Rapid tranquillisation policy and guidelines (pharmacological management of violence)

Contents

Restrictive intervention statement

The department of health launched positive and proactive care, reducing the need for restrictive interventions in April 2014, positive and proactive care reducing restrictive interventions guidance (opens in new window).

The document promotes the development of therapeutic environments and reducing all forms of restrictive practice so that they are used as a last resort only and then for the shortest possible time.

The trust is totally committed to providing high quality, person centred care that maintains the dignity of, and respect for our patients, ensuring that restrictive interventions used within inpatient areas are reduced.

All aspects of risk management are to be implemented, taking account of the person’s wishes and best interests, operating within a framework of continual monitoring, reviewing and reducing any necessary restrictive practice.

These frameworks are implemented via trust level policies and procedures with assurance being derived from internal audits and inspections and external review from monitor and CQC.

The trust’s lead for this work is the director of nursing and quality; who is the chair of the trust’s restrictive interventions steering group.
Six key aims have been identified to ensuring improved care:

• colleagues must not deliberately restrain people in a way that impacts on their airway, breathing or circulation, such as face down restrain on any surface, not just on the floor
• if restrictive intervention is used, it must not include the deliberate application of pain
• if a restrictive intervention has to be used, it must always represent the least restrictive option to meet the immediate need
• the use of seclusion is permitted under the guidance as detailed in the MHA Code of Practice (2008). However, as the purpose of seclusion is to contain exceptional emergency situations which compromise standards of safety, it is possible that seclusion could be used in relation to a patient who is not subject to detention under the MHA 183. In these circumstances common law powers would be used to seclude the patient, but in using these powers, colleagues must only use a degree of physical or medical intervention, which is sufficiently enough to bring the emergency to an end
• people who use services, families and carers must be involved in planning, reviewing and evaluating all aspects of their care and support
• individualised support plans, incorporating behaviour support plans must be implemented for all people who use our services

1 Introduction

• Rapid tranquillisation refers to the use of medication to manage acute behavioural disturbance by calming or lightly sedating the patient, to reduce the immediate risk of harm to self or others and reduce agitation and aggression. Thereby allowing an opportunity for a thorough psychiatric examination to take place. Prescribers should aim to ensure that the degree of sedation arising from rapid tranquillisation does not compromise the patient’s capacity to understand and respond to what is said to them. This should be a very short-term strategy designed solely to reduce immediate risk and is distinct from treating any underlying mental illness.
• Rapid tranquillisation should only be used, when other therapeutic interventions (de-escalation and other strategies) have failed, where a patient is highly aroused, agitated, overactive and aggressive, or is making serious threats or gestures towards others, or is being destructive to their surroundings
• Rapid tranquillisation should be considered as a management strategy and not a primary treatment technique. Throughout the process of administering rapid tranquillisation regard must be given to maintaining the patient’s privacy and dignity. This will, wherever possible include, the gender of colleagues administering the medication and caring for the patient for example, physical observations and the location of the procedure or incident.
• The guidelines on pharmacological treatments contained within this policy have been produced on behalf of the trust medicines management committee and represent a consensus view of the committee, in response to the NICE clinical guidelines for the use of rapid tranquillisation.
• The NICE clinical guidelines are recommendations for the care of patients by healthcare professionals and are based on the best available evidence.
• Such guidelines assist the practice of healthcare professionals, but do not replace their knowledge and skills.

2 Purpose

The purpose of this policy is to set out the arrangements for managing the risks associated with rapid tranquillisation, with the aim of reducing and managing risk through clear practice guidelines and standards.

The policy sets out:

• duties and responsibilities
• prescribing guidelines for rapid tranquillisation
• how observations are recorded, including timeframes when patients having received rapid tranquillisation
• how the organisation trains colleagues in line with the training needs analysis
• how the organisation monitors compliance with the policy

3 Scope

This policy is applicable to all clinical colleagues who work within the inpatient services of the following care groups:

• Rotherham adult mental health care group
• Doncaster adult mental health and learning disabilities care group
• North Lincolnshire adult mental health and talking therapies care group

4 Responsibilities, accountabilities and duties

4.1 The board of directors

The board of directors has responsibility for the implementation of this policy and the monitoring of compliance. This responsibility is delegated to the trust chief executive who delegates lead responsibility to the chief operating officer.

4.2 The care group directors

The care group directors are responsible for:

• the implementation of all policies and procedures which are in place to meet the needs of patients
• monitoring adherence to this and other related policies
• adequate resources and training being available to the Clinical team

4.3 The medical director

The medical director is responsible for,

• being the lead author of this policy
• the review and update of the policy contents
• identifying any risks posed to the trust by the use of rapid tranquillisation, or failure to adequately implement the policy
• agreeing the content of any training provided to colleagues in relation to this policy

4.4 Trust medicines optimisation group (TMOG)

Members of the TMOG are responsible for:

• advising on the content of this policy
• reviewing audit findings and agreeing the contents of any required action plans

4.5 Prescriber

When prescribing under the policy they must:

