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RAPID TRANQUILLISATION AND PRN
PSYCHOTROPIC MEDICATION;
POLICY AND GUIDANCE
Document name:
Rapid tranquillisation and PRN psychotropic
medication; policy and guidance.
Version 6
Staff group to whom it
applies:
Qualified medical staff, qualified nursing staff,
pharmacists and pharmacy staff.
All staff working on in-patient units.
Distribution:
Hard copy to in-patient areas
Intranet
Medical staff on induction
Issue date:
February 2016
Next review:
February 2018
Developed by:
Mark Payne
Mohammed Fazlee
Sandra Butler
Contacts for advice or
information:
Jane Riley, Chief Pharmacist
Dr Adrian Berry, Medical Director
Mark Payne, Senior Clinical Pharmacist
1
CONTENTS
Abbreviations ................................................................................................................. 3
Prescribing algorithm ..................................................................................................... 4
Flowchart ....................................................................................................................... 5
1
2
3
4
5
6
7
Introduction ............................................................................................................ 6
Definitions and Principles ...................................................................................... 7
Prescribing guidance ............................................................................................. 8
Formulary .............................................................................................................. 12
Carrying out Rapid Tranquillisation........................................................................ 17
Physical health monitoring ..................................................................................... 18
Managing side effects and complications .............................................................. 19
Appendix 1 Rapid Tranquillisation Episode Criteria and Review Pathway ................ 21
Appendix 2 Rapid Tranquillisation – Assessment and Progress Chart ....................... 22
Appendix 3 The Richmond Agitation – Sedation Scale............................................... 24
Appendix 4 48 Hour Intramuscular Clopixol Acuphase Monitoring Chart ................... 25
Appendix 5 Guidance on the Preparation & Administration of Aripiprazole (Abilify®) 26
Appendix 6 Haloperidol Administration ....................................................................... 27
Appendix 7 Guidance on the Preparation & Administration of Olanzapine
(Zyprexa®) …………………………………………………………………………………. .... 28
Appendix 8 Advice on the Preparation & Administration of Lorazepam (Ativan®) ..... 29
Appendix 9 Policy for the use of midazolam .............................................................. 30
Appendix 10 Implementation ........................................................................................ 32
Appendix 11 Equality Impact Assessment Tool ......................................................... 33
Appendix 12 Checklist for the Review and Approval of Procedural Document ............ 34
Appendix 13 Training Needs ....................................................................................... 36
Appendix 14 Version Control Sheet ............................................................................ 38
References .................................................................................................................... 40
2
Abbreviations used in this document
BNF
CNS
CPR
D&T
ECG
EPSE
ESR
FBC
IM
IV
LFT
MDT
MAV
NICE
NMS
PO
PRN
QT/QTc
RT
SPC
SWYPFT
ST
TFTs
TIA
U&Es
British National Formulary
Central Nervous System
Cardiopulmonary resuscitation
Drug and Therapeutics Sub Committee
Electrocardiogram
Extrapyramidal side effects
Electronic Staff Record
Full Blood Count
Intramuscular injection
Intravenous injection
Liver Function Tests
Multidisciplinary team
Managing Aggression and Violence
National Institute for Health and Care Excellence
Neuroleptic malignant syndrome
Oral/by mouth
Medicines to be taken as and when required
Interval in the cardiac cycle
Rapid Tranquillisation
Summary of Product Characteristics
South West Yorkshire Partnership NHS Foundation Trust
Speciality Trainee
Thyroid Function Tests
Transient Ischemic Attacks
Urea and Electrolytes
3
Version 6 Feb 16
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
Rapid Tranquillisation / PRN prescribing algorithm
Consider de-escalation techniques
eg: talking down, distractions, time out
Have access to procyclidine injection for acute dystonic
reactions and flumazenil for benzodiazepine induced
respiratory depression.
Have access to emergency resuscitation facilities
Consider starting/increasing regular oral
medication
No response
Consider pharmacological management
Seek consultant advice re MHA status. If necessary
treatment may continue under common law
Try Oral Therapy
Patient refusing oral /
Rapid response required /
No response to oral
Try intramuscular injection
Adult
Drug (oral)
Lorazepam 1-2mg
or
Promethazine 25-50mg
Where the use of benzodiazepines is inappropriate
Elderly/Physically Frail
Drug (oral)
Lorazepam
0.5-1mg
or
Promethazine 25mg
Where the use of benzodiazepines is inappropriate
And/or another from the list below
Olanzapine 5-15mg
Haloperidol 3-5mg
Risperidone 2mg
And/or another from the list below
Olanzapine 2.5-5mg
Haloperidol 1.5-2.5mg
Risperidone 1-2mg
Use formulation most appropriate to patient
Use formulation most appropriate to patient
Adult
Drug (IM)
Lorazepam
1-2 mg
or
Promethazine 25-50mg
Where the use of benzodiazepines is inappropriate
and/or
Haloperidol
2-5mg
(if known to tolerate typical antipsychotics)
Elderly/Physically Frail
Drug (IM)
Lorazepam
500 micrograms-1mg
or
Promethazine 25-50mg
Where the use of benzodiazepines is inappropriate
and/or
Haloperidol
1-2.5mg
(if known to tolerate typical antipsychotics)
Response
Optimise regular psychotropic
medication
Restart or start oral medication
Response
Review appropriateness of
continuing intramuscular
therapy
Monitor Patient
No response within ½ hour
Never mix two drugs in the same syringe.
Always dilute lorazepam injection before use
Review.
Complexity – refer to consultant
Outside normal working hours – refer
to on-call consultant. The On call pharmacist is
also available for advice.
Consider repeating IM lorazepam (Adult Max 4 mg in 24 hours) and haloperidol 5mg injections
(caution – maximum adult haloperidol dose is 12mg IM in 24 hours, avoid repeating haloperidol in the elderly
above a total of 5mg IM without Consultant advice)
or any of the following
Aripiprazole 5.25-15mg IM (max dose 30mg in 24hrs by any route, however only IM used in Rapid
Tranquillisation, do not give when other antipsychotics are prescribed)
4
Zuclopenthixol Acetate (Clopixol Acuphase)
• Not recommended for RT due to delayed onset and
long duration of action but may be considered as an
option when:
1 Patient will be disturbed/violent over extended
time period.
2. Past history of good/timely response.
3. Past history of parental administration.
4. Cited in an advance directive.
• Never administer to those without previous
antipsychotic exposure.
• Consult BNF and manufacturer’s SPC regarding its
use and SWYPFT guidelines and monitoring charts.
RAPID TRANQUILLISATION / PRN PRESCRIBING FLOWCHART
Review patient’s presentation
Check for physical health monitoring; ECG, pulse, BP, U&E’s
Patient requires rapid
tranquillisation (RT)
Patient requires pro re nata
(PRN)
Document treatment decision
(Appendix 1)
Document treatment decision
Medication administered
Monitor physical health / arousal for 2hrs or until
ambulant (whichever is longer).
