Download Benzodiazepines for seizure control

Document name:
Benzodiazepines for seizure
control
Document type:
Policy
What does this policy
replace?
Update of previous policy.
Staff group to whom it
applies:
All staff within the Trust
Distribution:
The whole of the Trust
Version 3
How to access:
Intranet
Issue date:
May 2015
Next review:
May 2017
Approved by:
Drug and Therapeutic Sub Committee
Developed by:
Mark Payne
Sandra Montisci
Joanne Brown
Director leads:
Medical Director
Contact for advice:
Med.information @SWYPFT.nhs.uk
Mark Payne
Contents
1
Introductions .................................................................................................................. 1
2
Care Planning ................................................................................................................ 1
3
Place in treatment.......................................................................................................... 2
4
Choice of agent ............................................................................................................. 2
5
Administration and monitoring of treatment .................................................................. 3
5.1 Administration
5.2 Post-administration monitoring
5.3 Physical health monitoring guidance
6
Training ....................................................................................................................... 4
Appendix 1
Midazolam Information Sheet ............................................................................................... 5
Appendix 2
Rectal Diazepam Information Sheet ..................................................................................... 7
Appendix 3
Flumazenil Information Sheet ............................................................................................... 9
Appendix 4
Different seizure types .......................................................................................................... 10
Appendix 5
Care Plan for Administration of Treatment for Seizures ........................................................ 11
Appendix 6
Administration of Benzodiazepines for the Treatment of Seizures
Assessment and Progress Chart .......................................................................................... 12
Appendix 7
Benzodiazepines for Seizure Control Standard Operating Procedure................................... 13
Appendix 8
Equality Impact Assessment Tool......................................................................................... 15
Appendix 9
Checklist for review and Approval of Procedural Document ................................................. 17
Appendix 10
Version Control Sheet .......................................................................................................... 18
Appendix 11
List of professional groups approved to administer in SWYT………………………………….19
i
Benzodiazepines for seizure control
1.
Introduction
Prolonged or repeated seizures are considered a medical emergency, and as such it is
important that there is a clear policy within the organisation for the management of seizures
to ensure that all service users receive an appropriate level of care.
Where benzodiazepines are prescribed for the management of seizure there should be a
clear, personal care plan, or protocol, for their treatment and monitoring. All healthcare staff
involved with their care should be made aware of this plan.
Standard first aid practice applies to all epilepsy medical emergencies with additional
specialist consideration to secure the individual’s airway and assess his or her cardiac and
respiratory function. This must be monitored closely and effectively.
SWYPFT is not a specialist provider of epilepsy services, and as such will aim to provide the
same care as patients would expect to receive in the community, with appropriate referral to
specialist services for support with diagnosis and management of ongoing seizure disorders.
Aim
This policy sets out the acceptable use of medication for the management of seizures within
SWYPFT, regardless to the aetiology of the seizure. It will also set out the standards for
providing treatment to those at an ongoing risk of seizures.
Scope
This policy applies to all staff working in SWYPFT hospital settings.
SWYPFT staff working in the community should consider completing a risk assessment /
care plan to cover the requirements that they cannot fulfil.
SWYPFT staff working within other partner organisations should work to the policy of that
organisation.
2.
Care planning
All patients prescribed benzodiazepines for the management of seizures in the context of an
on-going health condition that pre-disposes them to an increased risk of seizures should
have a detailed care plan.
Those patients prescribed benzodiazepines for the management of seizures in the context of
an acute health condition or medication side effect should have a brief care plan.
Details of the guidance about information for inclusion in a care plan are outlined in Appendix
5.
As epilepsy and other disorders pre-disposing to seizures can present differently in different
individuals it is essential to determine the existence of a care plan at the point of admission
to service, and to ensure that it is transferred with the individual where care is transferred to
a different provider / location.
The requirements of this policy should always be read in conjunction with the individuals care
plan; the policy provides the required approach to management, and the care plan details the
requirements specific to that individual. Unless otherwise stated all requirements in the policy
should be met, but timescales / monitoring / follow-up can be individualised according to the
care plan.
1
3.
