The Management of Rapid Tranquillisation

Transcription

1 Document Title Reference Number Lead Officer The Management of Rapid Tranquillisation NTW(C)02 Medical Director Author(s) (Name and Designation) Dr Prathibha Rao Consultant Psychiatrist Ruth Ayre- Senior Clinical Pharmacist Ratified by Trust Policy Group Date ratified February 2016 Implementation Date February 2016 Date of full implementation August 2016 Review date February 2019 Version number V04.1 Review and Amendment Log Version Type of change Date V04 Review Feb 16 V04.1 Update Aug 16 Description of change Updated according to NICE MVA guidelines (NG10) May 2015; Updated sections 2-10;12-14, 21; Appendices 1-6, A, B & C IM Aripiprazole as a medication choice for RT This policy supersedes the following document which must now be destroyed Reference Number NTW(C)02 V04 Rapid Tranquillisation Policy Title

2 The Management of Rapid Tranquillisation Section Contents Page No: 1 Introduction 1 2 Purpose 1 3 Definitions of Terms Used 1 4 Duties and Responsibilities 3 5 Use of Rapid Tranquilisation 7 6 Using p.r.n. medication in Rapid tranquillisation 8 7 Parenteral Therapy for Rapid Tranquillisation 9 8 Rapid tranquillisation and seclusion 11 9 Care Post Rapid Tranquillisation Capacity to Consent Service Users Concerns Legal Concerns Incident Reporting and Post Incident Reviews Training: Resuscitation Pulse Oximetry Rapid Tranquillisation AVPU Implementation Monitoring and Compliance Fair Blame Equality Impact Assessment Fraud, Bribery and Corruption Associated Documents References 18

3 Standard Appendices attached to policy Appendix Title Page No: Appendix A Equality and Diversity Impact Assessment Form 19 Appendix B Communication and Training Needs Information 21 Appendix C Audit and Monitoring Tool 22 Appendix D Policy Notification Record Sheet - click here Appendices listed separate to policy Appendix No: Description Issue No: Issue Date Review date Appendix 1 The Management of Rapid Tranquillisation (RT) in relation to pregnant women 2 Sep 16 Feb 19 Appendix 2 RT Monitoring Chart 1 Feb 16 Feb 19 Appendix 3 Appendix 4 Flow Chart Violence and Aggression Short Term Management over 18 years Flow Chart Violence and Aggression Short Term Management years 2 Aug 16 Feb 19 1 Feb 16 Feb 19 Appendix 5 Prescribing Notes over 18 years 2 Aug 16 Feb 19 Appendix 6 Prescribing Notes12-18 years 1 Feb 16 Feb 19

4 1 INTRODUCTION 1.1 With Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/NTW), all patients, regardless of culture, gender, diagnosis, sexuality, age or religious/spiritual beliefs will be treated with respect and dignity; and where possible will be at the centre of the clinical decision making process ensuring safety is the priority throughout each intervention. 1.2 The purpose of this policy is to outline the use of rapid tranquillisation (RT) within the context of the prevention and management of violence and aggression. 2 PURPOSE 2.1 This policy covers the safe use of medication in treating service users in a psychiatric/learning disability inpatient setting and/or service users within a learning disability setting, this includes service users who exhibit disturbed or challenging behaviour and present a real risk of harm to themselves or others. 2.2 Service specific protocols for special populations such as people with acquired brain injury, children and adolescents, the elderly and a learning disability may supersede the protocol for the general adult population. 2.3 Treatment and care should take account of individual needs and preferences. Service users should have the opportunity to make informed choices about their care and treatment in partnership with their healthcare professional 2.4 Practice Variation: Like all guidance, this is a generalisation of best practice and this policy sets out broad standards for RT, which is intended to inform clinicians in reaching the best treatment decision for individual in-patients at the time and in the current circumstances. There will be occasions when there may need to be some variation from this, and these will require an assessment of the balance of potential benefits and potential harm indicated by the prescribing clinician in consultation with other members of the multi-disciplinary team. If a decision is made to vary from this policy, there must be clear documentation of that decision along with the supporting assessments and related consultations. Before all occasions of variance from this policy, the opinion of the consultant psychiatrist or another senior psychiatrist (e.g. out of hours) should be sought 3 DEFINITION OF TERMS USED 3.1 RT - Rapid Tranquillisation: Rapid tranquillisation in this guideline refers to the use of medication by the parenteral route (usually intramuscular) if oral medication is not possible or appropriate and urgent sedation with medication is needed. (NICE Clinical Guidance NG10, May 2015). The Code of Practice defines RT as a restrictive intervention 1

