mixed methods was conducted at a 300-bed regional hospital in New South Wales, Australia. Pre-intervention data were collected from July–August 2018. Adult patients receiving C-ART calls were identified via the Incident Information Management System (IIMS); emergency department, mental health ward, and outpatient C-ART calls were excluded. File review captured documentation of aetiology, communication tools (TOP5, All About Me), psychotropic use, physical restraints, and de-escalation techniques. Semi-structured interviews were conducted with 22 staff members pre-intervention (7 doctors, 5 nurses, 5 security guards, 5 environmental support staff) and 6 medical officers post-intervention. Thematic analysis used the Braun and Clarke method. Logistic regression with generalised estimating equations accounted for repeated measures within patients.
**Results:** Pre-intervention, 57 C-ART calls occurred among 23 patients (mean age 79.0±11.5 years); post-intervention, 32 calls among 14 patients (mean age 75.5±14.0 years). All patients in both groups had delirium and/or dementia. In the pre-intervention group, 43% of patients had repeat C-ART calls accounting for 77% of total calls; post-intervention, 50% had repeat calls accounting for 78% of total calls. Documentation of a provisional diagnosis and differentials for behaviour improved from 36.8% to 65.6% post-intervention. Psychotropic use during C-ART calls decreased from 87.7% to 84.4% (OR 0.7, 95% CI 0.2–2.4, p=0.62). Use of clinical/communication tools after C-ART calls increased from 54.4% to 78.1% (OR 3.25, 95% CI 0.9–11.8, p=0.07). Physical restraint use increased from 38.6% to 53.1% (OR 1.8, 95% CI 0.4–4.1, p=0.69). Family contact decreased from 29.8% to 21.9% (p=0.62). Contact with specialist teams (geriatrician, liaison psychiatry, drug and alcohol) increased from 12.3% to 21.9% (OR 2.1, 95% CI 0.8–5.6, p=0.12). Documented instructions to nursing staff post-C-ART call remained low (33.3% to 37.5%, p=0.62). Qualitative themes post-intervention included better understanding of C-ART terminology and doctor roles, evidence of handover to medical teams, but ongoing pressure to prescribe sedation, lack of debriefing, and poor handover from ward staff at C-ART commencement.
**Clinical Implications:** This study confirms that the majority of patients requiring behavioural emergency responses in general hospitals have cognitive impairment (dementia/delirium), with a mean age over 75 years. Simple, low-cost interventions—particularly interactive orientation sessions for doctors and distribution of guidelines—can improve documentation of underlying aetiology and may modestly reduce pharmacological sedation. However, sustained pressure to use sedation, high rates of physical restraint, poor handover practices, and lack of debriefing remain significant challenges. Patients requiring multiple C-ART calls represent a high-need subgroup that may benefit from dedicated multidisciplinary review teams. The findings support prioritising non-pharmacological first-line management, improving post-sedation monitoring documentation, and embedding C-ART handover and debriefing into routine practice. Results should be generalised cautiously given the single-centre design and small sample size.