Rapid Tranquilisation
Background • Pharmacological method of managing uncontrollable violent or aggressive patients. • Primarily used within psychiatric in patient centres • Patients experiencing psychotic or nonpsychotic symptoms.
Public Health Implications • Prevents patients harming themselves. • Protects the staff, other patients and the general public.
Drugs • Drugs recommended for use included: – IM Lorazepam – IM Haloperidol – IM Olanzapine – IM Haloperidol and IM Lorazepam in combination.
Dangers • Patients tend to be agitated and distressed. • Potential harm to both the patient themselves, and those surrounding them. • The drugs used have potentially serious and fatal complications; – – – –
Respiratory depression Cardiotoxicity Coma Sudden death
Guidelines • Ensure safe practice – before – during – after rapid tranquilisation.
• Protection for – the patient – staff members.
How well are the staff of Leeds Mental Health Trust adhering to the guidelines?
Aim of the audit • To evaluate the clinical practice of rapid tranquillisation against the standards set in the LMHT guidelines
The audit tool • Questions generated from examination of the LMHT guidelines • Majority of answers in ‘yes/no’ format
The audit tool •
8. (a) Zuclopenthixol acetate (Acuphase) is not recommended for RT. It should only be used after discussion with a consultant or appropriate senior colleague. If Zuclopenthixol acetate was given, was it discussed prior to administration with a senior colleague? Yes
No
(b) Is there evidence of prior exposure to anti-psychotic medication? Yes
No
Audit tool pilot • Audit tool pilot undertaken using a current inpatients notes • Addition of unique identifying number – to prevent the same incidences being counted twice, especially as some patients had multiple RT incidences • Lack of documentation – revised instructions to record an absence of documentation as ‘NO’; in a court of law if it has not been documented, it did not happen!
Data collection plan • Liaise with Risk management within Seacroft Hospital • Gain access to IR1 forms and patient notes • Expected to pool patients from 3 wards over period of 6 months for a sample size of 30-50 patients
Data Collection – Reality • Many IR1 forms had not been completed or untraceable = Lack of patient notes to audit! – Revised plan: Contacted pharmacy and obtained list of patients for which IM RT drugs had been prescribed
• 20 incidences of RT identified and audited.
The database • Completed audit forms collated for analysis • A database was created • Graphs generated from database for analysis
Rapid tranquillisation according to the Leeds Mental Health Trust Guidelines
The patient displayed verbal and physical aggression upon sectioning
The Nurse attempted to deescalate the patient by talking to him and consoling him
Dr Cox was called and quickly rushed to the ward...
Nurse Andy checked the patients notes looking for advanced statements or evidence of past medication
The correct drug was chosen by Dr Cox and the Nurse using the British National Formulary
The right drug at the correct dose (calculated as a percentage of the BNF maximum) was quickly administered intramuscularly
The Nurse made regular observations of blood pressure . . .
. . . . temperature . . . .
. . . as well as pulse, arousal level and fluid balance
These observations were carried out at 10 minutes intervals
After the event both the patient and the Nurse had the chance to discuss what happened with a highly skilled counsellor An IR1 form was also filled out
Results
Reasons for Rapid Tranquilisation 8
7
Number of incidences
6
5
4
3
2
1
0 Violence Against Staff
Violence against other patients
Verbal aggression
Reason for RT
Other
Initiating Rapid Tranquillisation 20
18
16
Number of Incidences
14
12 Yes
10
No
8
6
4
2
0 Q2
Q3
Q4
Q5a
Q5b
Q6
Question Number
Q2: Was an attempt made to de-escalate the situation or talk down the patient? Q3: Was there an identified nurse who coordinated all nursing actions and interventions for the patient? Q4: Was the ward doctor or duty doctor called? Q5a: Was it documented that the notes were reviewed for evidence of previous or past episodes of severe aggression or violence and treatment? Q5b: Was it documented that the notes were reviewed for evidence of any advance statements by the patients? Q6: Has a previous diagnosis of the patient’s condition been considered and documented time of RT?
Drug Choice in Rapid Tranquillisation 15%
55%
25%
Lorazepam Lorazepam & Haloperidol 5%
Lorazepam & Acuphase Acuphase
Patient Monitoring & Safety 25
Number of incidences
20
15 Yes No 10
5
0 Q8a
Q8b
Q9
Q10
Q11
Q12
Drug Choice and Administration: Legend of Questions Q8a: If Zuclopenthixol acetate was given, was it discussed prior to administration with a senior colleague? Q8b: If Zuclopenthixol acetate was given, is there evidence of prior exposure to anti-psychotic medication? Q9: Does any evidence of IV route of administration appear on the chart? Q10: Have either IM chlorpromazine or IM diazepam been used for RT? Q11: Has the daily cumulative total for each class of medication been calculated drug chart (given as % BNF max)? Q12: Were the drugs administered within the BNF maximum?
Patient Monitoring 12
Patient Monitoring and Safety: Q17 Fluid Monitoring Summary Number of Incidences
Number of incidences
Patient Monitoring and Safety: Q15 Arousal Level Monitoring Summary
10
8
20 18 16 14 12 10
6
8 4
6 4
2
2 0
0 Not Completed
Partially Completed Degree of Completion
Fully Completed
Not Completed
Partially Completed Degree of Completion
Fully Completed
Recommendations • Universal care plan – to be filled put each time a patient under goes rapid tranquilisation – should include • indications for RT • drug administered, dose and route • monitoring of pulse rate, blood pressure, respiration rate, arousal rate and fluid input and output • reminder that this should be done every 10 minutes
• Prescription of Acuphase (zuclopenthixol acetate) – intervention to ensure its correct use incorporate a reminder into the care plan – ensure the patient has had previous exposure to antipsychotics – prescription of Acuphase dependent upon verbal discussion with senior staff member (consultant or senior registrar)
• Improve patient identification – for re-auditing and further audits – e.g. log book to be kept on the ward, each time a patient is tranquilised date of the procedure and patient number recorded – OR removable slip incorporated into the universal care plan.
Conclusions • Weaknesses – partial audit only – number of RT episodes limited – PICU – errors generated during data identification and collection
Conclusions • Strengths – first audit of its kind – objective audit tool – sampled patients taken from variety of different wards
• In general – many areas for improvement.
Any Questions?