5 3.2 The aim of drug treatment in such circumstances is to calm the service user and reduce the risk of violence or harm, so that the necessary care (including cooperation with the Management of Violence and Aggression (MVA) plan) for the underlying psychiatric condition can then be provided/ continued. The aim of rapid tranquilisation is not to treat the individual s underlying condition. An optimal response would be reduction in agitation or aggression without sedation, allowing the service user to participate in further assessment and treatment. Ideally, the drug should have a rapid onset of action and low levels of side effects. 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. 3.3 MVA (Management of Violence and Aggression The Trust recognises the following definition of work related violence: an incident where an individual is abused, threatened or assaulted in circumstances related to their involvement with the Trust, which includes an explicit or implicit challenge to their safety, well-being or health. (Adapted from DOH 2000). 3.4 IM (Intramuscular) The injection of drugs directly into the muscle 3.5 ILS (Immediate Life Support) Emergency medical care for sustaining life, including defibrillation, airway management, and drugs and medications 3.6 O2 (Oxygen) 3.7 BP (Blood Pressure) 3.8 O (Oral) Administration of a drug via the oral route 3.9 NMS (Neuroleptic Malignant Syndrome): NMS is caused almost exclusively by the use of antipsychotic medication. Rapid and large increases in dosage, such as rapid tranquillisation, can also trigger the development of NMS. Signs and symptoms include muscular rigidity, pyrexia and confusion; sometimes muscle tremors and a sore throat. If NMS occurs it should be treated as a medical emergency Advance Decisions/Advance Requests: An Advance Decision - is an actual refusal of all or some specified treatment and the circumstances in which this would apply. Advance Decisions to refuse treatment for mental disorder may not apply if the person who made the Advance Decision is or is liable to be detained under the Mental Health Act

6 Advance Statement is a statement of a person s wishes, views and feelings. Such wishes should be given the same consideration as wishes expressed at any other time. Clinicians must consider advance statements when determining what is in the patient s best interests if the patient subsequently loses capacity. Some patients will deliberately state their wishes in advance about a variety of issues, including their medical treatment, how families and carers should be involved; the steps that should be taken in emergencies and what should be done if particular situations occur 3.11 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 AVPU scale- Alert, Voice, Pain, Unresponsive Scale ECG- Electro CardioGram. 4 DUTIES AND RESPONSIBILITIES 4.1 The Chief Executive is responsible for ensuring that an appropriate and adequate infrastructure exists to support the provision of rapid tranquillisation policy amongst staff and patients throughout the organisation. 4.2 The Executive Director of Nursing and Operations in conjunction with the Medical Director and Trust Chief Pharmacist are responsible for the strategic and operational management of the rapid tranquillisation policy. 4.3 The roles and responsibilities of the Clinical Nurse Managers/Service Managers will be to: Ensure within their area of responsibility the application of the rapid tranquillisation policy is adhered to and where necessary, action is taken to ensure compliance. This will be monitored through the Quality and Performance Groups Monitor compliance of staff with training requirements and inclusion of rapid tranquillisation in their appraisals in line with the Trust s policy NTW(HR)09, Staff Appraisal Policy and practice guidance notes (PGN) Monitor the attendance of staff through their Quality and Performance groups Undertake monitoring in line with monitoring tool, Appendix C of this policy 4.4 The Unit/Ward manager is required to: Ensure that all staff are aware of this policy and other policies and guidance which relate to this policy Ensure that adequate training is given to allow staff to safely implement the guidelines 3

7 Audit the use of guidelines Inform Clinical Nurse Manager/Service Manager if the guidelines are not being adhered to appropriately To be involved in the monitoring of the application of this policy 4.5 The Nurse in charge is required to: Be fully aware of the contents of this policy and supporting policies and guidance before an incident arises Assess risk and implement the policy when they feel it is appropriate Ensure that non-pharmacological (de-escalation) methods are tried first Ensure that the incident is fully documented Ensure that the correct monitoring is done (including completing RT vital signs monitoring) Continue to use de-escalation techniques throughout if appropriate To be involved in the monitoring of the application of this policy Must be competent in Immediate Life Support (ILS) Follow the guidance of Mental Health Act Code of Practice in relation to the use of rapid tranquillisation and The Mental Capacity Act Code of practice Complete all relevant Rapid Tranquillisation documentation 4.6 Registered Nurses are required to: Ensure that they are familiar with the policy and adhere to the protocols and procedures referred to Ensure their mandatory training is undertaken in line with policy requirements Provides support and information to patient, carers and their families as required about the application of rapid tranquillisation Adhere to the Trust s policy, NTW(C)17 Medicines Management and the Nursing Midwifery Council Medicine Management Standards Ensure that they only use clinical procedures which they are competent to administer 4

