You are on page 1of 55

The Management of Acute Behavioural Disturbance in Adults

(including Rapid Tranquillisation)


Authorising Officer

Dr. Geraldine OSullivan


Medical Director

Signature of Authorising Officer


Version:

V2

Ratified by:

Risk Management and Patient Safety


Committee

Date ratified:

24th September 2008

Name of originator/author:

Practice Standards Facilitator

Name of responsible committee:

Drugs and Therapeutic Committee

Date issued:

October 2008

Review date:

November 2009 (review date extended until


May 2010)

Summary:

Guidance for the use of rapid


tranquillisation in the management of acute
behavioural disturbance
All medical, nursing and other health care
professionals and support staff who could
be involved in the management of acute
behavioural disturbance.

Target audience:

Hertfordshire Partnership NHS Foundation Trust is committed to providing an environment


where all staff, service users and carers enjoy equality of opportunity.
The Trust works to eliminate all forms of discrimination and recognise that this requires,
not only a commitment to remove discrimination, but also action through positive policies to
redress inequalities. Providing equality of opportunity means understanding and
appreciating the diversity of our staff, service users & carers and ensuring a supportive
environment free from harassment. Because of this Hertfordshire Partnership NHS
Foundation Trust actively encourages its staff to challenge discrimination and promote
equality of opportunity for all.

Page 1 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2 Oct
08.doc

Version Control
Version

Date

Author

Status

Comment

V1

Nov 05

P Crosby

Superseded

Archived

V2

Oct. 08

P Crosby

Current

Agreed HPFT Drugs and Therapeutic


Committee 8.9.08
Trust Executive 14.10.08

Performance Indicators
National Health Litigation Authority Risk Management Standards
Standard 4: Clinical Care (April 2008)
Level 1.4.1 The organisation has approved documentation which describes the process
for managing risks associated with rapid tranquillisation.
Level 2.4.1 The organisation can demonstrate implementation of the approved
documentation which describes the process for managing the risk associated with rapid
tranquillisation.
Key Objectives
The organisation can demonstrate monitoring in relation to the:

prescribing guidelines with regard to rapid tranquilisation

arrangements for monitoring service users having received rapid tranquilisation.

Comments and Feedback on this document were obtained from:


Medicines Management Team
Rapid Tranquillisation working group
Learning Disabilities Therapeutic Advisory Group
Lead Clinicians
Lead Nurses
Ward/Unit Teams via Service Managers
EIA Scrutiny Group
Acknowledgement to Birmingham and Solihull Mental Health NHS Trust Rapid Tranquillisation Policy

Page 2 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural
Disturbance(RT) V2 Oct 08.doc

Contents
1.

Introduction

2.

Purpose

3.

Responsibilities

4.

Training Strategy

5.

Rapid Tranquillisation (RT)

5.1

What Is Rapid Tranquillisation?

5.2

Service Users Experience

5.3

Advance Directions

5.4

Assessment Of The Cause Of Disturbed Behaviour

5.5

When Should Rapid Tranquillisation Be Used?

5.6

Cautions In The Use Of Rapid Tranquillisation

10

5.7

Risks Associated With Rapid Tranquillisation

10

5.8

Circumstances for special care

12

5.9

Observation and Escorting

12

5.10

Physical Monitoring

12

5.11

Rapid Tranquillisation And Seclusion

13

5.12

Recording

13
14

7
8
9
10

Guidelines For The Management Of Acute Behavioural


Disturbance In Adults Stepped Approach
STEP 1 Measures that do not involve rapid tranquillisation
STEP 2 Oral Medication
STEP 3 Intramuscular (IM) Medication
STEP 4 Intravenous (IV) Medication
Medications Not Recommended For Rapid Tranquillisation
Doses For Rapid Tranquillisation
Plan for the next 24 hours and afterwards
Common or serious side effects and their management

11

Consultation, Approval and Ratification Process

34

12

Dissemination, Implementation and Access to this document

34

13

Process for monitoring compliance with this document

34

14

Process for reviewing, approving and archiving this document

34

15

References

35

16

Associated Documents

35

15
16
22
28
30
31
32
33

Appendix 1 Prescribing Guidelines - List of preparations clinicians may use


in RT, their properties and side effects
Appendix 2
Effects of QT prolongation

36

Appendix 3

Drug Choice in Pregnancy

44

Appendix 4

Algorithm for Rapid Tranquillisation

46

38

Page 3 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2 Oct 08.doc

Appendix 5

5a Nursing Observations Pre and Post Rapid


Tranquillisation
5b Observation /Escorting Procedure
5c Agitation-Calmness Evaluation Scale (ACES)

Equality Impact Assessment Stage One

48

54

Page 4 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

1. Introduction
This document provides guidance for the use of medication (rapid tranquilisation) in the
management of acute behavioural disturbance for adults (16 years and over) in Trust inpatient units, day units and to both informal and service users detained under the Mental
Health Act.