• be satisfied that other interventions have been tried
• consider what medication the service user is already receiving
• clearly state on any prescriptions under this policy:
  • which medication is to be used?
  • the dose range and frequency of the medication
  • the minimum time between doses and the maximum dose to be administered within a specified timeframe

4.6 The nurse in charge of the ward

The nurse in charge of the ward at the time of rapid tranquillisation being utilised must be satisfied that:

• all attempts have been made to calm the patient utilising interventions other than rapid tranquillisation
• the prescription is followed
• the patient’s physical observations are monitored, accurate written clinical records are maintained, and the rapid tranquillisation care plan and IR1 completed
• any concerns about changes in the patient’s physical presentation are reported to the doctor
• the patient is given a full explanation as to why rapid tranquillisation has been used, and the patient should be given the opportunity to reflect on the incident, due consideration of capacity should be made and where appropriate others informed
• post incident the restrictive practice will be reviewed in line with the trust PMVA policy
• the patient’s privacy and dignity has been maintained

4.7 The person performing the monitoring of the patient’s physical observations

Will:

• carry out the monitoring as detailed within the policy
• record the patient’s physical observations
• record the reason why, if for any reason all the physical monitoring cannot be completed
• report to the nurse who will report to the doctor any changes in the patient’s physical condition which give cause for concern
• complete the rapid tranquillisation care plan

4.8 Pharmacist

• Wherever possible, the pharmacist should be included in the review of a patient for whom rapid tranquillisation is being considered.
• As part of the review the pharmacist will check any new prescriptions. This may be done remotely.

4.9 Multidisciplinary team

• A Multidisciplinary team that includes a psychiatrist or consultant physician where appropriate, and a specialist pharmacist (where available), should develop and document an individualised pharmacological strategy for using routine and PRN. 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 or neuro-rehabilitation ward.
• 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 and include:
  • clarification of target symptoms
  • the likely timescale for response to medication
  • the total daily dose of medication, prescribed and administered, including PRN
  • medication
  • the number of and reason for any missed doses
  • therapeutic response
  • the emergence of unwanted effects

If rapid tranquillisation is being used, a senior doctor must regularly review all medication.

5 Procedure or implementation

5.1 Definitions

One question that is often raised by colleagues is: what is the difference between rapid tranquillisation and the use of PRN (as required medication)?

For the purpose of this policy the following definitions are to be used,
“NICE defines rapid tranquillisation as the use of medication, given by injection, to attempt to rapidly calm, or modify the behaviour of a patient to end a period of violence or aggression which may be harmful to the patient or others. It will be prescribed as part of a response to violence or aggression.

For the purposes of the trust and monitoring rapid tranquillisation includes the use of oral medication to manage these situations, although when feeding data to partner organisations or national bodies only parenteral medication data will be sent in line with NICE guidance”.

PRN medication in the context of behavioural disturbance is use of medication as part of a strategy to de-escalate or prevent situations that may lead to violence or aggression.

Any prescription for PRN medication is to clearly indicate the following:

• circumstance in which administration of the medication is to be considered
• both the frequency and maximum dose that can be given within a 24-hour period

The prescriber should also:

• take into account any regular medication to check the total prescription dose does not exceed British national formulary (BNF) limits
• check that the prescribing does not fall outside any consent to treatment provisions for patients detained under the MHA 1983 (Forms T1 to T5, S62)

For patients who are showing mild signs of agitation, consideration should be given to the need for a single dose of a prescribed “as required “(PRN) medication to be administered. The use of such a prescription to relieve agitation as part of a de-escalation strategy is at the discretion of the nurse in charge and must be recorded in the patient’s clinical record.

A one-off dose used to manage agitation in this way does not constitute rapid tranquillisation but if the situation deteriorates or does not improve and further use of medication for the control of agitation or aggression is required, this is then rapid tranquillisation, and colleagues are to treat it as such.

5.2 Prior to the use of rapid tranquillisation

Rapid tranquillisation should only be considered if non-drug treatments have been tried or are felt to be inappropriate:

• de-escalation and diversional strategies should be attempted in the first instance
• other non-pharmacological interventions should, where possible, also be explored, for example, increasing the level of patient’s setting. This may include transfer to a psychiatric intensive care unit (PICU)
• the process of rapid tranquillisation should be clear and transparent at all stages
• patients should be given the opportunity to participate in decision-making and care planning at all stages, and their thoughts and wishes included
• if a patient is acutely disturbed, then a doctor must be called to attend immediately
• it is vital that the attending doctor obtains as much history as possible from the patient and other sources before medication is given, as the opportunity to make a diagnosis may be lost if the patient is sedated before an understanding of their mental state is reached
• the immediate safety of the patient, colleagues or others is of prime concern
• non-psychiatric causes of behavioural disturbance should be considered and managed accordingly, for example, hypoglycaemia, delirium, and drug or alcohol intoxication
• the aim is not to induce sleep or unconsciousness. The patient should be sedated but still ideally be able to participate in further assessment and treatment
• colleagues should always seek advice of a senior colleague or consultant when unsure
• patients should be treated with pharmacological treatments only after an assessment of risk and when it has been established that the risk of not doing so is greater than the risk of side effects of acute pharmacological treatment
• in all cases the patient should be informed that medication is going to be given and why
• the patient should be given the opportunity to make an informed choice voluntarily whenever possible
• the minimum effective dose of medication should be used
• if available any advance directives should be given due consideration, along with any carers or advocate’s views, and followed, if deemed clinically appropriate. In the event that a decision is made to go against these views, the reason why must be clearly recorded in the patient’s clinical records

