RAPID TRANQUILLISATION AND PRN PSYCHOTROPIC MEDICATION; POLICY AND GUIDANCE
Document name: / Rapid tranquillisation and PRN psychotropic medication; policy and guidance.Version 6
Staff group to whom it applies: / Qualified medical staff, qualified nursing staff, pharmacists and pharmacy staff.
All staff working on in-patient units.
Distribution: / Hard copy to in-patient areas
Intranet
Medical staff on induction
Issue date: / February 2016
Next review: / February 2018
Developed by: / Mark Payne
Mohammed Fazlee
Sandra Butler
Contacts for advice or information: / Jane Riley, Chief Pharmacist
Dr Adrian Berry, Medical Director
Mark Payne, Senior Clinical Pharmacist
CONTENTS
Abbreviations 3
Prescribing algorithm 4
Flowchart 5
1 Introduction 6
2 Definitions and Principles 7
3 Prescribing guidance 8
4 Formulary 12
5 Carrying out Rapid Tranquillisation 17
6 Physical health monitoring 18
7 Managing side effects and complications 19
Appendix 1 Rapid Tranquillisation Episode Criteria and Review Pathway 21
Appendix 2 Rapid Tranquillisation – Assessment and Progress Chart 22
Appendix 3 The Richmond Agitation – Sedation Scale 24
Appendix 4 48 Hour Intramuscular Clopixol Acuphase Monitoring Chart 25
Appendix 5 Guidance on the Preparation & Administration of Aripiprazole (Abilify®) 26
Appendix 6 Haloperidol Administration 27
Appendix 7 Guidance on the Preparation & Administration of Olanzapine (Zyprexa®) …………………………………………………………………………………. 28
Appendix 8 Advice on the Preparation & Administration of Lorazepam (Ativan®) 29
Appendix 9 Policy for the use of midazolam 30
Appendix 10 Implementation 32
Appendix 11 Equality Impact Assessment Tool 33
Appendix 12 Checklist for the Review and Approval of Procedural Document 34
Appendix 13 Training Needs 36
Appendix 14 Version Control Sheet 38
References 40
Abbreviations used in this document
BNF British National Formulary
CNS Central Nervous System
CPR Cardiopulmonary resuscitation
D&T Drug and Therapeutics Sub Committee
ECG Electrocardiogram
EPSE Extrapyramidal side effects
ESR Electronic Staff Record
FBC Full Blood Count
IM Intramuscular injection
IV Intravenous injection
LFT Liver Function Tests
MDT Multidisciplinary team
MAV Managing Aggression and Violence
NICE National Institute for Health and Care Excellence
NMS Neuroleptic malignant syndrome
PO Oral/by mouth
PRN Medicines to be taken as and when required
QT/QTc Interval in the cardiac cycle
RT Rapid Tranquillisation
SPC Summary of Product Characteristics
SWYPFT South West Yorkshire Partnership NHS Foundation Trust
ST Speciality Trainee
TFTs Thyroid Function Tests
TIA Transient Ischemic Attacks
U&Es Urea and Electrolytes
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RAPID TRANQUILLISATION / PRN PRESCRIBING FLOWCHART
SOUTH WEST YORKSHIRE PARTNERSHIP NHS FOUNDATION TRUST
Rapid Tranquillisation Policy
1. Introduction
1.1 Scope
This policy is intended to support the delivery of appropriate, safe and effective rapid tranquillisation in the context of in-patient care within SWYPFT and identifies which clinical staff need training. This policy replaces all previous local RT related policies or procedures and represents expected (i.e. usual) practice within all districts and the regional forensic service.
1.2 Practice Variation
This policy sets out the standards of care that are expected by SWYPFT when prescribing medication for the management of acute behaviour disturbance.
Where clinical need indicates that practice which falls outside of the scope of this guidance is necessary, the following should be discussed with a senior psychiatrist and recorded in the patient’s clinical notes :
- The exact nature of the intervention
- The rationale for this intervention, including acknowledgement of usual practice, and that this is a deviation from this
- A clearly defined aim of the treatment
- A clearly defined timescale for review
- The name of the senior psychiatrist with whom the plan has been discussed and agreed
1.3 Sources of Guidance
A full list of references is given at the end of this document, but this policy takes particular note of NICE Guideline 10 and 178 (management of Violence and Psychosis respectively) and is a successor to the SWYPFT Rapid Tranquillisation Protocol version 5.3.1, September 2014 and the Guidelines for Rapid Tranquillisation for acutely disturbed behaviour for adults in Barnsley approved May 2010.