Document monitoring (Appendix 2)
Review and record need for RT (Appendix 1)
Record intervention on Rio
If requiring high doses of medicines or formulary medication ineffective
contact senior medic (ST / Consultant)
File paperwork and complete DATIX
Debrief staff team and review medication regime in the MDT meeting
5
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
Rapid Tranquillisation Policy
1.
1.1
Introduction
Scope
This policy is intended to support the delivery of appropriate, safe and
effective rapid tranquillisation in the context of in-patient care within
SWYPFT and identifies which clinical staff need training. This policy
replaces all previous local RT related policies or procedures and represents
expected (i.e. usual) practice within all districts and the regional forensic
service.
1.2
Practice Variation
This policy sets out the standards of care that are expected by SWYPFT
when prescribing medication for the management of acute behaviour
disturbance.
Where clinical need indicates that practice which falls outside of the scope of
this guidance is necessary, the following should be discussed with a senior
psychiatrist and recorded in the patient’s clinical notes :
- The exact nature of the intervention
- The rationale for this intervention, including acknowledgement of
usual practice, and that this is a deviation from this
- A clearly defined aim of the treatment
- A clearly defined timescale for review
- The name of the senior psychiatrist with whom the plan has been
discussed and agreed
1.3
Sources of Guidance
A full list of references is given at the end of this document, but this policy
takes particular note of NICE Guideline 10 and 178 (management of
Violence and Psychosis respectively) and is a successor to the SWYPFT
Rapid Tranquillisation Protocol version 5.3.1, September 2014 and the
Guidelines for Rapid Tranquillisation for acutely disturbed behaviour for
adults in Barnsley approved May 2010.
1.4
Duties
1.4.1 Healthcare organisations have an obligation to provide an effective rapid
tranquillisation service to their patients and appropriate training to their staff.
A suitable infrastructure is required to establish and continue support for
these activities.
1.4.2 The Chief Executive is responsible for ensuring that resources and
mechanisms are in place for the overall implementation, monitoring and
review of this policy. Implementation of this document is outlined in appendix
10, page 35.
6
1.4.3 The Medical Director, the Director of Nursing and the Chief Pharmacist are
responsible for ensuring the policy is reviewed, approved and monitored by
the appropriate trust-wide group (currently the Drug & Therapeutic Sub
Committee).
1.4.4 The Executive Management Team will provide policy approval and
ratification.
1.4.5 The Drug & Therapeutic Sub Committee will consider the monitoring
evidence put before them and request actions as appropriate.
1.4.6 The General Manager, Practice Governance Coach and Clinical Lead are
responsible for ensuring that dissemination and implementation of the policy
occurs within their own area of responsibility. In addition, they are
responsible for providing relevant support for the training required around RT
as outlined in the training needs analysis.
1.4.7 Ward Managers must ensure staff have access to training on RT (see
appendix 13 training needs analysis and training matrix, Section 1 of the
Medicine Code).
1.4.8 As well as training on RT there must be staff trained on the use of oxygen,
pulsoximetry and defibrillators on the wards when RT is employed.
2
Definitions and Principles
2.1
Definitions
Throughout this document the following definitions have been used, in line
with NICE guidance:
2.1.1 p.r.n. (pro re nata): When needed. In this guideline, p.r.n. refers to the use
of medication as part of a strategy to de‑escalate or prevent situations that
may lead to violence or aggression; it does not refer to p.r.n. medication
used on its own for rapid tranquillisation during an episode of acutely
disturbed behaviour.
2.1.2 Rapid tranquillisation: Use of medication by the parenteral route (usually
intramuscular or, exceptionally, intravenous) if oral medication is not
possible or appropriate and urgent sedation with medication is needed.
2.1.3 A multidisciplinary team that includes a psychiatrist and a specialist
pharmacist should develop and document an individualized pharmacological
strategy for using routine and p.r.n. medication to calm, relax, tranquillise or
sedate patients who are at risk of violence and aggression as soon as
possible after admission to an inpatient psychiatric unit.
2.1.4 The administration of medication by a short-acting intramuscular injection
should always be considered rapid tranquillisation and the principles of this
policy adhered to, even where the patient expresses a preference for this
route of administration.
2.2
Principles
7
2.2.1 Patients should be involved in their care at the earliest opportunity, those
requiring p.r.n or rapid tranquillisation should not be denied this opportunity.
Where it is not possible to discuss these issues with a patient prior to the
administration of medication then this should be discussed with them at the
earliest opportunity following the intervention.
2.2.2 Checks should be made prior to administering medication whether there is
an advance decision or advance statement in place. Where there is not an
advance decision or statement in place regarding the use of p.r.n or rapid
tranquillisation the patient should be encouraged and supported to develop
one.
2.2.3 Where a patient is subject to a restrictive intervention such as rapid
tranquillisation, this should only be after less restrictive interventions have
been considered and deemed ineffective or inappropriate. Even where a
restrictive treatment has been required previously, the least restricitive
intervention should always be considered first before repeating this
intervention.
2.2.4 All treatment decisions, administrations of medication and discussions with
patients about their treatment should be documented in the patients notes to
inform future care.
3
Prescribing guidance
3.1
Baseline checks
3.1.1 Prior to prescribing medication for use as p.r.n or rapid tranquillisation the
following should be reviewed and documented:
3.1.2 The medication prescribed for regular administration
3.1.3 Whether there are any issues with administering the regular medication
e.g. refusal of doses / issues with swallowing
3.1.3 Whether any changes to the regular medication regime are indicated, and
how these will be reviewed / actioned (please consider local supply
arrangements for medication before making changes to the treatment
regime).
3.1.4 Whether there is currently a need for p.r.n or rapid tranquillisation
3.1.5 Where a need for p.r.n or rapid tranquillisation is identified the following
should be considered and documented:
3.1.5.1
3.1.5.2
3.1.5.3
The symptoms that are to be targeted by the p.r.n / rapid
tranquillisation
How these symptoms will be monitored
How to measure if the medication administered has been effective
e.g reduction in agitation / time spent out of seclusion
8
3.1.5.4
3.1.5.5
3.1.5.6
3.1.5.7
3.1.5.8
3.1.5.9
3.1.5.10
3.1.5.11
The medication that is to be prescribed, recording:
a) Name of the medication
b) Dose; individual and maximum
c)
Frequency of administration (minimum interval, and maximal
frequency)
d) Route of administration
Any available information on historical response to medication
Any available information on historical tolerability of medication
The patient’s preference including any documented advance
statements / advance decisions
Any physical health conditions, particularly those which may affect