5.3 Legal issues

If a patient refuses or lacks the capacity to give valid consent to treatment for mental disorders, they may be given treatment using reasonable force if necessary, in an emergency situation or where the treatment is deemed to be in their best interests, colleagues are to refer to the mental health units (use of force) policy. This applies to both informal and detained patients. (For further guidance on best interests, colleagues are to refer to the Mental Capacity Act 2005, code of practice) and the consent policy.

5.3.1 Mental Capacity Act 2005 (MCA)

Section 5 of the MCA provides ‘protection from liability’ by allowing necessary acts of care or treatment to take place as if a person who lacks capacity to consent had consented to them.

Section 5 also allows actions to be taken to ensure a person who lacks capacity to consent receives necessary medical treatment even if a person who lacks capacity to consent objects to the proposed treatment.

Sometimes people who lack capacity to consent will require emergency medical treatment to save their lives or prevent them from serious harm.

These actions only receive protection from liability if the person is reasonably believed to lack capacity to give permission for the action.

The action must also be in the person’s best interests and follow the Act’s principles. However, section 6 imposes some important limitations on acts which can be carried out with protection from liability under section 5 this includes inappropriate use of restraint or where a person who lacks capacity is deprived of their liberty.

Any action intended to restrain a person who lacks capacity will not attract protection from liability unless the following two conditions are met:

• the person taking action must reasonably believe that restraint is necessary to prevent harm to the person who lacks capacity
• the amount or type of restraint used and the amount of time it lasts must be a proportionate response to the likelihood and seriousness of harm

When action is taken under the MCA, colleagues should ensure that the necessary evidence is provided in the patients record and that the principles of the act is followed and the criteria for the use of restraint is met.

5.3.2 Common law

In addition to the requirements of the MCA, the common law imposes a duty of care on healthcare and social care colleagues in respect of all people to whom they provide services. Therefore, if a person who lacks capacity to consent has challenging behaviour or is in the acute stages of illness causing them to act in way which may cause harm to others, colleagues may, under the common law, take appropriate and necessary action to restrain or remove the person, in order to prevent harm, both to the person concerned and to anyone else. However, within this context, the common law would not provide sufficient grounds for an action that would have the effect of depriving someone of their liberty.

Patients detained under the Mental Health Act 1983 and subject to part IV of the act may in some circumstances be treated against their will regardless of their ability to give consent or withhold consent.

Section 57 applies to treatment where a second opinion and the patient’s consent is required and does not apply to rapid tranquillisation.

Section 58 outlines treatment where either the patient’s consent or a second opinion is required. This includes treatment with medication for patients who are subject to the 3 months consent to treatment rules.

If the patient is subject to Section 58 and either has not consented to treatment or the treatment has not been authorised by the second opinion approved doctor, it may be given if required urgently under Section 62 if it is treatment that is either:

• immediately necessary to save the patient’s life
• immediately necessary to prevent a serious deterioration of their condition (provided the treatment is not irreversible)
• immediately necessary to alleviate serious suffering by the patient (provided the treatment is not irreversible or hazardous)
• immediately necessary and represents the minimum interference necessary to prevent the patient from behaving violently or being a danger to themselves or others (provided the treatment is not irreversible or hazardous), see Mental Health Act Code of Practice, 2015

Section 62 can only be authorised by the patient’s responsible clinician and only applies to urgent situations where treatment is immediately necessary.

Urgent treatment cannot be continued beyond the point at which the crisis has been brought to an end.

The responsible clinician must complete the relevant form for section 62, and for full guidance colleagues should refer to the guidelines for nursing colleagues on the use of section 62, see the section 62 procedure for clinical colleagues.

However, even detained patients are subject to the best interest provisions and so treatment could be justified by these provisions.

5.4 Pharmacological treatments

• Patient preference should be followed where recorded in the care plan or advance directive to refuse treatment, if clinically appropriate.
• BNF doses should normally be followed. When these are exceeded, high dose protocols should be followed.
• In all circumstances, the decision to exceed current BNF limits must be taken in consultation with a consultant or senior doctor.
• Consideration should be given to concurrent physical problems and, or other medication previously prescribed or administered, drug allergies and combination doses of oral and intramuscular (IM) medication.
• Polypharmacy within a class of medication (for example, antipsychotics) should, where at all possible, be avoided.
• If a patient has already received antipsychotics medication that day, then the total dose of antipsychotics should not normally exceed the BNF maximum, and the use of Lorazepam as a single agent should be considered.
• Consideration should be given to any known pre-existing medical illnesses, known legal and illegal substances recently taken (alcohol, amphetamines and so on.) and any regularly prescribed oral or depot medication, as this may impact on dose requirements and potential side effects.
• NICE suggest that if urgent tranquillisation is needed then IM Lorazepam or Haloperidol combined with Promethazine be used (please see Intramuscular medication guidelines within the appendices). NICE guidance NG10 Violence and aggression, short-term management in mental health, health and community settings.
• Lorazepam alone should be considered as first-line treatment, unless inappropriate (for example, Benzodiazepine hypersensitivity, respiratory depression, pregnancy).
• When prescribing medication for use in rapid Tranquillisation, consider writing the initial prescription as a single dose, and do not repeat it until the effect of the initial dose has been reviewed.
• Always start at the lower end of the dosage range, and use the lowest effective dose, treat the patient according to their individual needs.

