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TRANSCRIPT
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Rapid Tranquilisation
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Background
• Pharmacological method of managing uncontrollable violent or aggressive patients.
• Primarily used within psychiatric in patient centres
• Patients experiencing psychotic or non-psychotic symptoms.
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Public Health Implications
• Prevents patients harming themselves.
• Protects the staff, other patients and the general public.
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Drugs
• Drugs recommended for use included:– IM Lorazepam– IM Haloperidol– IM Olanzapine– IM Haloperidol and IM Lorazepam in
combination.
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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
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Guidelines
• Ensure safe practice– before– during– after rapid tranquilisation.
• Protection for – the patient– staff members.
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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?
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Aim of the audit
• To evaluate the clinical practice of rapid tranquillisation against the standards set in the LMHT guidelines
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The audit tool
• Questions generated from examination of the LMHT guidelines
• Majority of answers in ‘yes/no’ format
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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
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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!
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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
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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.
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The database
• Completed audit forms collated for analysis
• A database was created
• Graphs generated from database for analysis
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Rapid tranquillisation according to the Leeds Mental
Health Trust Guidelines
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The patient displayed verbal and physical aggression upon
sectioning
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The Nurse attempted to de-escalate the patient by talking
to him and consoling him
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Dr Cox was called and quickly rushed to the ward...
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Nurse Andy checked the patients notes looking for advanced statements or
evidence of past medication
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The correct drug was chosen by Dr Cox and the Nurse using the British National
Formulary
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The right drug at the correct dose (calculated as a
percentage of the BNF maximum) was quickly
administered intramuscularly
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The Nurse made regular observations of blood
pressure . . .
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. . . . temperature . . . .
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. . . as well as pulse, arousal level and fluid balance
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These observations were carried out at 10 minutes
intervals
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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
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Results
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Reasons for Rapid Tranquilisation
0
1
2
3
4
5
6
7
8
Violence Against Staff Violence against otherpatients
Verbal aggression Other
Reason for RT
Nu
mb
er
of
inc
ide
nc
es
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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?
0
2
4
6
8
10
12
14
16
18
20
Q2 Q3 Q4 Q5a Q5b Q6
Question Number
Nu
mb
er
of
Inc
ide
nc
es
Yes
No
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Drug Choice in Rapid Tranquillisation
15%
25%
5%
55%
Lorazepam
Lorazepam & Haloperidol
Lorazepam & Acuphase
Acuphase
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Patient Monitoring & Safety
0
5
10
15
20
25
Q8a Q8b Q9 Q10 Q11 Q12
Nu
mb
er
of
inc
ide
nc
es
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?
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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
Nu
mb
er
of
inc
ide
nc
es
Patient Monitoring and Safety: Q17 Fluid Monitoring Summary
0
2
4
6
8
10
12
14
16
18
20
Not Completed Partially Completed Fully CompletedDegree of Completion
Nu
mb
er
of
Inc
ide
nc
es
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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
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• 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)
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• 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.
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Conclusions
• Weaknesses– partial audit only– number of RT episodes limited– PICU– errors generated during data identification and
collection
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Conclusions
• Strengths– first audit of its kind– objective audit tool– sampled patients taken from variety of
different wards
• In general– many areas for improvement.
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Any Questions?