There are a variety of approaches for managing acute behavioural disturbance, which
should be considered in the first instance. These include de-escalation, distraction
techniques, consideration of placement, physical restraint and seclusion. All of these
strategies should be considered in each case.

Sedative medication is one of several strategies commonly used in the management of


severely disturbed behaviour in in-patient settings. The severity of the disturbed behaviour
and associated risk to the patient or to other people, and the apparent imminence of that
risk, often determine the strategies that are employed in a particular situation.

For service users known to services where PRN is an accepted approach to managing their
behaviour within a flexible maintenance dose, A clear management plan must be in place,
which is regularly reviewed by the multidisciplinary team (This does not constitute RT). The
individuals management plan must specify the monitoring required following administration
of the PRN medication.

Where the risk is assessed as both severe and imminent, rapid tranquillisation may be
employed. In particular it should be considered rapid tranquillisation if:

Medication is to be given without the consent of the service user,


(remember to use sec 62 paperwork and be sure that treatment is
permitted under sec 62 if not sure consult MHA Code of Practice 2008 )

More than one dose of sedative medication is likely to be required (consider the
service users previous history of response to such medication), or

It is considered necessary to give intramuscular medication

or

The guidance of the Mental Health Act Code of Practice 2008, should be followed.
Any departure from that guidance must be clearly recorded and justified as being in the
service users best interest.

Rapid Tranquillisation (RT) is a pharmacological strategy. RT should only be considered


once de-escalation and other strategies have failed to calm a service user. Even when RT is
used, the other strategies should continue to be used alongside RT, as each is likely to
augment the effect of the others. Particular caution is necessary if combining RT with
seclusion and physical intervention

Page 5 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

RT is not a recognised clinical procedure in the British National Formulary (BNF). There is a
limited evidence base. Expert clinical opinion may be used to support prescribing outside
the limits set by the British National Formulary (BNF) or SPC (RCPsych Consensus
1
Statement on High-Dose Antipsychotic Medication ).

The accompanying guideline RT by oral and IM routes should be used in conjunction with
this broader guidance. (Appendix 1)
2. Purpose
This guidance provides all staff involved in the administration, prescribing or monitoring of
service users receiving RT with background information that will allow them to make
appropriate clinical decisions. Decisions should be based on the characteristics of an
individual service user and situation.
This guidance is based on the NICE Guideline The Short -term Management of Disturbed
Violent Behaviour in In-patient Psychiatric Settings and Emergency Departments 2005 and
the MHA 1983 Code of Practice revised 2008 and forms part of the HPFT Policy on the
Management of Aggression and Violence and meets the requirement of the National Health
Litigation Authority Risk Management Standards, Standard 4: Clinical Care
3. Responsibilities
As a Foundation Trust currently operating within a structure of Information Governance,
the Board and Chief Executive have the responsibility to ensure effective risk
management of users of the service, provide appropriate training to their staff and
provide a suitable infrastructure to establish and continue support for these activities
including recording and monitoring procedures.
The Executive Director Quality and Medical Leadership as lead for Medication
Management and is directly accountable to the Trust Board.
The Trust Drugs and Therapeutic Committee is responsible for ensuring that the
guidance meets current good practice.
The Risk Management and Patient Safety Group has the responsibility to ensure the
guidance meets national and legal standards including NHSLA requirements and the
monitoring of key objectives.
It is the responsibility of the Trust organizational management group to ensure
guidance distribution, implementation and compliance throughout the organisation.
Lead Clinicians/Team Leaders/Ward Managers must ensure that members of their
teams involved with management of acute behavioural disturbance understand their
responsibilities within this document.

Royal College of Psychiatrist, Consensus statement on high-dose antipsychotic medication, May 2006.