8 To be involved in the monitoring of the application of this policy Must be competent in Immediate Life Support (ILS) and remedial measures Follow the guidance of the Mental Health Act Code of Practice in relation to the use of rapid tranquillisation and The Mental Capacity Act Code of practice Complete all relevant Rapid Tranquillisation documentation Where appropriate, ensure that the Trust s practice guidance note within NTW(C)38 Pharmacological Therapy Policy, PPT-PGN-10 - Guidelines for the Use of High Dose Antipsychotics is followed 4.7 The Medical staff are required to: Ensure that they are familiar with the policy and adhere to the protocols and procedures referred to Ensure their mandatory training is undertaken in line with policy requirements Provides support and information to patient, carers and their families as required about the application of rapid tranquillisation Adhere to the Trust s policy, NTW(C)17 Medicines Management Ensure that they only use clinical procedures which they are competent to administer To be involved in the monitoring of the application of this policy Assess the patient and ensure a drug history is available, wherever possible, including ascertaining any past allergies and drug reactions from clinical notes Conduct a mental state examination, assessment of physical health (including ECG when possible), and ascertain a history of any physical health conditions before prescribing and administrating any medication in line with the Trust s NTW(C)29 - Trust Standard for the Assessment and Management of Physical Health Consider any advance decisions/statements before prescribing Consider if patient intoxicated 5

9 Always refer to the most recent British National Formulary (BNF) to check recommended drugs and dosages Consider interactions between medications Must be competent in Immediate Life Support (ILS) Consider the total daily dose of medications that are being prescribed Follow the guidance of the Mental Health Act Code of Practice in relation to the use of rapid tranquillisation and The Mental Capacity Act Code of practice Complete all relevant Rapid Tranquillisation documentation Ensure that the nurse in charge is fully aware of any decisions regarding medication Ensure the patient s current medication chart is amended to reflect the administration of Rapid Tranquillisation Where appropriate, ensure that the Trust s practice guidance note within NTW(C)38 Pharmacological Therapy Policy, PPT-PGN-10 - Guidelines for the Use of High Dose Antipsychotics is followed A prescription of RT must be in line with legal requirements (in respect of patients subject to the Act, the rules concerning treatment and emergency treatment powers under the Act) The person prescribing the injection should state the preferred injection site, having taken account of the need to avoid prone restraint, patient wishes and practicalities of the situation. Consider deltoid administration when possible 4.8 The Pharmacist is required to: Provide drug information and advice as required for both staff and patients Ensure medication to treat disturbed behaviour is available on all units where treatment may be carried out Ensure that medication to treat emergencies is available on all units where treatment may be carried out (as per Trust s policy NTW(C)01 Resuscitation Policy) Where appropriate, ensure that the Trust s practice guidance note within NTW(C)38 Pharmacological Therapy Policy, PPT-PGN-10 - Guidelines for the Use of High Dose Antipsychotics is followed 6

10 5 USE OF RAPID TRANQUILLISATION 5.1 Measures to reduce violence and aggression need to be based on comprehensive risk assessment and risk management. Therefore, mental health service providers must ensure that a full risk management strategy is introduced for all of their service users. 5.2 Rapid tranquillisation, physical interventions and seclusion should only be considered once de-escalation and other strategies have failed to calm the service users. When determining which of these interventions to employ, clinical need, safety of service users and others, and where possible advanced directives should be taken into account. 5.3 Rapid tranquillisation should only be used where a patient is aroused, agitated, overactive and aggressive and their actions present serious threat towards themselves or others, or is being destructive to their surroundings and where other therapeutic interventions of managing the behaviour have failed. 5.4 The team should ensure that they provide person-centred, values-based approach to care, in which personal relationships, continuity of care and a positive approach to promoting health underpin the therapeutic relationship 5.5 Rapid tranquillisation should never be used to manage patients as a substitute for adequate staffing. 5.6 A multidisciplinary team that includes a psychiatrist and a clinical pharmacist should develop and document an individualised pharmacological strategy for using routine and p.r.n. medication to calm, relax and tranquillise service users who are at risk of violence and aggression as soon as possible after admission to an inpatient psychiatric unit. They should also document a rapid tranquillisation treatment plan in anticipation of future incidents. 5.7 If rapid tranquillisation is being used, a senior doctor should review all medication at least once a day including the use of p.r.n. for RT. 5.8 In addition, 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 on RiO and include: clarification of target symptoms the likely timescale for response to medication the total daily dose of medication, prescribed and administered, including p.r.n. medication the number of and reason for any missed doses therapeutic response the emergence of unwanted effects 7