Place in treatment
Immediate emergency care and treatment including pharmacological management should be
administered to children, young people and adults who have prolonged (lasting 5 minutes or
more) or repeated (three or more in an hour) convulsive seizures.
Depending on response to treatment, the person's situation and any personalised care plan,
call an ambulance, particularly if:
 the seizure is continuing 5 minutes after the emergency medication has been
administered
 the person has a history of frequent episodes of serial seizures or has convulsive
status epilepticus, or this is the first episode requiring emergency treatment or
 there are concerns or difficulties monitoring the person's airway, breathing, circulation
or other vital signs
Medication for the acute management of seizures should be prescribed and available for all
service users who have a diagnosis of epilepsy or who are at high risk of experiencing
seizures due to medical co-morbidities or pharmacotherapy.
Benzodiazepines have a place in regular treatment as an adjunct to anti-epileptic drug
treatment; however these are not first-line choices and so should not be initiated except on
the advice of a specialist.
4.
Choice of agent
As SWYPFT does not have direct access to acute hospital medical facilities, the choices of
treatment are the same as those that would be offered to a service user in the community.
Where more intensive or specialist treatment is required a referral will be made to a general
hospital or epilepsy specialist as appropriate.
Drug
Route
Diazepam
Rectal
Dose
range
5-20mg
Midazolam
Buccal
2.5-10mg
NB: Different
preparations are
not interchangeable
Other
agents
Oral /
Injectable
Variable
Indication
Cost
High risk individuals
Individuals without a care
plan
Individuals with an existing
care plan
On specialist
recommendation
Individuals with an existing
care plan
On specialist
recommendation
Refer to pharmacy for
advice
£7.35 / 5 x 10mg
£91.50 / 4 x 10mg
£55.86 / 5ml x
10mg/ml
Variable
Rectal diazepam has been chosen as a first line agent due to the risk potential associated
with confusion between different forms of midazolam (see Appendix 1), and the practical
issues that would be associated with making all forms available to all service users. This is in
line with NICE guidance that rectal diazepam is offered where buccal midazolam is
unavailable.
2
5.
Administration and monitoring of treatment for the management of an acute
seizure
The following principles should be observed for all patients, however where there is a care
plan for the use of benzodiazepines for the acute management of seizures then this must
also be consulted prior to undertaking any of the specified activities.
5.1
Administration
Treatment should be administered in line with the manufacturer’s guidance.
Requests for routes of administration outside of the manufacturer’s guidance should be
referred to the locality pharmacist for individual patient care planning.
5.2
Post-administration monitoring
Care must be taken to secure the child, young person or adult's airway and assess his
or her respiratory and cardiac function.
Close monitoring (observation of patient within eyesight) by staff is required.
Observations should be particularly frequent when a patient is sedated.
The following should be monitored using standard ABCDE first aid methods and
recorded regularly in the patient’s notes (where available), at 15 minute intervals, until
the patient becomes active again.
1. Pulse
2. Breathing/Respiratory rate
3. Temperature (inpatient and specialist community units only)
4. Blood pressure (inpatient and specialist community units only)
5. Oxygen saturation (inpatient and specialist community units only)
6. Monitor ECG if equipment available
7. Blood glucose monitoring if equipment available
Where the service user exhibits lowered levels of consciousness post-administration
they should be placed into the recovery position.
Where a service user experiences adverse effects that put them at risk medical support
should be requested, either by use of locality medical team or the emergency services.
In all inpatient areas administering these medications flumazenil must be available.
Flumazenil must be given by intravenous injection so appropriately trained medical or
nursing staff must be available (see Appendix 3). This is only likely to be necessary in
exceptional circumstances but all areas should have a plan for dealing with these
situations.
If the individual’s respiratory rate drops below 10/minute, they do not respond to rectal
diazepam or buccal midazolam, or their oxygen saturation is less than 88% and it is not
responding to oxygen being administered:
CALL AN AMBULANCE IMMEDIATELY using 999
A Standard Operating Procedure for administration / monitoring is included
(Appendix 7)
5.3
Physical health monitoring guidance
Due to the nature of the situation in which these medications are used it is not always
possible to take baseline observations (blood pressure, pulse rate, respiratory rate and
the level of consciousness) prior to the administration of drugs.