Page 6 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Individual health care professionals have the duty to implement the requirements of this
document within their area of responsibility and professional code of conduct. This duty
extends to the supervision of support staff when duties are delegated.
Approval of the Trust Guidance for the Management of Acute Behavioural
Disturbance In Adults
The guidance is ratified by the Risk Management and Patient Safety Group and
accepted as an organisation wide guidance by the Trust Executive Committee.
4. Training
The organisation will provide sufficient and appropriate training in the use of rapid
tranquillisation as follows:
Induction for medical and nursing staff
During preceptorship for newly trained nursing staff
For medical staff the use of rapid tranquilisation is addressed during continual professional
development.
Medical and nursing staff involved in rapid tranquillisation receive resuscitation training as set
out in the Trust Resuscitation guidance.
Management of Aggression and Violence training via the Relating to people training for
medical and nursing staff (Module 4 and Module 5)
Medicine Management Education and Training Programme includes a session on
high dose and combination prescribing of antipsychotics.
Lead clinicians/ ward/team managers are responsible via supervision that their staff attend
the relevant training and updates. Records of training must be kept.
Members of staff are responsible for attending the required training at the required
intervals.
The training schedule applies to indicated staff groups whether temporary or
permanent.
Associated Training
Clinical Risk Assessment and Management
Mental Health Act 2007
Mental Capacity Act 2005
For further information refer to the appropriate procedural document.

Page 7 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

5. RAPID TRANQUILLISATION (RT)


5.1 WHAT IS RAPID TRANQUILLISATION?
The administration of medication to calm/lightly sedate the service user and achieve
reduction in agitation and aggression. The aim is to reduce service user suffering and related
risks, improve communication throughout the intervention, and allow mental state evaluation
to take place.
5.2 SERVICE USERS EXPERIENCE
5.2.1 The use of rapid tranquillization has the potential to affect the therapeutic
relationship and the context of this needs to be understood in ongoing assessment. As
a consequence of this intervention the reasons for using RT to be explained to the
service user at the earliest opportunity.
5.2.2 Effective communication is important during the management of acute behavioural
disturbance especially where there are specific language and sensory communication
requirements.
The information provided should meet the individuals communication needs, e.g.
people with physical, sensory or learning disabilities or people who do not speak or read
English. The Trust Policy on Communicating With Service Users From Diverse
Communities provides guidance on communication needs and the procedure on
accessing the interpreting service.
5.2.3 Service users should be offered the opportunity to discuss their experiences given
the opportunity to write their account of the experience to be included in the notes
thereby supporting the underlying principles of recovery.
5.3 ADVANCE DECISIONS
Service users identified to be at risk of disturbed or violent behaviour should be given
the opportunity to have their needs and wishes recorded in the form of an advance
decision. This should fit within the context of their overall care and should clearly state
what intervention(s) they would and would not wish to receive. This document should
be subject to periodic review. (Revised MHA Code of Practice, 2008).
Where there is an advance decision documented in the service users care plan for a
preferred treatment option in the event of acute illness, this should be adhered to if
legally and clinically appropriate.

Page 8 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

5.4 ASSESSMENT OF THE CAUSE OF DISTURBED BEHAVIOUR


It is a priority to consider physical causes e.g. an acute confusional state, intoxication,
head injury, epilepsy, infection or metabolic disturbance. The possibility of
hypoglycaemia must be considered as it requires urgent treatment.
Occasionally violence may not be the result of a disturbed mental state and in this
instance calling the police may be the most appropriate action.

Attempt to understand the situation that led up to the disturbed behaviour. For
further guidance refer to the Trust Prevention and Management of Physical and NonPhysical Assaults Policy.

5.5 WHEN SHOULD RAPID TRANQUILLISATION BE USED?


5.5.1 When determining which interventions to employ, clinical need, safety of
service users and others, and where possible advance directions, should be
taken into account.
5.5.2 The aim of RT is not to treat any underlying illness or disorder. Instead RT
should be used as a management strategy.
5.5.3 Acute behavioural disturbance may occur in the context of psychosis and nonpsychosis. For further guidance refer to the Trust Prevention and Management of
Non-Physical and Physical Assaults.
5.5.4 RT is potentially hazardous and there is a risk of adverse events. The decision
needs to be made at the stage of prescribing as to the intended purpose and if this
differs over time then it will need adjustment and be reflected in the care plan.
5.5.5 Clinical staff to make an important clinical judgement, distinguishing between
what is rapid tranquillisation and what is administration of PRN medication. This
decision should be made in advance of any administration of medication and
documented in the service users care plan. The level of the disturbed behaviour and
apparent imminence of the risk of violence are relevant to this decision. Medical
support must be available in case of adverse reactions, over-sedation or the need to
administer I.V. Flumazenil for respiratory depression.
5.5.6 Always be clear about Mental Health Act status prior to treatment.
5.5.7 If treating a service user against their will under common law, this must be clearly
stated in the medical record and continually updated. The approach to treatment must
be proportional and least restrictive and in the persons best interest at that point in time.