11 5.9 Drugs for rapid tranquillisation, particularly in the context of restraint, should be used with caution because of the following risks: - Loss of airway Loss of consciousness instead of sedation Respiratory depression or cardiac arrest (loss of airway) Over-sedation with loss of alertness Cardiovascular collapse Seizures Adverse effects, for example, neuroleptic malignant syndrome Interactions with medication (prescribed or illicit) Underlying coincidental physical disorders Possible damage to the therapeutic partnership between service user and clinician Specific issues in relation to diagnosis 5.10 Resuscitation equipment must be available and accessible where rapid tranquillisation is used as per the Trust s NTW(C)01 - Resuscitation Policy 5.11 With growing awareness that involuntary procedures produce traumatic reactions in service users, following the use of rapid tranquillisation, service user s should be offered the opportunity to discuss their experiences and should be provided with a clear explanation of the decision to use urgent sedation. This should be in the patient s record Service users will be given the opportunity to write up their account of the intervention. This may necessitate the assistance of advocates and relatives. The written account will be filed in the patient s record. Service users will be engaged in discussion with staff to learn and share lessons Older people, the elderly and other groups may require smaller doses of medication. Particularly consider: a) Altered levels of metabolism b) Existence of physical illness c) Use of concurrent medications 6 USING P.R.N MEDICATION IN RAPID TRANQUILLISATION 6.1 When prescribing p.r.n. medication as part of a strategy to de-escalate or prevent situations that may lead to violence and aggression: do not prescribe p.r.n. medication routinely or automatically on admission. Only prescribe p.r.n. medications for purposes of RT if there are good reasons to anticipate that this may be required. 8

12 6.2 When prescribing, ensure that the medicines chart is annotated to reflect administration of rapid tranquillisation e.g. use for RT as the indication for use. 6.3 Tailor p.r.n. medication to individual need and include discussion with the service user if possible and ensure there is clarity about the rationale and circumstances in which p.r.n. medication may be used and that these are included in the care plan. 6.4 A single dose should be prescribed and not repeated until the effects of the initial dose has been reviewed. It should be remembered that peak plasma concentrations occur approximately minutes following intramuscular administration. 6.5 Ensure that the maximum daily dose is specified and does not inadvertently exceed the maximum daily dose stated in the British national formulary (BNF) when combined with the person's standard dose or their dose for rapid tranquillisation. 6.6 Only exceed the BNF maximum daily dose (including p.r.n. dose, the standard dose and dose for rapid tranquillisation) if this is planned to achieve an agreed therapeutic goal, documented, and carried out under the direction of a senior doctor. Ensure that the interval between p.r.n. doses is specified. 6.7 If p.r.n. medication has not been used since the last review, consider stopping it. 7 PARENTERAL THERAPY FOR RAPID TRANQUILLISATION 7.1 If parenteral (I/M) treatment proves necessary, the service user should be transferred to oral routes of administration at the safest opportunity. 7.2 Where oral therapy for management of violence and aggression is refused, is not indicated by previous clinical response, is not a proportionate response, or is ineffective, a parenterally (I/M) administered rapid tranquillisation agent is recommended (see Appendix 3 -Prescribing flowchart >18 years, Appendix 4 Prescribing flowchart years, Appendix 5 - Prescribing notes >18 years, Appendix 6 - Prescribing notes years. 7.3 Sufficient time should be allowed for clinical response between intramuscular doses of medications for rapid tranquillisation. (See local rapid tranquillisation notes in Appendix 3). 7.4 The use of two drugs of the same class for the purpose of rapid tranquillisation is not recommended. 7.5 Medications should never be mixed in the same syringe. 7.6 When using I/M Haloperidol as a means of managing disturbed/violent behaviour, an antimuscarinic agent such as Procyclidine should be immediately available to reduce the risk of dystonia and other extrapyramidal side effects. This should be given intramuscularly as per manufacturer s recommendations. 9

13 7.7 All staff should be appropriately trained (see section Training) to recognise symptoms of respiratory depression, dystonia or cardiovascular compromise (such as palpitations, significant changes in blood pressure, reduction or sudden drop in respiratory rate or level of consciousness. 7.8 If intramuscular medication is used the service user should never be left unattended, and if in seclusion should be monitored on eye sight observations. Intramuscular administration should never occur without access to full support and resuscitation equipment that should be immediately available. This equipment should be maintained and checked weekly as per the Trust s NTW(C) 01 Resuscitation Policy. 7.9 NICE Guidelines state that zuclopenthixol acetate injection is not recommended in rapid tranquillisation due to long onset and duration of action. However, it may be used in certain specified circumstances: When disturbed/violent behaviour over an extended period of time is expected There is a history of good and timely response There is a history of requirement for repeated parenteral (I/M) administration An advance directive has been made indicating that this is a treatment of choice RT monitoring/patient observations should be completed as per Section 9 Care Post Rapid Tranquillisation 7.10 NICE guidelines do not recommend the use if aripiprazole injection in rapid tranquilisation. However, clinical trials have demonstrated the efficacy and safety of aripiprazole injection in acutely disturbed patients with schizophrenia, schizoaffective disorder, schizophreniform disorder or bipolar mania. The reported incidence of extrapyramidal side-effects was less with IM aripiprazole compared to IM haloperidol. Aripiprazole is also classed as lower risk in cardiovascular disease compared to Haloperidol. Aripiprazole injection can be considered for use when an antipsychotic is required and there is/are: a history of significant extrapyramidal side-effects pre-existing cardiac problems where lorazepam is of limited use 7.11 Particular care needs to be taken, if the patient is struggling and not held securely in an appropriate hold to ensure needlestick injuries, damage to nerves or accidental intraarterial injection do not occur. 10