5.5 Oral medication guidelines

5.5.1 Adults age 18 to 65 years

• Oral medication should be offered before parenteral medication.
• Note, Intramuscular medication antipsychotic medication usually has a faster onset of action.
• The following regimes represent the consensus of the trusts medicines management committee as appropriate choices of medication:
  • oral Lorazepam 1 to 2mg repeated after 45 minutes if required, up to a maximum of 6mg in 24-hours
  • oral Lorazepam 1 to 2mg and oral Haloperidol 2.5 to 5mg (Haloperidol maximum 20mg in 24-hours) repeat after 45 minutes if required
  • Risperidone 2mg together with Lorazepam 2mg (up to a maximum 4mg of each within 24-hours) may be considered as an alternative
  • if using Haloperidol in an antipsychotics naive service user, consider Procyclidine 5mg to prevent acute dystonic reactions
  • always start at the lower end of the dosage range, and use the lowest effective dose, treat the patient according to their individual needs
  • if oral medication is repeatedly refused, the decision to restrain a patient in order to administer intramuscular medication should be considered jointly by medical and nursing colleagues
  • once the decision has been made to restrain a patient in order to medicate, the physical intervention should be carried out in a manner which safeguards the patient’s dignity
  • nursing and medical colleagues involved in restraining the patient should be proficient in physical intervention techniques for managing work related violence

5.5.2 Elderly

• Lorazepam 0.5mg, 1mg TDS.
• Haloperidol 0.5mg, 1mg TDS.

Be aware of increased sensitivity to extrapyramidal side effects in patients with Lewy Body dementia and Parkinson’s disease dementia.

5.6 Intramuscular medication (IM) guidelines

5.6.1 Adults age 18 to 65 years

This should be considered for patients who have not responded to non-drug measures and oral medication, or who are refusing oral medication. In the context of rapid tranquillisation

At all stages patients must be given the option to accept oral medication. When deciding to use intramuscular medication, the prescriber should give due consideration to the amount of any oral medication already administered.

Consider Lorazepam first line in neuroleptic naive patients either:

• IM Lorazepam 1 to 2mg, repeat after 30 minutes if necessary, up to a maximum of 10mg in 24-hours
• IM Haloperidol 2.5 to 5mg and IM Promethazine 50mg, repeat after 30 minutes if necessary up to 20mg Haloperidol per 24-hours or 100mg Promethazine per 24-hours.
• Aripiprazole IM (for patients requiring antipsychotics and Haloperidol would be contraindicated for, like Lewy Body dementia.
• 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 to 15 mg as a single injection. 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 of medicinal products 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 and no more than three injections should be given in any 24-hour period.
• The maximum daily dose of Aripiprazole is 30 mg (including all formulations of Aripiprazole)”

5.6.2 Elderly

These are suggested doses for frail elderly, individual patient characteristics should be taken into account when considering dose:

• Lorazepam 0.5mg, 1mg TDS
• Haloperidol 0.5mg, 1mg TDS
• Promethazine 25mg (maximum 100mg in 24-hours)
• The effectiveness of Aripiprazole solution for injection in patients who are 65 years of age or older has not been established. Owing to the greater sensitivity of this population, a lower starting dose should be considered when clinical factors warrant
• Promethazine has significant anticholinergic properties and may worsen delirium in elderly patients.
• Lorazepam should be mixed in a 1 to 1 ratio with water for injections before administration and should not be mixed with other injections.
• If IM Haloperidol is used, anticholinergic (for example, Procyclidine 5 to 10mg IM) should also be considered in order to reduce the risk of extrapyramidal symptoms.
• Zuclopenthixol acetate (Acuphase) 50 to 150mg IM should only be considered if a patient has shown transient response to other short acting parenteral antipsychotics, and during the course of the episode they require two or more short acting injections. Or has been agreed as part of an advanced directive.
• Due to its pharmacokinetics, zuclopenthixol acetate (Acuphase) is not suitable for first line use within rapid tranquillisation. It should not be given to struggling patients, or antipsychotic naive patients.
• IM Diazepam should not be used due to pain on injection and an inconsistent rate of absorption.
• IM Chlorpromazine should not be used due to the risk of circulatory collapse and pain of injection.

For the purpose of administering rapid tranquillisation medication via intramuscular injection, the ventrogluteal and vastus lateralis should be the preferred injection sites. This site provides alternatives to the dorsogluteal, with fewer potential complications and a faster absorption rate, it can be accessed without using prone restraint, therefore less risk and more dignified as can be administered through clothing.