Page 9 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

5.6. CAUTIONS IN THE USE OF RAPID TRANQUILLISATION


The service user should be assessed considering the following factors:

Concurrent treatment both prescribed medicines and those bought over-the-counter.

Co-existing medical illnesses e.g. epilepsy, cardiac and respiratory conditions

Alcohol or illicit drug use - because of the serious risk to life, service users who are
heavily sedated or using illicit drugs or alcohol should be observed more closely.

Physical health and vital signs if possible -airway, pulse, colour and temperature.

Age for older adults use smaller doses e.g. if haloperidol is to be used, 500
micrograms is the usual dose. The maximum dose for lorazepam is 2mg in 24 hours.
Seek advice from senior colleagues where appropriate.

Dementia the MHRA have warned against the use of risperidone and olanzapine for
the treatment of behavioural symptoms of dementia, due to an increase risk of stroke
and death. Antipsychotics must be avoided in those with Lewy Body Dementia.

People with Learning Disability may be more sensitive to the effects of drugs used
for rapid tranquillisation and may therefore require lower doses.

Pregnancy risk-benefit analysis must be undertaken in cases where service users


are pregnant, as there is insufficient evidence on the safety of rapid tranquillisation in
pregnancy. (Refer to Appendix 3 Drug Choice in Pregnancy).
For further advice refer to the HPFT Policy Guidelines for the Care and
Management of Pregnant Service Users.

5.7 RISKS ASSOCIATED WITH RAPID TRANQUILLISATION

Rather than simple calming, over-sedation with loss of alertness or even loss of
consciousness can occur.

Polypharmacy within a class of medication should be avoided, e.g. the use of two
benzodiazepines

Medical risks include cardiac arrhythmias, respiratory depression, hypotension,


neuroleptic malignant syndrome (NMS) and extra-pyramidal side- effects (not
exhaustive).

There are specific risks associated with the different classes of medications that are
used in rapid tranquillisation. When combinations are used, risks may be
compounded. These include:

Page 10 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

BENZODIAZEPINES

Loss of consciousness
Respiratory depression or
arrest
Cardiovascular collapse
(in service users on both
clozapine and
benzodiazepines)

ANTIPSYCHOTICS

ANTIHISTAMINES

Loss of consciousness
Cardiovascular and
respiratory collapse
Seizures
Subjective experience of
restlessness (akathisia)
Involuntary movements
(dyskinesia)
Acute muscular rigidity
(dystonia)
Neuroleptic Malignant
Syndrome (NMS)
Excessive sedation

Excessive sedation
Painful injection
Additive antimuscarinic
effects

Paradoxical agitation may result from antipsychotic or benzodiazepine treatment.

Clinicians need to ensure that service users are not inadvertently given high doses of
antipsychotics, which can potentially be very dangerous. This could occur accidentally
through the use of PRN medication given in combination with regular medication.

Consider any antipsychotics taken recently i.e., within the last 24 hours or depot
antipsychotic injections given in the past 6 weeks.

It is sometimes necessary to knowingly exceed BNF limits and knowingly use drugs
outside of their marketing authorisation (off-label) for the purpose of rapid
tranquillisation. The rationale for this must be recorded in the care plan and monitoring
of the service users condition must be specified.

If PRN medication is given, it is important to allow time for the drug to work before
giving further doses by either oral or intramuscular means,

In addition, clinicians must bear in mind that the plasma concentration of the
antipsychotic is not only affected by the total dose but also the route of administration
and its rate of elimination. Elimination depends on a number of factors including drug
interactions, and the age of the service user. Clinicians should also be aware that
absorption from intramuscular (IM) administration can happen far more rapidly when a
service user is agitated, excited or physically overactive.

The need for medication should be re-assessed on a regular basis within the agreed
and on-going treatment plan.

See advice from the Consultant at any stage if there is any doubt about current care /
treatment plan / risk strategy.