the absorption / distribution / elimination of medication.
The current physical health parameters (ECG / blood tests /
cardiovascular monitoring)
Any other information taken into consideration when making the
decision.
The timescale for review
A proforma is provided (Appendix 1) to facilitate the recording of this
information.
3.2
Prescribing medication for use as P.R.N
3.2.1 When prescribing p.r.n. medication as part of a strategy to de‑escalate or
prevent situations that may lead to violence and aggression:
3.2.1.1 Do not prescribe p.r.n. medication routinely or automatically on
admission
3.2.1.2
Tailor p.r.n. medication to individual need and include discussion
with the patient if possible
3.2.1.3
Ensure there is clear documentation of the rationale and
circumstances in which p.r.n. medication may be used and that
these are included in the care plan and on the prescription.
3.2.1.4
Do not exceed the maximum daily dose stated in the British
National Formulary (BNF) for each drug, or exceed 100% of the
BNF maximum for a single drug when combined with the person's
standard dose and their dose for rapid tranquillisation unless this is
planned to achieve an agreed therapeutic goal, documented, and
carried out under the direction of a senior doctor (ST / Consultant)
3.2.1.5
Ensure that the interval between p.r.n. doses is specified.
3.2.1.6
Prescriptions for p.r.n medication should state:
a) Name of medication
b) Dose or dose range
c)
Route of administration
d) Frequency of administration / minimum interval between
doses
e) Maximum dose in 24 hours
f)
Prescribers signature
g) The indication for use
h) Start date for the prescription
9
3.2.1.7
Where a medication is prescribed by more than one route, this
should be indicated on the prescription. Prescriptions allowing the
administration of a medication by more than one route e.g PO/IM
are only acceptable where there is the facility to record the route of
administration on the drug chart and the doses are bioequivalent.
3.2.2 The multidisciplinary team should review the pharmacological strategy and
the use of medication at least once a week and more frequently if events are
escalating and restrictive interventions are being planned or used. The
review should be recorded in the MDT review and include:
a)
b)
c)
d)
e)
f)
g)
3.3
clarification of target symptoms
the likely timescale for response to medication
the total daily dose of medication, prescribed and administered,
including p.r.n. medication
the number of and reason for any missed doses
therapeutic response
the emergence of unwanted effects.
Consideration of the development of dependence or tolerance to
the medication
Prescribing medication for use as rapid tranquillisation
3.3.1 When prescribing medication for use as rapid tranquillisation:
3.3.1.1
3.3.1.2
3.3.1.3
3.3.1.4
Do not prescribe rapid tranquillisation for ongoing use
Tailor each episode of rapid tranquillisation to the patients needs,
giving consideration to:
a) Previous response to medication
b) Previous tolerability of medication
c)
Patients preference
d) Concurrent prescribed medication
e) Comorbid health conditions
Prescriptions should have a set duration of treatment , initial
prescriptions should be for no more than 24 hours treatment,
subsequent prescriptions should be based on a comprehensive
review of the efficacy and tolerability of the initial prescription.
Referral for review by the MDT should be at the earliest
opportunity.
Where an ongoing need is identified for the use of rapid
tranquillisation the MDT should review the need and make the
same documentation as they would for prn medication (see 3.2)
3.3.2 If rapid tranquillisation is being used as an ongoing part of a patients care
plan, a senior doctor (ST / Consultant) should review all medication at least
once a day. This review should be documented in the patients notes.
3.3.3 When IM medication is used the incident and associated monitoring should
be reported via the local incident reporting system.
10
3.4
Use of medication in combination with physical intervention
3.4.1 Patients may occasionally require physical restraint to prevent violence to
themselves or others. Swift, safe and effective drug treatment may then be
needed to effect rapid tranquillisation and to allow subsequent evaluation
and appropriate management. Medication should be used in the context of
a combination of approaches to the management of the agitated patient and
at all stages continue talking and using non-drug approaches and use the
least restrictive option available.
3.4.2 Medication for RT, particularly in the context of physical intervention, should
be used with caution owing to the following risks:a)
b)
c)
d)
e)
f)
g)
loss of consciousness instead of tranquillisation
sedation with loss of alertness
loss of airway
cardiovascular and respiratory collapse
interaction with medicines already prescribed or illicit
substances taken
possible damage to patient-staff relationship
underlying coincidental physical disorder
3.4.3 It should noted that the risks due to medication are increased when
combined with physical restraint due to increased physical activity and
restriction of motion.
11
4 Formulary
Drug
Lorazepam
Forms available
1mg tablets
1mg/1ml intramuscular injection
Dosing
Adult: 1-2mg, up to 4mg/24hrs.
Elderly / Frail: use half adult dose.
12-18yrs: as per adult dose.
At least 1hr between doses.
Adult: 1-2mg, up to 4mg/24hrs.
Elderly / Frail: use half adult dose.
12-18yrs: as per adult dose.
Additional information
Tablets can be dispersed in water where there
are issues with swallowing (off-label use).
Absorption is no more rapid than oral: use in
those unable / unwilling to take oral medication
only.
Injection needs to be diluted 1:1 with water for
injection prior to administration.
At least 1hr between doses.
Promethazine
Haloperidol
25mg tablets
25mg/5ml liquid
25mg/ml intramuscular injection
500microgram capsules
1.5mg tablets
5mg tablets
5mg/5ml liquid
5mg/ml intramuscular injection
Adult: 25-50mg, up to 100mg/24hrs.
Elderly / Frail: as per adult dose.
At least 2hrs between doses.
Oral Dosing
Adult: 3-5mg, up to 20mg/24hrs.
Elderly / Frail: use half adult dose.
At least 2hrs between doses.
Intramuscular Dosing
Adult: 2-5mg, up to 12mg/24hrs.
Elderly / Frail: use half adult dose.
At least 1hr between doses.
Olanzapine
2.5mg tablets
5mg tablets / orodispersible tablets
In cases of non-response to standard doses,
consider
dosing
by
weight:
25–30
micrograms/kg (usual range 1.5–2.5 mg),
repeated every 6 hours if necessary.
Consider using lower starting doses in the
elderly / frail until tolerability is established, due
to risk of sedation / postural hypotension /
anticholinergic side effects.
NB: dose / maximum varies according to route
of administration due to differences in
bioavailability.
5mg PO = 3mg IM
Consider prescribing bioequivalent doses PO
and IM, and giving stated maximum as a
number of doses per 24hrs:
e.g.
Haloperidol 5mg PO or 3mg IM, no more than
4 doses to be given in a 24hr period.
Adult: 5-10mg, up to 20mg in 24hrs.
Elderly / Frail: use half adult dose.
12
10mg tablets / orodispersible tablets
15mg tablets
Risperidone
500microgram
tablets
/
orodispersible tablets
1mg tablets / orodispersible tablets
2mg tablets / orodispersible tablets
1mg/ml liquid
Aripiprazole
7.5mg/ml intramuscular injection
Zuclopenthixol
acetate
50mg/ml intramuscular injection
Midazolam
1mg/ml intramuscular injection
5mg/ml intramuscular injection
At least 4hrs between doses.
Adult: 2mg, up to 2mg/24hrs
Licensed for use in dementia for up to 6 weeks
Elderly / Frail: 1-2mg, up to treatment.
2mg/24hrs
Dementia: 250-500micrograms, up Consider using in patients already prescribed