Close monitoring (observation of patient within eyesight) by staff is required.
Observations should be particularly frequent when a patient is sedated. A template
recording form is provided (See Appendix 6), where this is not used a local solution
must be implemented to ensure this data is recorded.
3
After administration of buccal / rectal benzodiazepines the monitoring of respiratory and
cardiac function are essential in an inpatient setting. If observations are difficult then
this should be clearly documented in the patient’s notes and discussed with the
prescriber or the clinical team. It is particularly important to ensure that wellbeing is
maintained if the patient is asleep or appears to be asleep, then the monitoring of vital
signs including saturation levels continues.
6. Training
Staff involved in administration of medication to individuals who require emergency rectal
diazepam and/or buccal midazolam must have:
 Read the information leaflets for both buccal midazolam and rectal diazepam
(Appendix 1 and 2)
 Familiarised themselves with the products
 Been informed of the need for care plans (Appendix 5), and where to find these
locally
 Have read and understood the information on different seizure types (Appendix 4)
 Have been trained in basic life support and AED
 Have familiarised themselves with the requirements of the policy.
Local training sessions will be arranged to cover these issues where they are not covered by
the individuals professional training and core competencies.
The training requirements automatically include, but are not limited to the following groups of
staff:
 Healthcare assistants
 Occupational therapists
 Physiotherapists
For other health professionals who need to undertake this activity, approval must be sought
from the SWYPFT lead for the profession, and support for this activity by the professional
body must be demonstrated, where appropriate this decision may also be made by the Drugs
and Therapeutics Committee. A register of the approved professional groups can be found in
Appendix 11.
Where additional learning needs are identified locally these should be referred to the
appropriate manager / practice governance coach. As SWYPFT is not a specialist provider of
epilepsy services partner organisations will be approached to assist in the development of
learning solutions
All carers should be provided with a care plan and an opportunity to discuss the care plan
with a member of SWYPFT staff and understand the indications for use.
NB SWYPFT cannot validate training provided by other organisations.
4
Appendix 1
Midazolam information sheet
There are currently two forms of buccal midazolam available for use; midazolam
hydrochloride 5mg/ml (Buccolam®) and midazolam maleate 10mg/ml (Various preparations
are available). There is no therapeutic difference between the two preparations.
Buccolam® is the preferred formulation as it is a licensed medical product and comes in prefilled syringes which reduce the risk of incorrect dose selection / administration in an
emergency.
To prevent confusion all prescriptions for buccal midazolam should be made by brand name
rather than by drug name or form.
NB: Buccolam (midazolam hydrochloride) is only licensed for use in the under 18’s
NB: Midazolam maleate does not hold a UK product license
Use of both of these products outwith the remit of a UK license is endorsed by NICE and so
should not be considered as a barrier to appropriate treatment.
Route of administration
Buccal cavity
Dosing
Age range
Dose
Label colour
3 to 6 months
hospital setting
2.5mg
Yellow
> 6 months to < 1 year
2.5mg
Yellow
1 year to < 5 years
5 mg
Blue
5 years to < 10 years
7.5 mg
Purple
10 years and over
10 mg
Orange
Common adverse effects
Sedation, somnolence, respiratory depression.
Nausea and vomiting.
Cautions
Midazolam should be used with caution in patients with chronic respiratory insufficiency
because midazolam may further depress respiration.
Midazolam should be used with caution in patients with chronic renal failure, impaired
hepatic or cardiac function. Midazolam may accumulate in patients with chronic renal failure
or impaired hepatic function whilst in patients with impaired cardiac function it may cause
decreased clearance of midazolam.
Debilitated patients are more prone to the central nervous system (CNS) effects of
benzodiazepines and, therefore, lower doses may be required.
Midazolam should be avoided in patients with a medical history of alcohol or drug abuse.
Midazolam may cause anterograde amnesia.
Contraindiactions
Hypersensitivity to the active substance, benzodiazepines or to any of the excipients.