1.4 Duties
1.4.1 Healthcare organisations have an obligation to provide an effective rapid tranquillisation service to their patients and appropriate training to their staff. A suitable infrastructure is required to establish and continue support for these activities.
1.4.2 The Chief Executive is responsible for ensuring that resources and mechanisms are in place for the overall implementation, monitoring and review of this policy. Implementation of this document is outlined in appendix 10, page 35.
1.4.3 The Medical Director, the Director of Nursing and the Chief Pharmacist are responsible for ensuring the policy is reviewed, approved and monitored by the appropriate trust-wide group (currently the Drug & Therapeutic Sub Committee).
1.4.4 The Executive Management Team will provide policy approval and ratification.
1.4.5 The Drug & Therapeutic Sub Committee will consider the monitoring evidence put before them and request actions as appropriate.
1.4.6 The General Manager, Practice Governance Coach and Clinical Lead are responsible for ensuring that dissemination and implementation of the policy occurs within their own area of responsibility. In addition, they are responsible for providing relevant support for the training required around RT as outlined in the training needs analysis.
1.4.7 Ward Managers must ensure staff have access to training on RT (see appendix 13 training needs analysis and training matrix, Section 1 of the Medicine Code).
1.4.8 As well as training on RT there must be staff trained on the use of oxygen, pulsoximetry and defibrillators on the wards when RT is employed.
2 Definitions and Principles
2.1 Definitions
Throughout this document the following definitions have been used, in line with NICE guidance:
2.1.1 p.r.n. (pro re nata): When needed. In this guideline, p.r.n. refers to the use of medication as part of a strategy to de‑escalate or prevent situations that may lead to violence or aggression; it does not refer to p.r.n. medication used on its own for rapid tranquillisation during an episode of acutely disturbed behaviour.
2.1.2 Rapid tranquillisation: Use of medication by the parenteral route (usually intramuscular or, exceptionally, intravenous) if oral medication is not possible or appropriate and urgent sedation with medication is needed.
2.1.3 A multidisciplinary team that includes a psychiatrist and a specialist pharmacist should develop and document an individualized pharmacological strategy for using routine and p.r.n. medication to calm, relax, tranquillise or sedate patients who are at risk of violence and aggression as soon as possible after admission to an inpatient psychiatric unit.
2.1.4 The administration of medication by a short-acting intramuscular injection should always be considered rapid tranquillisation and the principles of this policy adhered to, even where the patient expresses a preference for this route of administration.
2.2 Principles
2.2.1 Patients should be involved in their care at the earliest opportunity, those requiring p.r.n or rapid tranquillisation should not be denied this opportunity. Where it is not possible to discuss these issues with a patient prior to the administration of medication then this should be discussed with them at the earliest opportunity following the intervention.
2.2.2 Checks should be made prior to administering medication whether there is an advance decision or advance statement in place. Where there is not an advance decision or statement in place regarding the use of p.r.n or rapid tranquillisation the patient should be encouraged and supported to develop one.
2.2.3 Where a patient is subject to a restrictive intervention such as rapid tranquillisation, this should only be after less restrictive interventions have been considered and deemed ineffective or inappropriate. Even where a restrictive treatment has been required previously, the least restricitive intervention should always be considered first before repeating this intervention.
2.2.4 All treatment decisions, administrations of medication and discussions with patients about their treatment should be documented in the patients notes to inform future care.
3 Prescribing guidance
3.1 Baseline checks
3.1.1 Prior to prescribing medication for use as p.r.n or rapid tranquillisation the following should be reviewed and documented:
3.1.2 The medication prescribed for regular administration
3.1.3 Whether there are any issues with administering the regular medication
e.g. refusal of doses / issues with swallowing
3.1.3 Whether any changes to the regular medication regime are indicated, and how these will be reviewed / actioned (please consider local supply arrangements for medication before making changes to the treatment regime).
3.1.4 Whether there is currently a need for p.r.n or rapid tranquillisation
3.1.5 Where a need for p.r.n or rapid tranquillisation is identified the following should be considered and documented:
3.1.5.1 The symptoms that are to be targeted by the p.r.n / rapid tranquillisation
3.1.5.2 How these symptoms will be monitored
3.1.5.3 How to measure if the medication administered has been effective
e.g reduction in agitation / time spent out of seclusion
3.1.5.4 The medication that is to be prescribed, recording:
a) Name of the medication
b) Dose; individual and maximum
c) Frequency of administration (minimum interval, and maximal frequency)
d) Route of administration
3.1.5.5 Any available information on historical response to medication
3.1.5.6 Any available information on historical tolerability of medication
3.1.5.7 The patient’s preference including any documented advance statements / advance decisions
3.1.5.8 Any physical health conditions, particularly those which may affect the absorption / distribution / elimination of medication.