14 8 RAPID TRANQUILLISATION AND SECLUSION 8.1 The use of seclusion (see the Trust s NTW(C)10 - Seclusion Policy) with rapid tranquillisation is not absolutely contraindicated. However, the following advice should be carefully considered and followed in conjunction with the patient s MVA care plan: - If the service user is secluded, the potential complications of rapid tranquillisation should be taken particularly seriously The service user should be monitored within eyesight observation by an appropriately trained individual (see the Trust s NTW(C) 19 - Observation Policy) and vital signs monitored (see section 8). These physical health recordings must be documented: o either on a printed version of Appendix 2- RT monitoring chart immediately AND then the recordings transferred onto the electronic RT monitoring chart on RiO within 24 hours o or enter the recordings directly onto the electronic RT monitoring chart on RiO The electronic RT monitoring chart can be found on RiO under core clinical documents>physical health monitoring>link to IP rapid tranq chart The trust in addition recommends the use of The National Early Warning Score (NEWS) for monitoring any signs of physiological deterioration. Once rapid tranquillisation has taken effect, consider terminating the seclusion as soon as reasonably possible 9 CARE POST RAPID TRANQUILLISATION 9.1 After parenteral (IM) rapid tranquillisation is administered, vital signs should be monitored, (See Appendix 2 RT Monitoring Chart) and pulse oximeters should be used. 9.2 Blood pressure, pulse, temperature, respiratory rate, oxygen saturations, level of consciousness and hydration should be recorded as per monitoring chart initially, then at least every hour or at intervals agreed by a multi-disciplinary team, until the service user becomes alert again/ there are no concerns about their physical health. 9.3 These physical health recordings must be documented - either on a printed version of Appendix 2- RT monitoring chart immediately AND then the recordings transferred onto electronic RT monitoring chart on RiO within 24 hours or enter the recordings directly onto the electronic RT monitoring chart on RiO 11

15 The electronic RT monitoring chart can be found on RiO under core clinical documents>physical health monitoring>link to IP rapid tranq chart The trust in addition recommends the use of The National Early Warning Score (NEWS) for monitoring any signs of physiological deterioration 9.4 Where oral medication is used, no additional physical observation is required. NTW(C) In the following circumstances, more frequent and intensive monitoring (at least every 15 minutes) by appropriately trained staff is required and should be recorded in the care plan and on the monitoring chart as above. Particular attention should be paid to the service user s respiratory effort, airway and level of consciousness: If the service user appears to be, or, is asleep/sedated. Ensure to maintain service user on eyesight observation during the 1 st hour due to the risk of cardiac respiratory collapse If the British National Formulary (BNF) limit is exceeded In high risk situations e.g. clinically unwell patient, frail, known physical conditions/complications Where the service user has been using illicit substances or alcohol Where the service user has a relevant medical disorder or concurrently prescribed medication Where the service user has experienced any harm as a result of any restrictive intervention 9.7 If a patient becomes acutely unwell where physical observations are showing a deterioration, the Trust s NTW(C)01 - Resuscitation Policy must be followed. Also refer to the Trust s NTW(C)29 Trust standard for the assessment and management of physical health policy, practice guidance note AMPH-PGN-03 - National Early Warning Score (NEWS). 10 CAPACITY TO CONSENT 10.1 The principals of the Mental Capacity Act 2005 (MCA 2005) and Supplementary Code of Practice for Deprivation of Liberty Safeguards must be followed in relation to consent to treatment. The five statutory principles are: A person must be assumed to have capacity unless it is established that they lack capacity A person is not to be treated as unable to make a decision unless all practicable steps to help him/her to do so have been taken without success A person is not to be treated as unable to make a decision merely because he/she makes an unwise decision 12

