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Safe Monitoring of Intramuscular
Rapid Tranquilization - Audit
Dr. Karolina Szumanska-Ryt, Dr. Ruth Collins, Dr. John Cooney
St. Michael’s Unit, Mercy University Hospital, Grenville Place, Cork, Ireland
Introduction
Gold Standard
Rapid tranquilisation (RT) is defined as the use of medication to calm/lightly
sedate the service user, reduce the risk to self and/or others and achieve an
optimal reduction in agitation and aggression. This should allow for a thorough
psychiatric evaluation to take place with comprehension and response to
spoken messages throughout the intervention. It is recognised that rapid
tranquilisation may lead to deep sedation/anaesthesia, although this is not the
overt intention. It is therefore important to ensure that vital signs are frequently
monitored to avoid any possible adverse effects as a result of intramuscular RT.
Based on a review of international guidelines, the following were developed as
the gold standard of the audit;
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All physical restraints (100%) which required intramuscular rapid
tranquilization had immediate and regular monitoring
 5 - 10 minutes for the first hour
 30 minutes for the next 2 hours
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Should a repeat intramuscular rapid tranquilization occur, the same
monitoring standards were examined.
Aim
The purpose of this audit was to assess the current monitoring standards of vital
signs and to identify any adverse events that may have resulted in relation to
poor monitoring.
Methods
This is a retrospective audit examining the clinical practice forms for physical
restraints between November 2006 and December 2009.
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Thorough examination of case notes present within ward filing system to
identify the cases which required IM rapid tranquilization.
Physical restraints which did not required IM rapid tranquilization were
excluded in the audit.
Inspection of commonly used tranquilizing agents and their effectiveness.
To assess if any adverse events occurred.
Results
A total of 92 physical restraints were examined. Of these, 62 required IM RT. 12 RT
were repeated events (24%) Fig. 1.
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The gold standard was not achieved as there was no evidence of safe
monitoring (0%) Fig. 3.
Adverse events were seen in 19% of overall cases, of these 40% were seen
in repeat RT events.
Most commonly used agents were a combination of benzodiazepine +
antipsychotic (52%).
Single agent use was associated with a higher risk of repeat physical
restraint and RT (32%) versus combination of agents (18%) Fig. 4.
Evidence of Safe Monitoring
An adverse event was defined as;
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Gold Standard (100%)
RT resulted in direct injury to patient as a result of poor monitoring of
vitals and patient.
High dose administering or unsafe combination use without monitoring of
vitals.
Clinical situation prior to RT is deemed unsafe and would warrant closer
monitoring of vitals.
Mean arterial pressure (MAP) < 70 based on documented vitals and no
action taken.
no Evidence of Safe Monitoring (0%)
Evidence of Safe Monitoring
Data was collected with standard pro forma and basic statistical calculations
were used.
92 Physical Restraints examined
-> (30 no IM Rapid Tranquilization)
Fig. 3. Results of safe monitoring
-> 62 IM Rapid Tranquilization
50 Initial IM Rapid Tranquilization
12 Repeat IM Rapid Tranquilization
Medications
RT
(n= 50)
Required a
repeat RT
(n= 12)
Total repeat RT
Benzodiazepine
12 (24%)
4 (33%)
7/22 single agent use (32%)
Antipsychotic
10 (20%)
3 (30%)
Benzodiazepine +
Antipsychotic
26 (52%)
4 (15%)
Antipsychotic +
Antipsychotic
2 (4%)
1 (50%)
(24%)
Fig. 1. Breakdown of RT events
RAPID TRANQUILIZATION RECORDING FORM:
Name
Consultant
5/28 combination agent use (18%)
Date/Time
MHA Status
List the medication given during the episode of Rapid Tranquilization
Medication
Dose
Time
Route
Fig. 4. Types of agents used in RT
Notes
Conclusions
Please note, this is NOT a prescription
Physical Monitoring:
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Alertness
Respiratory rate
Pulse
Blood pressure
Temperature
Spo2
1. Every 5-10 minutes for 1 hour
2. Then every 30 minutes until patient is ambulatory
3. Then continue to monitor alertness, mental state and behaviour.
Restart physical observations if there are any concerns.
The use of a single agent (22 cases) was associated with a higher risk of repeat RT
versus the use of 2 agents in combination (28 cases) Fig. 4.
Fluid balance & electrolyte balance should be monitored as clinically indicated
ECG monitoring is recommended when parenteral antipsychotics have been given in high doses
If a patient is unconscious continuous pulse oximetry is recommended
Time:
Respiratory
Rate / min
Pulse
/ min
02
Saturations
Blood
Pressure
Temp
Alertness
Adequate monitoring of vital signs could have prevented many of the adverse
events seen in this audit. Evidence also suggests that training of staff in both
monitoring of patient and the use of de-escalation techniques can prevent and
provide safe RT to the service user.
Signature
(see chart below)
Baseline:
The following were recommendations from the results of the audit;
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A
V
P
U
Alert: Eyes open with normal verbal response.
Voice: Eyes closed but will open eyes on command, and with normal verbal response.
Pain: Eyes closed, responds to painful stimuli (nail bed depression – finger or toe nail).
Unresponsive: Does not respond to ANY of the above. Completely unconscious
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Summary:
(Main issues should be recorded in case notes including comments from service user or adverse events)
Staff Name:
Fig. 2. RT vital sign monitoring form
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Propose a document for vital sign monitoring (Fig. 2) along with guidance on
managing common adverse events
Incorporate this document into the development of a departmental guideline
for IM rapid tranquilization
Incorporate the IM RT guideline into the induction teaching program to raise
awareness of key management decisions.
Training for all staff members in;
 Preventative measures – recognizing risk situations
 De-escalation techniques
 Use of monitoring equipment
 Resuscitation skills and equipment training
Re-audit to complete cycle