to 2mg/24hrs
risperidone, due to inflexibility of dosing.
At least 6hrs between doses.
Adult: 5.25mg / 7.5mg / 9.75mg / Not recommended in combination with other
15mg , up to 30mg/24hrs or 3 antipsychotics. Suggest to use in those
injections.
patients treated with regular aripiprazole.
Elderly / Frail: as per adult dosing.
At least 2hrs between doses.
Adults: 50-150mg, maximum 400mg Consider when:
/ 4 injections in 14 days.
- Repeated IM administration has been
Elderly / Frail: 50-100mg, maximum
necessary
400mg / 4 injections in 14 days.
- Patient expresses a preference for this
At least 24hrs must be left after the
first dose before administering
subsequent doses.
At least 48hrs must be left after
subsequent doses before a further
dose is administered.
Adult:
2.5-7.5mg,
maximum
15mg/24hrs.
Elderly / Frail: 1-2mg, maximum
7.5mg/24hrs.
At least 1hr between doses.
Not for use in:
- Pregnancy
- Antipsychotic naiive patients
- Patients who have experienced intolerable
EPSE with typical antipsychotic medication
ONLY APPROVED FOR USE IN CASES OF
LORAZEPAM SHORTAGE.
NB: this is a controlled drug, and so
consideration needs to be given to storage /
administration restrictions.
13
4.1 Choice of treatment
4.1.1 The following should be considered when choosing which treatment is appropriate for
use, and documented in the patients notes:
a) The patients preferences or advance statements and decisions
b) Pre-existing physical health conditions
c)
Whether there is a chance the patient may be pregnant, and whether
this has been tested
d) Previous response to medication, including adverse effects
e) Potential for interaction with other medications
f)
The total daily dose of medication prescribed and administered
4.1.2 The Trust recommends the following approach be considered:
4.1.2.1
Ensure appropriate p.r.n medication is available
4.1.2.2
Where rapid tranquillisation is required:
a) Use lorazepam alone where there is no clear psychotic component to
the presentation
b) Antipsychotic medication should be avoided where there is prologation
of the QT / QTc interval (see: Reference document for monitoring the
physical health of service users taking psychotropic medication )
c)
Do not prescribe more than one antipsychotic medication and one
sedative medication at a time.
d) Where clinically necessary a sedative and antipsychotic medication
can be administered at the same time, however co-administration of
these medications should not be considered “standard treatment”.
4.1.2.3
Combined antipsychotic dosages (regular / PRN / rapid tranquillisation)
should not exceed 100% BNF maximum for a single drug unless this is
planned to achieve an agreed therapeutic goal, documented, and carried
out under the direction of a senior doctor (ST / Consultant)
4.1.2.4
Zuclopenthixol acetate is not considered to be part of rapid tranquillisation, it
should form part of a patient’s ongoing management plan, and as such
should only be prescribed by the regular MDT, except where there is a clear
indication that this is part of the MDT care plan, or it is stated in an advance
directive.
4.1.3 Zuclopenthixol acetate injection is not recommended for RT due to its significantly
delayed onset and relatively long duration of action. However, it may be considered as
an option in the management of RT when:a) Initial calming has been achieved and it is likely that repeated doses of
IM antipsychotics will be necessary.
b) It is clearly expected that the patient will be disturbed/violent over an
extended period of time and will refuse oral medication.
c)
A patient has a past history of good and timely response to it.
d) An advance directive indicates that it is the treatment of choice.
4.1.4 Zuclopenthixol acetate SHOULD NOT BE USED on individuals who:
a) Are antipsychotic (neuroleptic) naïve i.e. patients without any previous
exposure to antipsychotic medication
b) Are sensitive to extrapyramidal side effects
c)
Have cardiac disease
d) Have hepatic or renal impairment
14
e)
Are pregnant
4.1.5 The efficacy and tolerability of each individual dose should be assessed before a
decision is made regarding the prescribing or administration of further doses.
15
4.2 Decision support tool
This tool provides a summary of the information available on the use of these medications in patients with a documented co-morbidity, it
is intended as a guide, and should not be used as a replacement for clinical judgement.
Drug
Cardiac
disease
Respiritory Hepatic
Renal
Pregnancy Epilepsy
depression impairment impairment *
Effect
on QT**
No effect
Additional info
Zuclopenthixol
acetate
No effect
Contra-indicated in
patients with depressed
CNS function
Midazolam
No effect
Lorazepam
Contra-indicated in sleep
apnoea
Low
Contra-indicated in
effect
patients with depressed
CNS function
Moderate Contra-indicated in severe
effect
/ uncontrolled cardiac
disease
Low
effect
Moderate
effect
No effect
Promethazine
Haloperidol
Olanzapine
Risperidone
Aripiprazole
Key
Reccomended
Seek further guidance***
Avoid
*the use of any medication during pregnancy carries some risk, even the “recommended” treatments are not risk free. See trust policy on prescribing psychotropic medication in
pregnancy
**when used at therapeutic doses
***further guidance should be sought from a senior doctor (ST / Consultant) or a pharmacist
For up-to-date guidance on interactions or dose information please see the electronic BNF
(http://www.evidence.nhs.uk/formulary/bnf/current)
16
5
5.1
5.2
Carrying Out Rapid Tranquillisation
The advice of the senior doctor (ST / Consultant) should be available at all
times and should be used accordingly.
The patient should be able to respond to communication throughout.
5.3
The aim is to achieve a state of calm sufficient to minimise the risk posed to
the patient or to others.
5.4
Keep the drug regimen simple and document the treatment plan.
5.5
The initial doses of medicine should be small and within the recommended
BNF limits unless the patient is categorically known from previous episodes
to require larger doses.
5.6
are
Sufficient time should be allowed for the therapeutic response before doses
repeated.
5.7
Review of the efficacy and tolerability of the medication administered should
take place regularly, at intervals appropriate to the patients presentation.
5.8
After using intramuscular medication, and when the risks of harm have been
contained, conduct an immediate post‑incident review in line with the policy
on Management of Aggression and Violence, including a nurse, doctor and
where appropriate the patient, to identify and address physical harm to
patients or staff, ongoing risks and the emotional impact on patients and
staff, including witnesses.
5.9
There should be regular review of the doses of intramuscular medication
administered in order to identify any patterns of use which may inform future
care planning.
5.10
When a patient is transferred between units, a full medical history, including
the patient’s response to medications, any adverse effects, and an advance
directive should accompany them. Where possible, the patient’s account of
their experience of RT should also be included.
5.11
On discharge, all such information should be filed in the persons healthcare
record .
17
6
Physical health monitoring
6.1
Following the administration of p.r.n medication there is no additional
physical health monitoring required.
6.2
Following the administration of rapid tranquillisation the following parameters
should be monitored:
a) Blood pressure
b) Pulse
c)
Temperature
d) Respirations
e) Alertness (Using the RASS, Appendix 3)
f)
Hydration
g) Pulse oximetry (where the patient is unconscious)
6.3
Monitoring should be carried out at 15 minute intervals for the first hour, and