5.7 Patient monitoring or observation requirements or use of the early warning score

• The use of rapid tranquillisation should be viewed as a medical emergency due to the risk associated with its use.
• At all times throughout this procedure the physical safety of the patient and others must be considered.
• All colleagues expected to monitor patients post rapid tranquillisation should be trained in immediate life support (ILS) and emergency equipment should be available at all times (see resuscitation policy).
• A doctor must be able to attend as quickly as possible (ideally within 30 minutes of alert).
• Where physical restraint is required colleagues must be trained to an appropriate level as per their training needs analysis and follow trust policy and guidance for the prevention and management of violence and aggression.
• Colleagues must be aware that the risks to the patient are increased if they have taken alcohol or illicit drugs, are obese or if they have a physical condition that may affect cardiopulmonary function.
• Constant visual observation of the patient must be maintained.
• Following the use of rapid tranquillisation, a series of physical observations should be carried out on the patient, calculated using the early warning score (appendix A). And recorded on the physical observation chart

The Following observations should be taken every 15 minutes for the first hour, then every 30 minutes for the next 3 hours:

• respiration rate
• level of consciousness AVPU (levels of response AVPU (alert, voice, pain, unresponsive))
• oxygen saturation via pulse oximeter (if clinically indicated and only if safe to do so for both colleagues and patient)
• pulse (if clinically indicated and safe to do so for both colleagues and patient)
• blood pressure (if clinically indicated and only if safe to do so for both colleagues and patient)
• temperature (if clinically indicated and only if safe to do so for both colleagues and patient)

Colleagues should also look out for the following:

• verbal complaints of pain and discomfort
• non-verbal clues as to pain or discomfort (especially if communication is identified as difficult)

If for any reason it is not possible for colleagues to complete all the above physical monitoring requirements, the reason why is to be recorded and as a minimum colleagues must monitor and record the patient’s:

• respiration rate
• level of consciousness. (AVPU)

5.7.1 Patients due for leave or transfer

Any patient due for leave or transfer within the 4-hour observation period must remain within an area that has the ability to, and accepts responsibility for the physical observations needed, or be accompanied by colleagues who will continue the observations.

If a patient had planned to go on unescorted leave before the incident that led to rapid tranquillisation the leave must be reviewed, and, if still appropriate delayed until the 4-hour observation period has elapsed, and observations have shown no cause for concern.

5.7.2 Electrocardiogram (ECG) requirements

If using Antipsychotics, where the summary of product characteristics indicates ECG monitoring, (currently haloperidol) an ECG should be performed at the earliest opportunity when:

• a previous ECG showed abnormalities
• the last recorded ECG was over 3 months ago

The ECG should be reviewed the next working day. If an ECG cannot be performed a note must be made in the rapid tranquillisation care plan as to the reason why.

5.8 Action to consider if there are changes to the patient’s physical observations

The doctor must be contacted immediately if the patient’s:

• temperature becomes raised (colleagues should also withhold the administration of any further antipsychotic medication due to the risk of neuroleptic malignant syndrome)
• pulse becomes irregular or falls below 60 per minute
• blood pressure drops below 80mmHg Systolic. If it is not possible to take a blood pressure due to the patient’s presentation contact a doctor if a radial pulse can no longer be detected
• Or if colleagues become concerned about the clinical presentation of the patient

If the patient is asleep, a more frequent and intensive monitoring by appropriately trained colleagues is required and should be recorded in the clinical record. Particular attention should be paid to the patient’s respiratory rate, effort, airway and level of consciousness (AVPU). In the event that the patient falls asleep whilst in seclusion, the need to continue the episode of seclusion should be reviewed.

5.9 Action following the use of rapid tranquillisation

• The reason for prescribing any medication for the acutely disturbed patient must be documented in the clinical record, as well as the working diagnosis.
• Any medication administered and the patient’s response should be recorded in the clinical record.
• The patient’s risk assessment is to be reviewed and their plan of care amended accordingly.
• The patient should be reviewed at the next multidisciplinary meeting or sooner if appropriate for discussion of long-term management.
• After the treatment of an acute disturbance, the patient should be debriefed, and this should be recorded in the clinical record.
• The patient should be offered the opportunity to write an account in their clinical record (NICE NG10, 2015).
• Incident report and Rapid Tranquillisation care plan completed.

5.10 Debriefing

5.10.1 Patient

At a time that is appropriate to the patient their thoughts and feelings regarding the incident should be explored and documented.in the rapid tranquillisation care plan this will include:

• any identified triggers which led to the incident occurring
• could anything be done differently should a similar incident occur
• a reflection of the service user’s feelings about the incident

5.10.2 Colleagues

After the incident this will be reviewed in line with the trust reducing restrictive interventions policy.

5.11 Guidance specific to older adults

• The principles as for adults of working age patients apply, but particular care should be given to co-existing medical states and prescribed medication as well as the risk of accumulation of sedatives and the possibility of delirium.

• Note: MHRA guidance on avoiding Olanzapine and Risperidone in behavioural disturbance in patients with dementia.
• The dose of Haloperidol is a critical factor when determining the likelihood of severe adverse effects.
• Benzodiazepines are to be avoided in patients who have significant respiratory impairment.