3.1.5.9 The current physical health parameters (ECG / blood tests / cardiovascular monitoring)
3.1.5.10 Any other information taken into consideration when making the decision.
3.1.5.11 The timescale for review
A proforma is provided (Appendix 1) to facilitate the recording of this information.
3.2 Prescribing medication for use as P.R.N
3.2.1 When prescribing p.r.n. medication as part of a strategy to de‑escalate or prevent situations that may lead to violence and aggression:
3.2.1.1 Do not prescribe p.r.n. medication routinely or automatically on admission
3.2.1.2 Tailor p.r.n. medication to individual need and include discussion with the patient if possible
3.2.1.3 Ensure there is clear documentation of the rationale and circumstances in which p.r.n. medication may be used and that these are included in the care plan and on the prescription.
3.2.1.4 Do not exceed the maximum daily dose stated in the British National Formulary (BNF) for each drug, or exceed 100% of the BNF maximum for a single drug when combined with the person's standard dose and their dose for rapid tranquillisation unless this is planned to achieve an agreed therapeutic goal, documented, and carried out under the direction of a senior doctor (ST / Consultant)
3.2.1.5 Ensure that the interval between p.r.n. doses is specified.
3.2.1.6 Prescriptions for p.r.n medication should state:
a) Name of medication
b) Dose or dose range
c) Route of administration
d) Frequency of administration / minimum interval between doses
e) Maximum dose in 24 hours
f) Prescribers signature
g) The indication for use
h) Start date for the prescription
3.2.1.7 Where a medication is prescribed by more than one route, this should be indicated on the prescription. Prescriptions allowing the administration of a medication by more than one route e.g PO/IM are only acceptable where there is the facility to record the route of administration on the drug chart and the doses are bioequivalent.
3.2.2 The multidisciplinary team should review the pharmacological strategy and the use of medication at least once a week and more frequently if events are escalating and restrictive interventions are being planned or used. The review should be recorded in the MDT review and include:
a) clarification of target symptoms
b) the likely timescale for response to medication
c) the total daily dose of medication, prescribed and administered, including p.r.n. medication
d) the number of and reason for any missed doses
e) therapeutic response
f) the emergence of unwanted effects.
g) Consideration of the development of dependence or tolerance to the medication
3.3 Prescribing medication for use as rapid tranquillisation
3.3.1 When prescribing medication for use as rapid tranquillisation:
3.3.1.1 Do not prescribe rapid tranquillisation for ongoing use
3.3.1.2 Tailor each episode of rapid tranquillisation to the patients needs, giving consideration to:
a) Previous response to medication
b) Previous tolerability of medication
c) Patients preference
d) Concurrent prescribed medication
e) Comorbid health conditions
3.3.1.3 Prescriptions should have a set duration of treatment , initial prescriptions should be for no more than 24 hours treatment, subsequent prescriptions should be based on a comprehensive review of the efficacy and tolerability of the initial prescription. Referral for review by the MDT should be at the earliest opportunity.
3.3.1.4 Where an ongoing need is identified for the use of rapid tranquillisation the MDT should review the need and make the same documentation as they would for prn medication (see 3.2)
3.3.2 If rapid tranquillisation is being used as an ongoing part of a patients care plan, a senior doctor (ST / Consultant) should review all medication at least once a day. This review should be documented in the patients notes.
3.3.3 When IM medication is used the incident and associated monitoring should be reported via the local incident reporting system.
3.4 Use of medication in combination with physical intervention
3.4.1 Patients may occasionally require physical restraint to prevent violence to themselves or others. Swift, safe and effective drug treatment may then be needed to effect rapid tranquillisation and to allow subsequent evaluation and appropriate management. Medication should be used in the context of a combination of approaches to the management of the agitated patient and at all stages continue talking and using non-drug approaches and use the least restrictive option available.
3.4.2 Medication for RT, particularly in the context of physical intervention, should be used with caution owing to the following risks:-
a) loss of consciousness instead of tranquillisation
b) sedation with loss of alertness
c) loss of airway
d) cardiovascular and respiratory collapse
e) interaction with medicines already prescribed or illicit substances taken
f) possible damage to patient-staff relationship
g) underlying coincidental physical disorder
3.4.3 It should noted that the risks due to medication are increased when combined with physical restraint due to increased physical activity and restriction of motion.