30 minute intervals for the second hour. Where the patient is not ambulatory
at 2 hours monitoring should continue at least every 30 minutes until the
patient is ambulatory.
6.4
An ECG should be carried out where the patient has received a dose of
antipsychtoics which takes them above a combined 100% BNF maximum.
6.5
Where it is not possible to monitor the required parameters the reasons for
this should be clearly documented and reviewed with the prescriber or the
clinical team prior to the administration of further doses.
6.6
Where it is not possible to record all of the required parameters this should
not prevent the team from recording those which are possible.
6.7
Monitoring forms should be submitted as part of an incident report via the
local incident reporting system, and filed in the patients notes.
18
7
Management of side effects and complications
7.1
Recognition and management of side effects which require medical attention
Complications Symptoms/Signs Management
Acute
Procyclidine 5-10mg IM: for severe
dystonias
Severe painful
reactions.
including
muscular stiffness Procyclidine 5-10mg PO: for moderate
oculogyric
reactions.
crisis
Hypotension
Lie patient flat and raise legs Monitor
(orthostatic or
Fall in blood
closely.
<50mmHg
pressure
Seek medical advice.
diastolic)
Increasing
temperature,
Neuroleptic
Withhold antipsychotics.
fluctuating blood
Malignant
Monitor closely.
pressure,
Syndrome
Liaise with general medical team.
muscular rigidity,
(NMS)
Creatinine Kinase levels
confusion, altered
consciousness
Arrhythmias
Respiratory
Depression
Perform an ECG.
Slow (<50/minute) Withhold antipsychotics.
or irregular pulse
Monitor closely and liaise with specialist
medical team immediately.
Reducing
respiratory rate,
reducing
consciousness
Give oxygen.
Raise legs.
If necessary ventilate mechanically.
If respiratory rate drops below 10/minute or
Oxygen Saturation <90% ring emergency
services as per cardiopulmonary
resuscitation procedures.
7.2
Respiratory depression is a well characterized side effect of
benzodiazepines, the risks of this are increased by:
a) Underlying respiratory disease
b) Existing compromised respiratory function
c)
Co-administration with other medications known to suppress
respiratory function e.g opiates.
d) Administration via the parenteral route
e) Administration of higher doses
7.3
Where a patient has received benzodiazepines and experiences respiratory
depression flumazenil should be administered. At the time of administration
the emergency services should be contacted.
19
7.4
Guidance on the use of Flumazenil
7.4.1 Flumazenil is a benzodiazepine antagonist, it will only reverse the effects of
benzodiazepine administration. If the respiratory depression is thought to be
due to other causes then do not administer flumazenil.
7.4.2 Flumazenil is a non-specific benzodiazepine antagonist, it will reverse the
effects of all benzodiazepine treatment. Where there is a prescription for
regular benzodiazepine treatment the impact of the reversal of this
therapeutic effect should be considered.
7.4.2 Flumazenil is required to be given by IV injection so this is only possible by
trained medical personnel.
7.4.3 How to give flumazenil:
i.
200 micrograms IV over 15 seconds.
ii.
If consciousness is not resumed within 60 seconds give 100
micrograms over 10 seconds.
iii.
Repeat at 60 second intervals. Maximum dose 1mg/24 hours.
7.4.4 Continue to monitor after respiratory rate returns to normal.
7.4.5 Flumazenil has a short duration of action so further doses may be
required. Patients may become agitated or anxious on awakening.
20
Appendix 1
RAPID TRANQUILLISATION EPISODE
CRITERIA AND REVIEW PATHWAY, SWYPFT
NAME
WARD
RiO NUMBER
MHA STATUS
DOB
ETHNICITY
(OR AFFIX LABEL HERE)
Criteria of Need for RT episode:
The patient currently is suffering from: (ring all symptoms)
Severe Aggression
Severe Agitation
Severe Disinhibition
Other (please specify)……………………………………………………………
Symptomatic
improvement
to
be
by………………………………………………..
There is an immediate risk to self or others (tick box)
Non-pharmacological interventions not de-escalated behaviour
measured
There is an immediate need for Rapid Tranquillisation
The following criteria have been considered ( - considered,  - unavailable)
ECG
TFT
FBC
Previous response
Patient preference
U&E
LFT
Previous tolerability
Physical health conditions
Medication regime prescribed by:
Print
Sign
Medication regime initiated by:
Print
Sign
Date
Time
Reviews of need for RT
(enter next due review and time after each review)
Planned
Actual review
Medication review
Print
review date / date / time
Effective? Tolerated?
time
Sign
21
Appendix 2
RAPID TRANQUILLISATION – ASSESSMENT AND PROGRESS CHART
Patient name
RiO Number
Date
Time
Before IM medication is administered, the following has been considered
Physical examination
Recent U & E
Recent Drug Screen
Recent ECG
History of EPSE
Past response to RT
This review led to these investigations or actions (specify any deemed necessary)
Time
Actual date and
time
Temp
BP
Pulse
bpm
Resprn.
Per min
pO2
RASS
score
Comments
Signature
0 mins
15 mins
30 mins
45 mins
60 mins
90 mins
120 mins
22
RAPID TRANQUILLISATION – ASSESSMENT AND PROGRESS CHART: GUIDANCE
Temperature
Blood pressure
Pulse (Beats / min)
Respirations (per min)
1. pO2
RASS
If temperature increasing monitor closely for Neuroleptic Malignant Syndrome:
1. Fluctuating blood pressure
2. Muscular rigidity
3. Confusion
4. Altered consciousness
If any of these feature present seek urgent medical advice.
If Diastolic <50 mmHg:
1. Lie patient flat and raise legs
2. Monitor closely.
3. Seek medical advice.
If pulse slow (<50 bpm) or irregular:
1. Perform an ECG.
2. Withhold antipsychotics.
3. Monitor closely
4. Seek medical advice
If respirations slowing:
1. Give oxygen.
2. Raise legs.
3. If necessary ventilate mechanically.
4. Seek medical advice
If respiratory rate drops below 10/minute or Oxygen Saturation <90% ring emergency services as per
cardiopulmonary resuscitation procedures.
If benzodiazepines have been administered consider administration of Flumazenil.
If < 0
1. Increase frequency of monitoring
2. If decreasing rapidly seek medical advice
23
Appendix 3
The Richmond Agitation – Sedation Scale (SWYPFT adaptations)
Score Term Description
+4 Combative:
+3 Very agitated
Overtly combative or violent; immediate danger to staff
Frequently irritable/aggressive. damaging property.
+2 Agitated
Marked restlessness such as pacing, some irritability.
+1 Restless:
vigorous
Anxious or apprehensive but movements not aggressive or
0 Alert and calm
-1 Drowsy:
Not fully alert, but has sustained (more than 10 seconds)
awakening, with eye contact to voice
-2 Light sedation:
Briefly (less than 10 seconds) awakens with eye contact to
voice
-3 Moderate sedation: Any movement (but no eye contact) to voice
-4 Deep sedation:
No response to voice, but any movement to physical
stimulation
-5 Unarousable:
No response to voice or physical stimulation
Procedure
1. Observe patient. Is patient alert and calm? (score 0)
Does patient have behaviour that is consistent with restlessness or agitation?
2. If patient is not alert, in a loud speaking voice state patient’s name and direct
patient to
open eyes and look at speaker. Repeat once if necessary.
Can prompt patient to continue looking at speaker.
24
Appendix 4
48 hour Intramuscular Zuclopenthixol Acetate Monitoring Chart
Date of injection……………………………..Time of injection…………………………..Dose………………..
Date
Time
Temp
Pulse
Resp
BP
EPSE’s
Comment/Action
Within 2 hours
1
4 hourly onwards
2
3
4
5
6
7
8
25
Appendix 5
Guidance on the Preparation and Administration of
Aripiprazole (Abilify®) Intramuscular (IM) Injection