5.12 Guidance for adolescents

It is recognised that on rare occasions adolescents under the age of 18 are admitted on to an acute ward. See appendix E for guidance

5.13 Guidance specific to pregnant women

For any patient who is known or suspected to be pregnant the consultant psychiatrist in charge of their care and treatment is to give clear guidance in respect of any medication that is to be or can be administered. This will include the potential need for the use of medication for the purpose of rapid tranquillisation. These decisions will need to be determined on a case by case basis taking into account the stage of the pregnancy and may necessitate advice being sought from the patient’s obstetrician. In such cases it is recommended that antipsychotics or benzodiazepines with shorter half lives are administered.

5.14 Additional guidance for patients post head injury on neuro rehabilitation ward

These patients are likely to be more sensitive to the paradoxical reactions associated with benzodiazepines and the extra-pyramidal side effects of antipsychotics. If oral medication is required for severe agitation, consider promethazine and or quetiapine. If parenteral medication is required, consider Promethazine or Aripiprazole Intramuscularly. Monitoring should be in line with adult monitoring. Doses should be tailored to the individual circumstances but start at the lower end of the dosage range.

5.15 Rapid tranquillisation and seclusion

Wherever possible the use of seclusion for patients that have been subject to rapid tranquillisation should be avoided. However, in the event that it is felt to be the safest course of action due to the patient presenting a serious risk of violence, the Nurse in charge of the ward must:

• have the patient monitored within sight by a trained person
• terminate the episode of seclusion at the earliest opportunity

5.16 Documenting rapid tranquillisation

All incidents of rapid tranquillisation should be documented using the rapid tranquillisation care plan and incident reporting form appendix B. This plan will be used in place of the nursing notes and must be used in conjunction with the patients existing TPR chart (all observations must be recorded on the chart itself).

6 Training implications

The training needs analysis (TNA) for this policy can be found in the training needs analysis document which is part of the trust’s mandatory risk management training policy located under the policy section of the trust website.

Rapid tranquillisation training should cover:

• all colleagues involved in rapid tranquillisation to be trained in immediate life support
• prescribers and those who administer medicines should be familiar with and have received training in rapid tranquillisation, including: the properties of benzodiazepines; antipsychotics; antimuscarinics and antihistamines
• associated risks, including cardio-respiratory effects of the acute administration of the drugs, particularly when the service user is highly aroused and may have been misusing drugs; is dehydrated or is possibly physically ill
• the need to titrate doses to affect
• colleagues must be trained in how to assess and manage potential and actual violence, using de-escalation techniques, restraint, seclusion and rapid tranquillisation

7 Monitoring arrangements

7.1 Duties

• How: Clinical audit.
• Who by: Resuscitation officer.
• Reported to: medicines management committee (reports to clinical governance group) divisional governance groups.
• Frequency: Annually.

7.2 Prescribing guidelines for rapid tranquillisation

• How: Clinical audit.
• Who by: Effectiveness team.
• Reported to: medicines management committee (reports to clinical governance group) divisional governance groups.
• Frequency: Annually.

7.3 How observations are recorded, including timeframes, when patients have received rapid tranquillisation

• How: Clinical audit.
• Who by: Modern matrons.
• Reported to: medicines management committee (reports to clinical governance group) divisional governance groups.
• Frequency: Annually.

7.4 How the organisation trains colleagues in line with the training needs analysis

• How: Monitoring of training content and training compliance conjunction with the above.
• Who by: Head of learning and development.
• Reported to: Medicines management committee (reports to clinical governance group) divisional governance groups.
• Frequency: Annually.

7.5 Induction training for trainee doctors

• How: Review of induction records.
• Who by: Medical director.
• Reported to: Medicines management committee (reports to clinical governance group) divisional governance groups.
• Frequency: Twice or three times a year depending on training grade.

7.6 Local induction of new colleagues within inpatient services

• How: Review of induction records.
• Who by: Modern matrons.
• Reported to: Medicines management committee (reports to clinical governance group) divisional governance groups.
• Frequency: Twice a year.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

There is no requirement for additional consideration to be given with regard to privacy, dignity or respect.

8.2 Mental Capacity Act 2005

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all colleagues working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

Where English is not the preferred language of the patient or service user, using an interpreting service should enhance the assessment of Mental Capacity.

9 Links to any other associated documents

• Safe and secure handling of medicines manual
• Reducing restrictive interventions policy
• Mandatory and statutory training policy
• Resuscitation manual
• Clinical risk assessment and management policy
• Management of a secluded or segregated patient policy
• MCA, Advance statements and advance decisions to refuse treatment
• MHL, Section 62, procedure for clinical staff
• MCA, Mental Capacity Act 2005 policy
• Mental health units (use of force) policy

10 References

• NICE (2015) Violence and aggression: short term management in mental health, health and community settings (accessed 11 November 2024) (opens in new window).
• Department of health (2015) code of practice, Mental Health Act 1983 (accessed 11 November 2024) (opens in new window).
• Department of constitutional affairs (2007) code of practice, Mental Capacity Act 2005, the stationery office (accessed 11 November 2024) (opens in new window).
• Mental Health Act, Richard Jones (accessed 11 November 2024) (opens in new window).
• British national formulary (BNF) latest edition (accessed 11 November 2024) (opens in new window).