Myasthenia gravis
Severe respiratory insufficiency
Sleep apnoea syndrome
Severe hepatic impairment
5
Instructions for use
BUCCOLAM® (MIDAZOLAM OROMUCOSAL
SOLUTION): ADMINISTRATION
 The full amount of solution
should be inserted slowly
into the space between the
gum and the cheek
 Can be administered
while the patient is lying on
his/her back or in a seated position
 If necessary (for larger volumes of BUCCOLAM and/or smaller
patients), approximately half the dose should be given slowly
into one side of the mouth, then the other half given slowly
into the other side.
6
Appendix 2
Diazepam information sheet
Concerns have been raised about the use of rectal diazepam regarding the privacy and
dignity of the route of administration for service users in the community; however it remains
an effective and well tolerated treatment and due to cost pressures should be considered as
the first line treatment where there is not a clear history of prolonged / repeated seizures.
Dosing
Dosage depends on age and weight.
Children:
0.5mg/kg
(not recommended for use in children < one year old)
Adults:
0.5mg/kg
In practice there are two strengths available, 5mg and 10mg. For both presentations it is
impractical to give anything other than the full dose accurately, so the following guidance
should be used:
<15kg
5mg
>15kg
10mg
Where a first dose is ineffective within 5 minutes of administration a second dose should not
be given and emergency medical assistance should be sought.
Where a second episode of seizure activity occurs after successful treatment of an initial
episode a further dose may be given provided that at least 12 hours have elapsed.
Common adverse effects
Sedation, somnolence, respiratory depression.
Nausea and vomiting.
Cautions
Diazepam should be used with caution in patients with renal or hepatic dysfunction, chronic
pulmonary insufficiency, porphyria, myasthenia gravis, coma, organic brain changes,
particularly arteriosclerosis.
Diazepam may enhance the effects of other CNS depressants; their concurrent use should
be avoided.
Elderly and debilitated patients are more prone to the CNS effects of benzodiazepines and,
therefore, lower doses are required.
Benzodiazepines may induce anterograde amnesia. The condition occurs most often several
hours after administration. To reduce the risk, where appropriate and possible, patients
should be able to have an uninterrupted sleep of 7-8 hours after administration.
Reactions like restlessness, agitation, irritability, aggressiveness, delusion, rages,
nightmares, hallucinations, psychoses, inappropriate behaviour and other adverse
behavioural effects are known to occur when using benzodiazepines. Should they occur, use
of diazepam should be discontinued.
The disinhibiting effects of benzodiazepines may be manifested as the precipitation of
suicide in patients who show aggressive behaviour towards self and others.
This medicinal product contains 0.85mmol sodium per dose. This should be taken into
consideration in patients on a controlled sodium diet.
Contraindications
Known hypersensitivity to benzodiazepines or any of the ingredients.
Severe or acute respiratory insufficiency/depression
Sleep apnoea syndrome
Severe hepatic insufficiency
7
Instructions for use
8
Appendix 3
Flumazenil information sheet
Flumazenil is a specific competitive inhibitor of substances which act via the benzodiazepine
receptors, specifically blocking their central effects. It is indicated for use for the reversal of
the central effects of benzodiazepines including their respiratory depressant and
consciousness depressant effects; it is also likely to reverse any effects on the
cardiovascular system.
It is important to note that the reversal of effects is non-specific, so any beneficial effects will
be reversed along with any adverse effects. This may lead to a recurrence of seizures and
this must be considered when administering this medication.
The hypnotic-sedative effects of benzodiazepines are rapidly reversed by flumazenil and
may then reappear gradually within a few hours, depending on the half-life and dose ratio of
the agonist and antagonist.
Flumazenil should only be administered by staff who are trained to give intravenous
injections.
Dosing/ Administration
Flumazenil is given intravenously:
1) 200mcg IV. over 15 seconds
2) If reversal of effects is not achieved within 60 seconds give 100mcg over 10 seconds
3) Repeat at 60 second intervals. Maximum dose 1mg/24 hours
Continue to monitor after respiratory rate returns to normal.
Flumazenil has a short duration of action so further doses may be required. Patients may
become agitated or anxious on awakening.