16 An act done or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his/her best interests Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person s rights and freedom of action 10.2 The assessment of the individual s capacity to consent should be taken by the staff team who carry out the intervention required to manage the situation. Whether the person has the capacity to consent is incident specific and time specific, this means there may be parts of treatment a person may have capacity to consent to; and at times they may have capacity to consent. An assessment may draw upon the expertise of other healthcare professionals, family, carers and advocates who are close to that person The assessment should follow the 2 stage test as outlined in the MCA 2005 Code of Practice and the Trust s NTW(C) 34 Mental Capacity Act 2005 Policy. Namely this means establishing if the person has; a) An impairment of the mind or brain, or some sort of disturbance affecting the way their mind or brain works (It doesn t matter whether the impairment or disturbance is temporary or permanent.) b) If so, does that impairment or disturbance mean that the person is unable to make the decision in question at the time it needs to be made? 10.4 A person may be said to lack capacity if they can t understand the treatment, explain consequences of having/not having the treatment; can t retain, use or weigh up the information relevant to the treatment; or can t communicate their decision in relation to the treatment (by whatever means) A treatment can only be given to a person if they have capacity and consent; or lack capacity to consent and it is in their best interests; or they are subject to the Mental Health Act 1983 where consent would not normally be required, any assessment and decision to treat must be recorded in the person s records If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards 10.7 Rapid tranquillisation must not be used to treat an informal patient who has the capacity to refuse treatment and who has done so. 11 SERVICE USER CONCERNS 11.1 When using interventions such as restraint, rapid tranquillisation or seclusion, steps must be taken to try to ensure that such treatment has the least impact on privacy and dignity as possible. 13

17 11.2 The reasons for using rapid tranquillisation; physical interventions or seclusion should be explained to the service user at the earliest opportunity After the use of rapid tranquillisation, physical interventions or seclusion, the service user s care plan should be reassessed, if required, and the service user should be helped to reintegrate into the ward milieu at the earliest safe opportunity Service users will be given the opportunity to write up their account of the intervention wherever possible, this will be managed at the service user s communication level, for example documentation of a verbal account or facilitated using talking mats / symbols etc; and may be part of a post incident support scenario. This may necessitate the assistance of advocates and relatives. The written account will be filed in the service user notes. Service users will be engaged in discussion with staff to learn and share lessons. 12 LEGAL CONCERNS 12.1 Regard must be made to any advance decisions and/or advance statements which the person may have made in relation to rapid tranquilisation as detailed in the Trust s NTW(C)34 Mental Capacity Act Policy, practice guidance note, MCA-PGN-02 Advance Decision to Refuse Treatment and Advance Statement PGN All staff must be aware of the legal framework that authorises the use of rapid tranquillisation, physical intervention and seclusion. The guidance of the Mental Health Act 1983 Code of Practice 2015 should be followed, with any departures from that guidance clearly recorded and justified as being in the service user s best interest. CYPS staff should be familiar with the Children Act 1989 and 2004 and the Mental Health Act 1983, as well as the Mental Capacity Act 2005 and the Human Rights Act They should also be aware of the United Nations Convention on the Rights of the Child The service should provide easy access to competent legal advice in relation to the management of any contentious aspect of disturbed/violent behaviour as detailed in the Trust s policy, NTW (O) 16 - Access to Legal Advice Prescription of RT must be in line with legal requirements (in respect of patients subject to the Act, the rules concerning treatment and emergency treatment powers under the Act. 13 INCIDENT REPORTING AND POST INCIDENT REVIEWS 13.1 Incident Reporting Any incident requiring intramuscular (I/M) rapid tranquillisation, physical restraint or seclusion should be reported by staff to their line manager, in line with the Trust s NTW(O)05 Incident Policy, which follows the principles of the guidance issued by the Security Management Service (SMS) and the National Patient Safety Agency (NPSA): Seven Steps to Patient Safety: Step 4: Promote Reporting. 14

18 13.2 Post-Incident Reviews Following administration of Rapid Tranquillisation, an immediate post-incident review that includes at least a doctor and a nurse to identify and address any physical harm to service users and to develop further medication plans and RT plans should be conducted As soon as possible, but no later than 72 hours, a post incident review that includes the service user will need to happen in order to evaluate what could have been done differently, determine alternatives and record management plan for future RT incidents that are tailor made for the service user For anyone (to include service users and staff) that has witnessed rapid tranquillisation, consideration should be given to offering support and further help as appropriate. 14 TRAINING See Standard Appendix B 14.1 The Trust will ensure that all staff has access to appropriate levels of training, it is the responsibility of each Group Director to ensure staff attend. Levels of training are identified in the training needs analysis (see Appendix B) and are included within the Essential Training Guide which forms part of NTW(HR)09 Staff Appraisal Policy and Practice Guidance Notes Levels of training are identified in the training needs analysis and are included within the Training Guide which can be accessed via this link Resuscitation All staff involved in administering or prescribing rapid tranquillisation, or monitoring service users to whom parenteral rapid tranquillisation has been administered, will receive annual competency based resuscitation training. This will be provided by the Trust, detailed in the Trust s NTW(C)01 Resuscitation Policy Pulse Oximetry Prescribers and those who administer rapid tranquillisation should have received training in the use of pulse oximeters (see Appendix B: Training Needs Analysis). This will be updated annually, be provided by the Trust and include: - The basic principles of pulse Oximetry Physiological risk factors in relation to physical intervention rapid tranquillisation Changes that can occur in an individual during control and restraint/rapid tranquillisation 15