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4 Formulary
Drug / Forms available / Dosing / Additional informationLorazepam / 1mg tablets / Adult: 1-2mg, up to 4mg/24hrs.
Elderly / Frail: use half adult dose.
12-18yrs: as per adult dose.
At least 1hr between doses. / Tablets can be dispersed in water where there are issues with swallowing (off-label use).
1mg/1ml intramuscular injection / Adult: 1-2mg, up to 4mg/24hrs.
Elderly / Frail: use half adult dose.
12-18yrs: as per adult dose.
At least 1hr between doses. / Absorption is no more rapid than oral: use in those unable / unwilling to take oral medication only.
Injection needs to be diluted 1:1 with water for injection prior to administration.
In cases of non-response to standard doses, consider dosing by weight: 25–30 micrograms/kg (usual range 1.5–2.5 mg), repeated every 6 hours if necessary.
Promethazine / 25mg tablets
25mg/5ml liquid / Adult: 25-50mg, up to 100mg/24hrs.
Elderly / Frail: as per adult dose.
At least 2hrs between doses. / Consider using lower starting doses in the elderly / frail until tolerability is established, due to risk of sedation / postural hypotension / anticholinergic side effects.
25mg/ml intramuscular injection
Haloperidol / 500microgram capsules
1.5mg tablets
5mg tablets
5mg/5ml liquid / Oral Dosing
Adult: 3-5mg, up to 20mg/24hrs.
Elderly / Frail: use half adult dose.
At least 2hrs between doses. / NB: dose / maximum varies according to route of administration due to differences in bioavailability.
5mg PO = 3mg IM
Consider prescribing bioequivalent doses PO and IM, and giving stated maximum as a number of doses per 24hrs:
e.g.
Haloperidol 5mg PO or 3mg IM, no more than 4 doses to be given in a 24hr period.
5mg/ml intramuscular injection / Intramuscular Dosing
Adult: 2-5mg, up to 12mg/24hrs.
Elderly / Frail: use half adult dose.
At least 1hr between doses.
Olanzapine / 2.5mg tablets
5mg tablets / orodispersible tablets
10mg tablets / orodispersible tablets
15mg tablets / Adult: 5-10mg, up to 20mg in 24hrs.
Elderly / Frail: use half adult dose.
At least 4hrs between doses.
Risperidone / 500microgram tablets / orodispersible tablets
1mg tablets / orodispersible tablets
2mg tablets / orodispersible tablets / Adult: 2mg, up to 2mg/24hrs
Elderly / Frail: 1-2mg, up to 2mg/24hrs
Dementia: 250-500micrograms, up to 2mg/24hrs
At least 6hrs between doses. / Licensed for use in dementia for up to 6 weeks treatment.
Consider using in patients already prescribed risperidone, due to inflexibility of dosing.
1mg/ml liquid
Aripiprazole / 7.5mg/ml intramuscular injection / Adult: 5.25mg / 7.5mg / 9.75mg / 15mg , up to 30mg/24hrs or 3 injections.
Elderly / Frail: as per adult dosing.
At least 2hrs between doses. / Not recommended in combination with other antipsychotics. Suggest to use in those patients treated with regular aripiprazole.
Zuclopenthixol acetate / 50mg/ml intramuscular injection / Adults: 50-150mg, maximum 400mg / 4 injections in 14 days.
Elderly / Frail: 50-100mg, maximum 400mg / 4 injections in 14 days.
At least 24hrs must be left after the first dose before administering subsequent doses.
At least 48hrs must be left after subsequent doses before a further dose is administered. / Consider when:
- Repeated IM administration has been necessary
- Patient expresses a preference for this
Not for use in:
- Pregnancy
- Antipsychotic naiive patients
- Patients who have experienced intolerable EPSE with typical antipsychotic medication
Midazolam / 1mg/ml intramuscular injection
5mg/ml intramuscular injection / Adult: 2.5-7.5mg, maximum 15mg/24hrs.
Elderly / Frail: 1-2mg, maximum 7.5mg/24hrs.
At least 1hr between doses. / ONLY APPROVED FOR USE IN CASES OF LORAZEPAM SHORTAGE.
NB: this is a controlled drug, and so consideration needs to be given to storage / administration restrictions.
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