Indicated for the rapid control of agitation and disturbed behaviours in
patients with schizophrenia or in patients with manic episodes in Bipolar I
Disorder, when oral therapy is not appropriate.

For intramuscular use only. Do not administer intravenously or
subcutaneously.

The aripiprazole injection strength is 7.5mg/ml

The aripiprazole vial contains 9.75mg in 1.3ml

The recommended initial dose for aripiprazole solution for injection is 9.75
mg (1.3 ml), administered as a single intramuscular injection.

The effective dose range of aripiprazole solution for injection is 5.25-15 mg
as a single injection. Patients with hepatic impairment should be managed
cautiously.

A lower dose of 5.25 mg (0.7 ml) may be given, on the basis of individual
clinical status, which should also include consideration other medication
already administered either for maintenance or acute treatment.

A second injection may be administered 2 hours after the first injection, on
the basis of individual clinical status.

No more than three injections should be given in any 24-hour period.

The maximum dose in 24 hours of aripiprazole is 30 mg (including all
formulations of aripiprazole).

The following shows the volume required for doses of aripiprazole injection:
Dose of aripirazole required
5.25mg
9.75mg
15mg
Volume of aripiprazole inj.
(7.5mg/ml)
0.7ml
1.3ml (complete vial)
2ml (2 vials needed)
26
Appendix 6
HALOPERIDOL ADMINISTRATION – ORAL and INTRAMUSCULAR EQUIVALENT DOSES
Intramuscular doses have a greater bioavailability than oral doses, therefore the maximum recommended daily dose
for each route of administration is different. Use separate lines on the treatment sheet for each route of administration
.
Maximum oral dose in 24 hours is 20mg
Maximum IM dose in 24 hours is 12mg
Any doses above these should be monitored according to High Dose Antipsychotic
guidance
If a patient has received both haloperidol IM and oral in the last 24 hours. Use the conversion chart below to calculate how much the
patient has received in total:
APPROXIMATE EQUIVALENT DOSES (mg)
Oral Haloperidol
0.5
1
1.5
2.5
4.2
5
7.5
8.3
10
12.5
16.7
20
IM Haloperidol
0.3
0.6
0.9
1.5
2.5
3
4.5
5
6
7.5
10
12
For example:
Patient has been given 1 x 5mg haloperidol IM, followed 30 minutes later by 5mg orally, then 30 minutes later by another 5mg orally.
Convert to all oral doses, i.e. 8.3mg + 5mg + 5mg = 18.3mg oral equivalent
OR
Convert to all IM doses, i.e. 5mg + 3mg + 3mg = 11mg IM equivalent
Therefore the patient may receive a further 10mg oral equivalent or 5mg IM equivalent haloperidol within the 24 hour period.
References - Psychotropic Drug Directory 2012
eMC – SPC Haloperidol 5.5.04
Medicines Bulletin Number 3 Writing Prescriptions: Providing a Clear Record of Drug Therapy
27
Appendix 7
Guidance on the Preparation and Administration of
Olanzapine (Zyprexa®) Intramuscular (IM) Injection

Indicated for the rapid control of agitation and disturbed behaviours in
patients with schizophrenia or manic episode, when oral therapy is not
appropriate.

For intramuscular use only. Do not administer intravenously or subcutaneously.

Administration is a maximum of three consecutive days.

The maximum dose in 24 hours is 20mg (including all formulations of olanzapine).

The recommended initial dose is 10mg. A lower dose (5mg or 7.5mg) may be
given, on the basis of individual clinical status (e.g. renal and/or hepatic
impairment).

A second injection, 5-10mg, may be administered 2 hours after the first injection.

Not more than three injections should be given in any 24-hour period.

Patients receiving olanzapine intramuscularly should be closely monitored for the
first 4 hours following the injection for hypotension, bradyarrhythmia and
hypoventilation.

Intramuscular olanzapine and intramuscular lorazepam must not be administered
within 1 hour of each other.

If olanzapine IM is prescribed as part of rapid tranquillisation ALWAYS follow the
Rapid Tranquillisation Policy, including patient monitoring parameters.
The following shows the volume required for doses of olanzapine injection:
Dose of olanzapine required
2.5mg
5mg
7.5mg
10mg
Volume of olanzapine inj.
5mg in ml
0.5ml
1.0ml
1.5ml
2.0ml
Reconstitution
1. Withdraw 2.1ml of water for injection into a sterile syringe. Inject into a vial of
olanzapine.
2. Rotate the vial until the contents have completely dissolved, giving a yellow
coloured solution. Inspected visually for particulate matter prior to administration.
3. The vial contains 11 mg olanzapine as a solution of 5mg/ml.
4. Discard the syringe and any unused solution in accordance with appropriate clinical
procedures.
5. Use the solution immediately within 1 hour of reconstitution.
28
Appendix 8
Advice on the Preparation and Administration of
Lorazepam (Ativan®) Intramuscular (IM) Injection

IM lorazepam must only be administered diluted 1:1 with sodium chloride
0.9% or water for injection.

IM Lorazepam must not be mixed with any diluents other than sodium
chloride 0.9% or water for injection.

Lorazepam injection is only manufactured as one strength: 4mg in 1ml.