19 Reasons for monitoring service users when control and restraint/rapid tranquillisation is used Potential difficulties in achieving accurate pulse oximetry readings Responsibilities in using pulse Oximetry Knowledge assessment 14.4 Rapid Tranquillisation All staff involved in administering or prescribing rapid tranquillisation, or monitoring service users to whom parenteral rapid tranquillisation has been administered, will receive rapid tranquillisation training every three years (see Appendix B: Training Needs Analysis). This will be provided by the Trust and will include: - The properties of Benzodiazepines; their antagonist, Flumazenil; Antipsychotics; Antimuscarines and Antihistamines The risks associated with rapid tranquillisation, including cardiorespiratory effects of the acute administration of these drugs, particularly when the service user if highly aroused and may have been misusing drugs; is dehydrated or possibly physically ill The need to titrate doses to effect Will include alternative approaches to rapid tranquillisation and the importance of staged interventions 14.5 All staff involved in monitoring service users to whom parenteral rapid tranquillisation has been administered will need to be familiar with interpreting the AVPU Scale modified in assessing the level of consciousness and seeking help as required 15 IMPLEMENTATION 15.1 An awareness of the policy, its content and implementation will be undertaken 6 months post implementation to establish the level of embedding of the policy and plan any remedial action needed. 16 MONITORING COMPLIANCE See Appendix C 16.1 As part of Post-Incident Reviews there will be a Review of documentation (as detailed in Appendix C) by Ward Manager, following each incident of rapid tranquillisation. Compliance with training requirements will be monitored via dashboards and by the provision of regular reports to workforce and development group 16

20 17 FAIR BLAME 17.1 The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken. 18 EQUALITY IMPACT ASSESSMENT 18.1 In conjunction with the Trust s Equality and Diversity Officer this policy has undergone an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner. 19 FRAUD, BRIBERY and CORRUPTION 19.1 In accordance with the Trust s policy NTW (O) 23 Fraud, Bribery and Corruption Policy, all suspected cases of fraud and corruption should be reported immediately to the Trust s Local Counter Fraud Specialist or to the Executive Director of Finance. 20 ASSOCIATED DOCUMENTS: NTW(C)01 - Resuscitation Policy NTW(C)03 Leave, absent without leave and missing person policy o LP-PGN-02 Entry and Exit from wards practice guidance note NTW(C)05 - Consent to Examination or Treatment Policy NTW(C)10 - Seclusion Policy NTW(C)16- Recognition, Prevention, MVA Policy NTW(C)17 - Medicines Management Policy NTW(C)19 - Observation Policy NTW(C)34 - Mental Capacity Act 2005 Policy o MCA-PGN-02 Advance Decision to refuse treatment and advance statements NTW(C)38 Pharmacological Therapy Policy, PGN o PPT-PGN-10 - Guidelines for the Use of High Dose Antipsychotics NTW(O)01 - Development and Management of Procedural Documents NTW(O)05 - Incident Policy (including management of serious incidents) and practice guidance notes NTW(O)16 - Access to Legal Advice NTW(O)21 Security Management Policy, PGN o SM-PGN-06 Police Liaison PGN o SM-PGN-06.1 Missing Persons PGN 17

21 NTW(HR)09 Staff Appraisal Policy and Practice Guidance Notes 21 REFERENCES: o SA-PGN-01 Training/Development Needs Analysis Process and attendance management NTW(C) 02 o SA-PGN-02 - Appraisal and Annually Earned Pay Points for Bands 8c,d and 9 Mental Health Act 1983 Code of Practice Mental Health Act 2007 Code of Practice in relation to the use of rapid tranquillisation Mental Capacity Act 2005 (MCA 2005) Mental Capacity Act 2005 Code of Practice and Supplementary Code of Practice in relation to Deprivation of Liberty safeguards Security Management Service (SMS) and the National Patient Safety Agency (NPSA): Seven Steps to Patient Safety: Step 4: Promote Reporting. Immediate Life Support (ILS) Resuscitation Council UK Basic Life support (BLS) Resuscitation Council UK) NICE Clinical Guideline May 2015 NG10 Children Act 1989 and 2004 Human Rights Act 1998 United Nations Convention on the Rights of the Child. Current lists should be retained in the front of policy file. Andrezina R et al Psychopharmacological (3) Tran-Johnson TK et al Journal of Clinical Psychiatry Product Characteristics (SPC) - for all medications included in the policy. Accessed Sept 2015 and April 2016 Taylor D, Paton C, Kapur S. (2015). The Maudsley Prescribing Guidelines. 12th ed. London: Wiley-Blackwell. Bazire S. (2014). Psychotropic Drug Directory London: Lloyd Reinhold Communications. 18