Common adverse effects
Nausea and vomiting
Use in renal and hepatic insufficiency
No dosage adjustments are necessary in patients with renal impairment. However, since
flumazenil is primarily metabolised in the liver, careful titration of dosage is recommended in
patients with impaired hepatic function.
The individually titrated, slow injections or infusions of flumazenil should not produce
withdrawal symptoms, even in patients exposed to high doses of benzodiazepines and/or for
long periods of time. If, however, unexpected signs of overstimulation occur, an individually
titrated dose of diazepam or midazolam should be given.
If a significant improvement in consciousness or respiratory function is not obtained after
repeated doses of flumazenil, a non-benzodiazepine aetiology must be assumed.
9
Appendix 4
Different seizure types
Seizure type
Tonic-clonic seizures
Tonic seizures
Atonic seizures
Absence seizures
Focal seizures
(Partial seizures)
Common features
At the start of the seizure:
 the person becomes unconscious
 their body goes stiff and if they are standing up they usually
fall backwards
 they may cry out
 they may bite their tongue or cheek.
During the seizure:
 they jerk and shake (convulse) as their muscles relax and
tighten rhythmically
 their breathing might be affected and become difficult or
sound noisy
 their skin may change colour and become very pale or
bluish
 they may wet themselves.
After the seizure (once the jerking stops):
 their breathing and colour return to normal
 they may feel tired, confused, have a headache or want to
sleep
In a tonic seizure the person’s muscles suddenly become stiff. If
they are standing they often fall, usually backwards, and may injure
the back of their head. Tonic seizures tend to be very brief and
happen without warning.
In an atonic seizure (or 'drop attack') the person’s muscles
suddenly relax, and they become floppy. If they are standing they
often fall, usually forwards, and may injure the front of their head or
face. With both tonic and atonic seizures people usually recover
quickly, apart from possible injuries.
During an absence a person becomes unconscious for a
short time. They may look blank and stare, or their eyelids might
flutter. They will not respond to what is happening around them. If
they are walking they may carry on walking, but will not be aware of
what they are doing.
In focal seizures the seizure starts in, and affects, just part of the
brain, sometimes called the 'focus' of the seizures. It might affect a
large part of one hemisphere or just a small area in one of the
lobes. What happens during the seizure depends on where in the
brain the seizure happens and what that part of the brain normally
does.
In simple focal seizures (SFS) a small part of one of the lobes of
the brain is affected. The person is conscious (aware and alert) and
will usually know that something is happening and will remember
the seizure afterwards.
Some people find their simple focal seizures (SFS) hard to put into
words. During the seizure they may feel ‘strange’ but not able to
describe the feeling. This may be upsetting or frustrating for them.
Complex focal seizures (CFS) affect a bigger part of one
hemisphere (side) of the brain than a simple focal seizure. The
person’s consciousness is affected and they may be confused.
They might make strange or repetitive movements that have no
purpose (called ‘automatisms’). They may wander around, or
behave strangely, and they may not be aware of what they are
doing.
10
Appendix 5
Care planning
When developing care plans for the management of seizures, two separate levels of care
planning should be considered, dependant on whether the risk of seizures is on-going or
acute.
Basic care planning (acute health need)
 Name of individual
 The rationale for prescribing.
 When this will be reviewed
Prescribing in these situations should be in line with the current dosing guidance as laid out
in the BNF.
Detailed care plan (on-going health need)
 Name of individual
 Seizure classification/description
 Possible seizure triggers
 Possible seizure warning signs
 Usual duration of seizure
 Usual recovery from seizure
 When rectal diazepam / buccal midazolam should be administered
 How much is to be given
 What the usual reaction is
 Whether a repeated dose can be given
 Time interval for a repeat administration
 Maximum dose in a 24-hour period
 When rectal diazepam/ buccal midazolam should not be administered
 When emergency services should be contacted
 Other people to be contacted (if appropriate)
The seizure management care plan should have a review date of no longer than six months,
to ensure that it is reviewed and remains current.
Where a care plan exists this must be clearly documented in the service user’s notes.
It is good practice to check for the existence of a care plan at the point of entry to services.