11 Appendices

11.1 Appendix A Early warning score system and score chart

• Appendix A Early warning score system and score chart (staff access only) (opens in new window)

11.2 Appendix B Rapid tranquillisation care plan

• Appendix B Rapid tranquillisation care plan (staff access only) (opens in new window)

11.3 Appendix C Rapid tranquillisation for frail or elderly people

11.3.1 When to use

When all other non-pharmacological interventions and de-escalation options have been tried and failed.

11.3.2 Prior to use

• Seek senior advice.
• Assess and establish risk of not doing so is greater than risk of side effects of acute pharmacological intervention.
• Inform patient medication is going to be given and why.
• Refer to rapid tranquillisation care plan, check consent to treatment where appropriate.
• Document authority to administer rapid tranquillisation.

11.3.3 Potential risks

• over sedation causing loss of consciousness
• over sedation causing loss of alertness
• loss of airway
• cardiovascular and respiratory collapse
• interaction with medication (prescribed or illicit)
• damage to therapeutic relationship
• underlying co-incidental physical disorders

11.3.4 Specific Risks

Benzodiazepine:

• loss of consciousness
• respiratory depression or arrest
• cardiovascular collapse when receiving both clozapine and benzodiazepines

Antipsychotics:

• loss of consciousness
• cardiovascular or respiratory complications and collapse
• seizures
• akathisia
• dystonia
• dyskinesia
• excessive sedation
• neuroleptic malignant syndrome

Antihistamine:

• excessive sedation
• painful injection
• additional anti-muscarinic effects

11.3.5 Lorazepam

Oral:

• first choice unless contraindicated 0.5 to 1mg (maximum 6mg in 24-hours) can repeat after 45 minutes

Intramuscular medication injection:

• 0.5 to 1mg maximum 10mg in 24-hours including regular can repeat after 30 minutes

Concerns consult senior before administering:

• contraindicated in respiratory depression, marked neuromuscular respiratory weakness

11.3.6 Promethazine

Intramuscular medication injection:

• 25 to 50mg (maximum 100mg in 24-hours can repeat after 30 minutes

Concerns consult senior before administering:

• significant anti-muscarinic properties, may worsen delirium, heavily sedating

11.3.7 Haloperidol

Oral:

• 0.5 to 1mg (maximum 20mg in 24-hours including any regular prescription), can repeat after 45 minutes

Intramuscular medication injection:

• 0.5 to 1mg (maximum 20mg in 24-hours including any regular prescription), can repeat after 30 mins

Concerns consult senior before administering:

• caution in patients with Lewy body dementia and Parkinson’s disease due to extrapyramidal side effects, consider procyclidine if using haloperidol in naive patients

11.3.8 Aripiprazole

Intramuscular medication injection:

• start on 2.5mg and monitor closely, max dose 30mg per 24-hours, can repeat after 2 hours

11.3.9 After use

Physical observations:

• AVPU and respiratory rate as minimum if vital signs cannot be measured.
• blood pressure, temperature, respiration rate, level of consciousness, oxygen saturation, pulse if safe and clinically indicated.
• every 15 minutes for the first hour, then every half hour for the next 3 hours
• doctor to attend within 30 minutes
• document, rationale, medication given, response risk assessment, patient preference
• MDT for post event review as soon as possible
• ECG if using antipsychotics at earliest opportunity
• refer to policy for full guidance

11.4 Appendix D Rapid tranquillisation for adult inpatient

11.4.1 When to use

When all other non-pharmacological interventions and de-escalation options have been tried and failed.

11.4.2 Prior to use

• Seek senior advice.
• Assess and establish risk of not doing so is greater than risk of side effects of acute pharmacological intervention.
• Inform patient medication is going to be given and why.
• Refer to rapid tranquillisation care plan, check consent to treatment where appropriate.
• Document authority to administer rapid tranquillisation.

11.4.3 Potential risks

• Over sedation causing loss of consciousness.
• Over sedation causing loss of alertness.
• Loss of airway.
• Cardiovascular and respiratory collapse.
• Interaction with medication (prescribed or illicit).
• Damage to therapeutic relationship.
• Underlying co-incidental physical disorders.

11.4.4 Specific Risks

Benzodiazepine:

• loss of consciousness
• respiratory depression or arrest
• cardiovascular collapse when receiving both clozapine and benzodiazepines

Antipsychotics:

• loss of consciousness
• cardiovascular or respiratory complications and collapse
• seizures
• akathisia
• dystonia
• dyskinesia
• excessive sedation
• neuroleptic malignant syndrome

Antihistamine:

• excessive sedation
• painful injection
• additional anti-muscarinic effects

11.4.5 Lorazepam

Oral:

• first choice unless contraindicated 1 to 2mg (maximum 6mg in 24-hours) can repeat after 45 minutes

Intramuscular medication injection:

• 1 to 2mg maximum 10mg in 24-hours including regular can repeat after 30 minutes

