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Rapid Tranquilisation

Background

• Pharmacological method of managing uncontrollable violent or aggressive patients.

• Primarily used within psychiatric in patient centres

• Patients experiencing psychotic or non-psychotic 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 How well are the staff of Leeds Mental of Leeds Mental

Health Trust adhering Health Trust adhering to the guidelines?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 in-patients 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 de-escalate 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

0

1

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5

6

7

8

Violence Against Staff Violence against otherpatients

Verbal aggression Other

Reason for RT

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Initiating Rapid Tranquillisation

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?

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4

6

8

10

12

14

16

18

20

Q2 Q3 Q4 Q5a Q5b Q6

Question Number

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Yes

No

Drug Choice in Rapid Tranquillisation

15%

25%

5%

55%

Lorazepam

Lorazepam & Haloperidol

Lorazepam & Acuphase

Acuphase

Patient Monitoring & Safety

0

5

10

15

20

25

Q8a Q8b Q9 Q10 Q11 Q12

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Yes

No

Drug Choice and Administration: Legend of QuestionsQ8a: 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

Patient Monitoring and Safety: Q15 Arousal Level Monitoring Summary

0

2

4

6

8

10

12

Not Completed Partially Completed Fully CompletedDegree of Completion

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Patient Monitoring and Safety: Q17 Fluid Monitoring Summary

0

2

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14

16

18

20

Not Completed Partially Completed Fully CompletedDegree of Completion

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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?