It is the responsibility of the MDT for the ward to develop and document a care plan for each
individual prescribed these medications. Where service users are admitted to services with
an existing prescription for these medications this can be continued for up to 48hrs without a
care plan until the regular treating team can carry out a review.
11
Appendix 6
ADMINISTRATION OF BENZODIAZEPINES FOR THE TREATMENT OF SEIZURES – ASSESSMENT AND PROGRESS CHART
NAME:
DOB:
RiO No/NHS No:
Step
Actual date and
time
Temp
BP
Pulse
Bpm
Resprn.
Per min
Comments
Signature
Review
num 1*
2
3
4
5
6
7
8
9
10
11
12
13
14
*Every 15 minutes until patient is ambulatory
12
Appendix 7
Benzodiazepines for seizure control
Standard Operating Procedure
Objective
This procedure outlines the process to be undertaken when administering benzodiazepines
for the treatment of seizures, and the monitoring that is required post-administration.
Scope
This policy is applicable to all members of SWYPFT staff who are involved in the
administration of benzodiazepines for the treatment of seizures and any post-administration
monitoring.
This procedure must be read in conjunction with the policy for the pharmacological control of
seizures.
Procedure:
Equipment required
Disposable gloves
Alcohol hand gel
Medication for administration
Service user care plan (if available)
Procedure
Action
Rationale
1. Check care plan (where one exists)
To be aware of the service user’s
presentation when medication is required
2. Check stock of medication and where
necessary order medication from local
pharmacy department
To ensure that medication is available when
needed
NB Midazolam is a controlled drug
3. Check prescription chart against care plan
(where one exists)
To ensure it is clear what treatment should
be administered
4. Select medication from storage cupboard
5. Check medication against prescription
chart / MAR chart
To ensure the medication is given as
prescribed
6. Ensure hands are clean and free from dirt,
or apply sterile gloves
To prevent spread of infection
7. Optimise privacy
To maintain dignity
8. Explain procedure to service user (even if
they appear unconscious)
To allay anxiety and promote reassurance
9. Administer the medication in accordance
with the manufacturers instructions
To ensure medication is given appropriately
and the therapeutic effect is achieved
10. Monitor service user for signs of efficacy
of treatment
To ensure appropriate care is given
13
11. Monitor physical health parameters
a. Pulse
b. Breathing/Respiratory rate
c. Temperature (inpatient and specialist
community units only)
d. Blood pressure (inpatient and
specialist community units only)
e. Oxygen saturation (inpatient and
specialist community units only)
f. Monitor ECG if equipment available
g. Blood glucose monitoring if equipment
available
To ensure appropriate care is given
12. If the treatment has not had the desired
effect at 5 minutes alert the emergency
services.
To reduce risk of seizure related harm
13. If respirations fall below 10 / minute alert
the emergency services
To reduce risk of treatment related harm
14. If blood oxygenation falls below 88% or
the level specified in the care plan alert the
emergency services
To reduce risk of treatment related harm
15. If the service user experiences severe
adverse effects of the medication summon
medical assistance to consider suitability for
administration of flumazenil
To reduce the risk of treatment related harm
16. Clear away any items used during
administration and dispose of them in the
appropriate waste stream.
To reduce risk of cross contamination of
waste and ensure a clean and tidy working
environment
17. Remove gloves (if worn), wash and dry
hands in line with local infection control
procedures
To reduce risk of infection.
18. Record administration using the
prescription / MAR chart / care plan
To ensure a clear audit trail is available and
maintain patient records
14
Appendix 8 - Equality Impact Assessment Tool
To be completed and attached to any policy document when submitted to the Executive
Management Team for consideration and approval.
Equality Impact Assessment
Evidence based Answers & Actions:
Questions:
1
Name of the policy that you
are Equality Impact Assessing
Benzodiazepines for seizure control
2
Describe the overall aim of
your policy and context?
The overall aim of the policy is to describe the Trust’s
approach to the use of benzodiazepines for the control
of seizures
All staff
Who will benefit from this
policy?
3
Who is the overall lead for this
assessment?
4
Who else was involved in
conducting this assessment?
5
Have you involved and
consulted service users,
carers, and staff in developing
this policy?
The LD MM group were involved in the development of
the original policy from which this was developed.