The following shows the volume required for doses of lorazepam injection
4mg in 1ml:
Dose required
0.5mg
1mg
2mg
3mg
4mg

Vol. of lorazepam
=
=
=
=
=
0.125ml
0.25ml
0.50ml
0.75ml
1.00ml
Vol. of diluent
+
+
+
+
+
0.125ml
0.25ml
0.50ml
0.75ml
1.00ml
Example:
For a prescription of lorazepam 2mg IM
Draw up 0.5ml of lorazepam 4mg in 1ml and 0.5ml of sodium chloride
0.9% or 0.5ml water for injection
Always remember to mix lorazepam 1:1 with diluent

If lorazepam IM is prescribed as part of rapid tranquillisation ALWAYS follow
the Rapid Tranquillisation Policy, including patient monitoring parameters.
Lorazepam injection MUST be stored in the FRIDGE
29
Appendix 9
Policy for the use of midazolam
injection in rapid tranquillisation
Introduction
This policy outlines the use of intramuscular midazolam for rapid tranquillisation, or
the treatment of agitation or aggression. This is only to be considered for action on
receipt of a memorandum from either the Chief Pharmacist, the Deputy Chief
Pharmacist or the Principal Pharmacist for Wakefield and Forensic. declaring an
official shortage of lorazepam injection and authorising the use of intramuscular
midazolam
Midazolam is a benzodiazepine available as an intramuscular injection. It is not
licensed for agitation, but has been investigated in a randomised trial.
All formulations of midazolam were changed to controlled drug (schedule 3) status
in 2008. Within the trust this means that it should be stored in the controlled drugs
cupboard (midazolam does not need to be stored in a refrigerator) and all receipt
and administration of midazolam must be recorded in the ward controlled drugs
register.
Prescribing and administering midazolam
Where an intramuscular benzodiazepine is required, in the event of an official
shortage of lorazepam, midazolam should be prescribed instead.
The recommended dose in adults is 2.5mg (2.5ml), or 5mg (5ml) if judged to be
clinically appropriate. A further dose may be given 30 minutes later if required. This
may be titrated up to 5mg or 7.5mg according to response.
The maximum cumulative dose should not exceed 15mg in 24 hours.
In elderly patients the initial dose should be 1 to 2mg (1 to 2ml). In working age
adults where renal, hepatic, respiratory or cardiac impairment is judged to be
significant enough to compromise the patient’s well-being, this starting dose can
also be employed.
This may be repeated after 30 minutes.
The maximum cumulative dose should not exceed 7.5mg in 24 hours.
Midazolam is available at a strength of 1mg /1ml in either a 2ml or 5ml injection. It
does not require dilution before administration. Administration must be recorded in
the controlled drug register.
Wards must ensure they have access to flumazenil injection before administration.
After administration patients should be monitored according to the requirements of
the rapid tranquillisation policy, for four hours post dose.
30
Explanatory Notes
Repeated episodes of supply failure of lorazepam injection mean that an alternative
intramuscular (IM) benzodiazepine may be needed. Diazepam is inappropriate for
use as an intramuscular injection, despite this route being listed in the British
National Formulary (BNF) and manufacturer’s literature. Absorption following an IM
injection is inconsistent, leading to unpredictable therapeutic effect.
Midazolam is a benzodiazepine available as an intramuscular injection. It is
indicated for sedation before or during diagnostic or therapeutic procedures;
premedication before anaesthesia; induction of anaesthesia; and sedation in
intensive care units. It has also been investigated in rapid tranquillisation in
randomized trials (TREC, 2003)
Doses used in these studies range from 2.5mg to 15mg, however higher doses led
to a large proportion of patients being asleep within 20 minutes. The risk of
respiratory depression with midazolam is thought to be greater than with
lorazepam, so a more cautious approach to initial doses is reasonable.
Absorption from intramuscular sites is rapid and complete, with peak plasma
concentrations reached within thirty minutes. Onset of sedation and subsequent
arousal has been reported to be quicker than lorazepam 1. Elimination is also rapid,
but repeated administration can lead to accumulation, and increased risk of
adverse effects such as respiratory depression. Monitoring of the patient should
continue for at least four hours after administration, using the monitoring chart in
the rapid tranquillisation policy.
Following IM administration patients may experience anterograde amnesia, with the
patient not able to remember events which occurred when the product was at
maximum effect.
Midazolam products were reclassified as controlled drugs (schedule 3) on 1st
January 2008. This means that it is subject to controlled drug procedures, and
receipt and administration must be recorded in the controlled drug register.
The National Patient Safety Agency produced a Rapid Response Report
concerning risks of overdose caused by confusion between the different strengths
of midazolam injection (NPSA, 2008). The only strength which should be used in
the trust for rapid tranquilisation is the 1mg per ml preparation.
31
Appendix 10
Implementation
Dissemination
This policy will be implemented and disseminated throughout the organisation
immediately
following approval and will be published on the Trust Intranet site.
Local dissemination of updates will be coordinated by the pharmacy team in
conjuction with the appropriate TRIO (Clinical Lead / Practice Governance Coach /
General Manager)
Staff will be alerted to changes to the policy through the Trust management briefing
process.
Associated Documentation:
1. The antipsychotic prescribing guidelines:
Aripiprazole communication
Haloperidol communication
2. Cardiopulmonary resuscitation policy.
3. Management of violence and aggression.
Review
The Drug and Therapeutics Sub Committee will review this policy 2 years after the
implementation, although it may be fully or part reviewed on any occasion prior to
this formal review in response to legislative changes or significant procedural
changes in nursing, medical or pharmacy practice. The D&T will however
continuously monitor its implementation and practice through an agreed
programme of clinical audit as well as reviewing annual reports, incident reports
and minutes.
Compliance will be checked via the following audit parameters
1. Rapid Tranquillisation episode criteria and review pathway.
a. Record of completion
b. Completion of required data
2. Rapid Tranquillisation – assessment and progress chart.
a. Record of completion
b. Evidence of reporting via local reporting system
c. Completion of required data
3. Training
a. Percentage of staff trained
This will be carried out by the clinical governance sub-group of the D&T with each
locality/area being subject to audit at least every two years.
32
Appendix 11 - Equality Impact Assessment Tool
To be completed and attached to any policy document when submitted to the Executive
Management Team for consideration and approval.
Yes/No
1.
Comments
Does the policy/guidance affect one group
less or more favourably than another on the
basis of:
 Race
 Ethnic origins
travellers)
No
(including
gypsies
and
No
 Nationality
No
 Gender
No
 Culture
No
 Religion or belief
No
 Sexual orientation including lesbian, gay
and bisexual people
No
 Age
Yes
Older people may require
lower doses of medication
 Disability - learning disabilities, physical
disability, sensory impairment and mental
health problems
Yes
People with physical disability
may require different doses of
medicines
2.
Is there any evidence that some groups are
affected differently?
Yes
Older people and people with
a physical disability
3.
If you have identified potential