22 Appendix A Equality Analysis Screening Toolkit Names of Individuals involved in Review Date of Initial Screening Review Date Chris Rowlands V04 Oct 18 Service Area / Directorate Policy to be analysed Management of Rapid Tranquillisation-V04 Is this policy new or existing? Existing What are the intended outcomes of this work? Include outline of objectives and function aims This policy covers the safe use of medication in treating service users in a psychiatric/learning disability inpatient setting and/or service users within a learning disability setting (residential and day care), this includes service users who exhibit disturbed or challenging behaviour and present a real risk of harm to themselves or others Trust Policy NTW(C)05 Incident Policy (including management of serious incidents) which follows the principles of the guidance issues by the Security Management Service (SMS) and the National Patient Safety Agency (NPSA): Seven Steps to Patient Safety: Step 4: Promote Reporting. Consent, Advanced Decisions. Who will be affected? e.g. staff, service users, carers, wider public etc Protected Characteristics under the Equality Act The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them Disability Sex Race Age Gender reassignment (including transgender) Sexual orientation. Religion or belief Marriage and Civil Partnership Consent issues Older People - Consent issues Children and Young People - Use the Trust protocol with reference to age and weight of the child/ young person. N/A 19

23 Pregnancy and maternity Carers Other identified groups How have you engaged stakeholders in gathering evidence or testing the evidence available? Through standard policy process procedures How have you engaged stakeholders in testing the policy or programme proposals? Through standard policy process procedures For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: Appropriate review by author/team Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life. Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic Eliminate discrimination, harassment and victimisation This policy does not unlawfully discriminate against equality target groups Advance equality of opportunity Promote good relations between groups N/A N/A What is the overall impact? Addressing the impact on equalities From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? If yes, has a Full Impact Assessment been recommended? If not, why not? Manager s signature: Date: November

24 Appendix B Communication and Training Check list for policies Key Questions for the committees accountable designing, reviewing or agreeing a new Trust policy Is this a new policy with new training requirements or a change to an existing policy? If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below. Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice? Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHSLA etc. Please identify the risks if training does not occur. Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training. Is there a staff group that should be prioritised for this training / awareness? Please outline how the training will be delivered. Include who will deliver it and by what method. Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc. This is an amendment to the previous policy. No NICE guidelines, CQC, Royal College of Psychiatrists It could have a detrimental impact of patient safety and care. All clinicians within an in-patient setting require awareness and training. Nursing and medical staff. Management cascade E Learning Team brief Local Induction Training Awareness sessions for those affected by the new policy Medicines Management Committee Newsletter Shared learning NICE website NICE - usingguidance/sharedlearningimplemention Prathibha Rao Ruth Ayre 21

25 Statement Audit and Monitoring Tool Appendix C The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework. NTW(C)02 Rapid Tranquillisation Policy - Monitoring Framework Auditable Standard/Key Performance Indicators Frequency/Method/Person Responsible Where Results and Any Associate Action Plan Will Be Reported To, Implemented and Monitored; (this will usually be via the relevant Governance Group). 1 Staff in in-patient settings receive training in Rapid Tranquillisation and Pulse Oximetry in line with training standards (Appendix 1&2) Line manager to ensure training is updated 3 yearly (rapid tranquillisation) and annually for pulse oximetry. Monitored via dashboard. and performance report Monitored monthly at individual Group Q+P via performance report 2 3 Arrangements for post rapid tranquillisation monitoring are clearly documented on patients records For parenteral (I/M) Rapid Tranquillisation only all seven key elements of monitoring have been conducted BP, Pulse, Respiratory rate,temperature hydration, O 2 Saturation and level of consciousness This will also be captured within the seclusion audit. Additional audits as decided by the groups plus national POMH audits Seclusion audit reported to Groups (frequency of reporting to be determined by GBM and the Groups). Additional audits as decided by the groups plus national POMH audits Seclusion and additional audits are reviewed by the Group Q+P and safe subgroup Seclusion audits are reviewed by the Group Q+P and GBM Additional audits reviewed by Q&P safe subgroup 4 NTW Prescribing standards are followed on prescription cards Review of documentation by clinical staff (nurses, medical and pharmacy). Findings to be to be resolved by clinical team. Repeated issues to be raised through the appropriate management. 6 monthly full prescribing standards audit completed on every ward. Prescribing standards audit reported to Group Q+P 6 monthly The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out. 22