N/A
What did you find out and how
have you used this
information?
6
What equality data have you
used to inform this equality
impact assessment?
N/A
7
What does this data say?
N/A
8
Taking into account the
information gathered.
Does this policy affect one
group less or more favourably
than another on the basis of:
Where Negative impact has been identified please
explain what action you will take to remove or
mitigate this impact.
Race
Disability
Gender
Age
Sexual Orientation
Religion or Belief
Transgender
Carers
If no action is to be taken please explain your
reasoning.
YES
NO
N
N
N
N
N
N
N
15
9
What monitoring
arrangements are you
implementing or already have
in place to ensure that this
policy:
 promotes equality of
opportunity who share
the above protected
characteristics
 eliminates
discrimination,
harassment and
bullying for people who
share the above
protected
characteristics
 promotes good
relations between
different equality
groups,
10
Have you developed an Action
Plan arising from this
assessment?
11
Who will approve this
assessment and when will you
publish this assessment.
12
Once approved, please
forward a copy of this
assessment to the Equality &
Inclusion Team:
[email protected]
Adherence with the policy will be audited after it has
been agreed and implemented.
Patient characteristics will be recorded as part of the
audit and underlying trends can be examined to
ensure equality.
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.
16
Appendix 9 - 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.
Yes/No/
Benzodiazepines for seizure control
Comments
Unsure
1.
Title
Is the title clear and unambiguous?
YES
Is it clear whether the document is a
YES
guideline, policy, protocol or standard?
Is it clear in the introduction whether this
YES
document replaces or supersedes a
previous document?
2.
Rationale
Are reasons for development of the
YES
document stated?
3.
Development Process
Is the method described in brief?
YES
Are people involved in the development
YES
identified?
Do you feel a reasonable attempt has
YES
been made to ensure relevant expertise
has been used?
Is there evidence of consultation with
NO
stakeholders and users?
4.
Content
Is the objective of the document clear?
YES
Is the target population clear and
YES
unambiguous?
Are the intended outcomes described?
YES
Are the statements clear and
YES
unambiguous?
5.
Evidence Base
Is the type of evidence to support the
YES
document identified explicitly?
Are key references cited?
YES
Are the references cited in full?
YES
Are supporting documents referenced?
YES
6.
Approval
Does the document identify which
YES
committee/group will approve it?
If appropriate have the joint Human
N/A
Resources/staff side committee (or
equivalent) approved the document?
7.
8.
9.
Dissemination and Implementation
Is there an outline/plan to identify how this
will be done?
Does the plan include the necessary
training/support to ensure compliance?
Document Control
Does the document identify where it will be
held?
Have archiving arrangements for
superseded documents been addressed?
Process to Monitor Compliance and
Effectiveness
Are there measurable standards or KPIs to
YES
N/A
YES
YES
YES
17
Benzodiazepines for seizure control
10.
11.
support the monitoring of compliance with
and effectiveness of the document?
Is there a plan to review or audit
compliance with the document?
Review Date
Is the review date identified?
Is the frequency of review identified? If so
is it acceptable?
Overall Responsibility for the Document
Is it clear who will be responsible
implementation and review of the
document?
Yes/No/
Unsure
Comments
YES
YES
YES
YES
Appendix 10 - Version Control Sheet
This sheet should provide a history of previous versions of the policy and changes made
Version
Date
Author
Status Comment / changes
3
May 15 Mark Payne
Review of policy content / structure to
Joanne Brown
make it more accessible
Sandra Montesci
Review of rationale for use of
diazepam first line, as the NICE
costing statement has been
withdrawn.
Review of training requirements.
2
Dec 12 Mark Payne
Final
Change of name and update to
Lead Clinical
include children’s services and new
Pharmacist for PLD
product Buccolam
1.1
Additions by Simon
Addition of oxygen information
Plummer
Dec 09 Mark Payne and
Lynn Haygarth
18
Appendix 11 – List of professional groups authorised to administer in SWYT
Professional group
Physiotherapists
Approval
Drugs and Therapeutics
Date of approval
May 2015
Occupational therapists
Drugs and Therapeutics
May 2015
19