discrimination, are any exceptions valid,
legal and/or justifiable?
Yes
4.
Is the impact of the policy/guidance likely to
be negative?
NO
5.
If so can the impact be avoided?
N/A
6.
What alternatives are there to achieving the
policy/guidance without the impact?
N/A
7.
Can we reduce the impact by taking
different action?
N/A
If you have identified a potential discriminatory impact of this policy, please refer it to the Director of
Corporate Development or Head of Involvement and Inclusion together with any suggestions as to
the action required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact the Director of Corporate
Development or Head of Involvement and Inclusion.
33
Appendix 12 - Checklist for the Review and Approval of Procedural Document
To be completed and attached to any policy document when submitted to EMT for consideration
and approval.
Title of document being reviewed:
1.
2.
4.
5.
Comments
Title
Is the title clear and unambiguous?
Yes
Is it clear whether the document is a guideline,
policy, protocol or standard?
Yes
Rationale
Are reasons for development of the document
stated?
3.
Yes/No/
Unsure
Yes
Development Process
Is the method described in brief?
Yes
Are people involved in the development
identified?
Yes
Do you feel a reasonable attempt has been
made to ensure relevant expertise has been
used?
Yes
Is there evidence of consultation with
stakeholders and users?
Yes
Content
Is the objective of the document clear?
Yes
Is the target population clear and
unambiguous?
Yes
Are the intended outcomes described?
Yes
Are the statements clear and unambiguous?
Yes
Evidence Base
Is the type of evidence to support the
document identified explicitly?
Yes
Are key references cited?
Yes
Are the references cited in full?
Yes
Are supporting documents referenced?
6.
Approval
Does the document identify which
committee/group will approve it?
Yes
If appropriate have the joint Human
Resources/staff side committee (or equivalent)
approved the document?
7.
Dissemination and Implementation
Is there an outline/plan to identify how this will
be done?
Yes
34
Title of document being reviewed:
Does the plan include the necessary
training/support to ensure compliance?
8.
9.
10.
11.
Yes/No/
Unsure
Comments
Yes
Document Control
Does the document identify where it will be
held?
Yes
Have archiving arrangements for superseded
documents been addressed?
Yes
Historical documentation to be
kept on file electronically for
2yrs.
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to
support the monitoring of compliance with and
effectiveness of the document?
Yes
Is there a plan to review or audit compliance
with the document?
Yes
Review Date
Is the review date identified?
Yes
Is the frequency of review identified? If so is it
acceptable?
Yes
Overall Responsibility for the Document
Is it clear who will be responsible for
implementation and review of the document?
Jane
Riley,
Chief
Pharmacis
t
35
Appendix 13
TRAINING NEEDS
1. Medical staffing
1.1. All medical staff working within the Trust will be directed to the rapid
tranquillisation guidance on the intranet at induction.
1.2. All medical staff are required to be trained on the use of rapid
tranquillisation. Junior medical staff will be required to undertake training
annually. Middle grade medical staff will be required to attend an update
every 2 years. Consultant Psychiatrists will be required to attend an
update every 2 years.
2. Nursing Staff
2.1. There will be a rapid tranquillisation policy on each in-patient area and a
laminated copy of the algorithm in the clinic room.
2.2. Rapid tranquillisation will form part of the induction programme for the
nursing staff, including locum and agency staff.
2.3. Band 5+ nursing staff who work in the areas defined below.
2.3.1. They will be required to attend training on rapid tranquillisation
annually
2.3.2. Although rapid tranquillisation is only suitable to be carried out on inpatient areas it is important for staff working in crisis teams to be
aware of the processes.
2.3.3. It is the responsibility of the BDUs and the ward manager to ensure
staff are trained in the use of rapid tranquillisation.
3. Pharmacists
3.1. Rapid tranquillisation will form part of the induction programme for the
pharmacists including locum and agency staff.
3.2. All pharmacists who work in mental health are required to be trained on the
use of medicines in rapid tranquillisation. They will be required to attend
training annually.
4. Records of training will be held on the Trusts Education and Training
Management system.
4.1. All medical staff, ward based qualified nursing staff and pharmacists should
be familiar with the use and dangers of RT, the medications used in RT as
well as those used to reverse the effects (e.g. flumazenil in respiratory
depression).
36
4.2. At least one member of staff, per ward, per shift should be be trained to
CPR, Basic Life Support and Advisory De-fibrillation. They should be
trained to use the oxygen available on the ward and in puloximetry.
Areas identified as requiring mandatory training in Rapid Tranquillisation
Calderdale
Beechdale
Elmdale
Ashdale
Kirklees
8 Fox View
Ward 19
Ward 18
Enfield Down
Wakefield
Chantry
Horizon Centre
Priory
Trinity 1
Trinity 2
Sycamores
Poplars
Saville Park View House
Castle Lodge
Forensic Services
Low Secure
The Bretton Centre:
Sandal, Thornhill, Ryburn and Almondbury
Newhaven
Medium Secure
Appleton
Bronte
Chippendale
Gaskell
Hepworth
Priestley
Waterton
Barnsley
Melton Suite (PICU)
Clark Ward (Female acute)
Beamshaw (Male Acute)
Willow (older adult)
Intensive Home Based Treatment staff to be trained in all localities, this
training is considered essential for this group.
37
Appendix 14 - Version Control Sheet
This sheet should provide a history of previous versions of the policy and changes
made
Version
Date
Author
Statu
s
Comment / changes
1
2002
Lynn Haygarth,
Professor
Curran, David
Hargreaves,
Professor
Wattis, Nisreen
Booya
2
August
2005
Updated by
Lynn Haygarth
and David
Hargreaves
Updated to include olanzapine IM
injection
3
Septembe
r 2008
Used principles
in Bradford
District Care
Trust policy with
consent.
Updated by
Lynn Haygarth
Updated to include aripiprazole IM
injection and requirement for ECG when
prescribing haloperidol
Format brought in line with trust
requirements.
4
June 2010
Updated in line
with new
guidance
Updated by
Lynn Haygarth
 The introduction of a flow chart.
 Increase use of the forms for
assessment and progress and the
consideration of the process as a
rapid tranquillisation pathway.
 Appendices have been introduced for
the administration of the IM
injectables.
5
November
2011
Updated to
include practice
in Barnsley.
Updated by
Mark Payne
5.1
December
2012
Updated to
include
Lorazepam IM
by Paul Hardy
 Change in the therapeutic positioning
of midazolam IM
 Addition of risperidone oral as
treatment option
 Amended interval for post-intervention
monitoring
 Reformatting of flow chart
 Lorazepam IM injection has recently
become available again. To enable
either Lorazepam IM or Midazolam IM
to be used within the Trust.
5.2
January
2013
Updated to
stand down
midazolam
memo by Lynn
Haygarth
 Following D&T it was decided that
lorazepam to be IM benzodiazepine
of first choice and that midazolam
1mg/1ml injection to be removed from
wards
5.3
Septembe
r 2013
Updated The
Richmond
Agitation –
Sedation Scale
Paul Hardy
 Updated the Richmond Agitiation
Sedation Scale for ease of use.
38
5.3.1
Septembe
r 2014
Mark Payne
 Updated doses for haloperidol in line
with changes to BNF / SPC
6
February
2016
Mark Payne
Mohammed
Fazlee
Sandra Butler
 Updated in line with NICE NG 10
 Reformatted document
 Updated monitoring documents /
pathway
39
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40