Concerns consult senior before administering

• contraindicated in respiratory depression, marked neuromuscular respiratory weakness

11.4.6 Promethazine

Intramuscular medication injection:

• 25 to 50mg (maximum 100mg in 24-hours can repeat after 30 minutes

Concerns consult senior before administering:

• significant anti-muscarinic properties, may worsen delirium, heavily sedating

11.4.7 Haloperidol

Oral

• 2 to 5mg (maximum 20mg in 24-hours including any regular prescription), can repeat after 45 minutes

Intramuscular medication injection:

• 2.5 to 5mg (maximum 20mg in 24-hours including any regular prescription), can repeat after 30 minutes

Concerns consult senior before administering:

• caution in patients with Lewy body dementia and Parkinson’s disease due to extrapyramidal side effects, consider procyclidine if using haloperidol in naive patients

11.4.8 Aripiprazole

Intramuscular medication injection:

• start on 9.75mg and monitor closely, max dose 30mg in 24-hours, can repeat after 2 hours

11.4.9 After use

Physical observations:

• AVPU and respiratory rate as minimum if vital signs cannot be measured.
• blood pressure, temperature, respiration rate, level of consciousness, oxygen saturation, pulse if safe and clinically indicated.
• every 15 minutes for the first hour, then every half hour for the next 3 hours
• doctor to attend within 30 minutes
• document, rationale, medication given, response risk assessment, patient preference
• MDT for post event review as soon as possible
• ECG if using antipsychotics at earliest opportunity
• refer to policy for full guidance

11.5 Appendix E Rapid tranquillisation for adolescent inpatients

11.5.1 When to use

When all other non-pharmacological interventions and de-escalation options have been tried and failed.

11.5.2 Prior to use

• Seek consultant advice, prescribing to be consultant led.
• Assess and establish risk of not doing so is greater than risk of side effects of acute pharmacological intervention.
• Inform patient medication is going to be given and why:
  • monitoring in line with adults
  • be aware of unlicensed use and dosage regimes and document this in the clinical records
  • adolescents and children are more sensitive to extrapyramidal side effects and more likely to be antipsychotic naive
  • disinhibition is more likely to occur with benzodiazepines in adolescents or children.
    Adolescents and children are more sensitive to extrapyramidal side effects (EPSE)
  • use oral medication first line wherever possible
• Consider age, weight, physiological maturity, and differences in pharmacodynamics and pharmacokinetics.
• Refer to rapid tranquillisation care plan, check consent to treatment where appropriate.
• Document authority to administer rapid tranquillisation.

11.5.3 Potential risks

• Over sedation causing loss of consciousness.
• Over sedation causing loss of alertness.
• Loss of airway.
• Cardiovascular and respiratory collapse.
• Interaction with medication (prescribed or illicit).
• Damage to therapeutic relationship.
• Underlying co-incidental physical disorders.

11.5.4 Specific Risks

Benzodiazepine:

• loss of consciousness
• respiratory depression or arrest
• cardiovascular collapse when receiving both clozapine and benzodiazepines

Antipsychotics:

• loss of consciousness
• cardiovascular or respiratory complications and collapse
• seizures
• akathisia
• dystonia
• dyskinesia
• excessive sedation
• neuroleptic malignant syndrome

Antihistamine:

• excessive sedation
• painful injection
• additional anti-muscarinic effects

11.5.5 Lorazepam

Oral:

• first choice unless contraindicated 0.5 to 1mg (maximum 4mg in 24-hours) can repeat after 60 minutes

Intramuscular medication injection:

• 0.5 to 1mg maximum 4mg in 24-hours including regular can repeat after 60 minutes

Concerns consult senior before administering:

• contraindicated in respiratory depression, marked neuromuscular respiratory weakness

11.5.6 Haloperidol

Oral:

• 1 to 2.5mg (maximum 10mg in 24-hours including any regular prescription), can repeat after 60 minutes

Intramuscular medication injection:

• 1 to 2.5mg (maximum 5mg in 24-hours including any regular prescription), can repeat after 60 minutes.

Concerns, consult senior before administering:

• consider Procyclidine 2.5m po/IM, if using haloperidol in naive patients

11.5.7 After use

Physical observations:

• AVPU and respiratory rate as minimum if vital signs cannot be measured
• blood pressure, temperature, respiration rate, level of consciousness, oxygen saturation, pulse if safe and clinically indicated
• every 15 minutes for the first hour, then every half hour for the next 3 hours
• doctor to attend within 30 minutes
• document, rationale, medication given, response risk assessment, patient preference
• MDT for post event review as soon as possible
• ECG if using antipsychotics at earliest opportunity
• refer to policy for full guidance

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Document control

• Version: 12.
• Unique reference number: 130.
• Ratified by: Clinical policy review and approvals group.
• Date ratified: 12 November 2024.
• Name of responsible individual: Medicines Management Committee.
• Date issued: 4 December 2024.
• Review date: 31 December 2027.
• Description of changes: Doses used in rapid tranquilisation updated. Tables updated and reinstated to ensure they match the text in appendices. References checked.

Page last reviewed: December 12, 2024
Next review due: December 12, 2025

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