Page 11 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

5.8 CIRCUMSTANCES FOR SPECIAL CARE


Extreme care needs to be taken when initiating rapid tranquillisation in the following
circumstances:
Almost all serious adverse events occur to service users undergoing physical restraint.
The restraining period is one of particular risk and should be kept to a minimum. For
guidance refer to the Prevention and Management of Physical and Non-Physical
Assaults.
The presence of congenital prolonged QTc syndromes. The concurrent prescription or
use of other medication that lengthens QTc intervals both directly and indirectly. (refer
to Appendix 2)
The presence of certain disorders affecting metabolism such as hypo- and
hyperthermia, stress and extreme emotions, and extreme physical exertion.
In service users who are pregnant. (refer to Appendix 3)
In service users who are heavily sedated and/or used illicit substances or alcohol.
5.9 OBSERVATIONS AND ESCORTING
Staff should ensure that the minimum standards of observation and escorting
procedures set out in Appendix 5 are part of a comprehensive approach to the
management of risks associated with responding to disturbed / aggressive behaviour
involving medication and physical interventions.
5.10 PHYSICAL MONITORING
If medication is used for the management of acute behavioural disturbance the
equipment for carrying out the following monitoring is required to be available
immediately:

BP
Pulse
Temperature using tympanic device
Oxygen Saturation Levels via pulse oximeter (where available)
Resuscitation equipment as set out in the Trust Resuscitation policy.

An Electro Cardio Graph to be carried out at the earliest opportunity.


Details of physical monitoring are set out in the step approach. For further information
on physical monitoring refer to Appendix 5.
If current BNF doses are exceeded it is particularly important that frequent and
intensive monitoring of a calmed service user is undertaken. This must be specified and
Page 12 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

recorded in the care record. Pay particular attention to regular checks of airway, level of
consciousness, pulse, blood pressure, respiratory effort, temperature and hydration.
Members of staff must know the procedure for obtaining emergency assistance.
Resuscitation equipment must be available for immediate use. For further information
on equipment needs refer to the Trust Resuscitation policy.
5.11 RAPID TRANQUILLISATION AND SECLUSION
The use of seclusion with rapid tranquillisation is not absolutely contraindicated.

If the service user is secluded, the potential complications of rapid


tranquillisation should be taken particularly seriously.

The service user should be monitored by within eyesight observation by


a suitably trained individual. Refer to the Trust Supportive Observation
Policy.

Once rapid tranquillisation has taken effect, seclusion should be


terminated.

5.12 Recording
A full record of the management of the acute behaviour episode is made in the
individuals care record.
All drugs prescribed are entered on to the prescribing chart and administered
medication on the administration of medication recording chart in line with the Trust
Medicine Policy.
All monitoring activity must be recorded in the care record, the HPFT observation
recording forms ( refer to the HPFT Supportive observation policy) and vital signs
recording chart.

Page 13 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

6. GUIDELINES FOR THE MANAGEMENT OF ACUTE BEHAVIOURAL


DISTURBANCE IN ADULTS STEPPED APPROACH
INTRODUCTION
The following is a stepped approach for the management of acute behavioural
disturbance that outlines the various approaches that may be used.
An important clinical judgement must be made as to which step(s) would be appropriate
for individual service users, based on the severity of behavioural disturbance and
associated risk. The least restrictive intervention must be employed whenever possible.

STEP ONE:
Includes measures that do not involve medication i.e. de-escalation and distraction
techniques.

STEP TWO:
Involves the use of oral medication and should be tried when step one is not feasible
and / or does not achieve a satisfactory outcome i.e. sufficiently calm a service user
thereby reducing risk to self and others.

STEP THREE:
Involves the use of IM medication. The interventions suggested within this step must
only be employed when steps one and two are not feasible, or when both steps have
been tried and failed to achieve a satisfactory outcome.

STEP FOUR:
Involves the use of IV medication. The interventions suggested within this step must
only be employed in very exceptional circumstances. The decision should not be
made by junior medical staff in isolation and can only be used following consultation
with on-call Consultant.
Also provided for steps two, three and four is guidance for the necessary physical
monitoring that should be carried out.

Page 14 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

STEP ONE Measures that do not involve medication

Measures that do not involve medication should be the first approach for the control
of disturbed or violent behaviour.

The ongoing risk management plan must be followed and evaluated to reflect
changes in intervention.

Employ distraction techniques and de-escalation using non-drug approaches.

Ensure ongoing risk assessment and physical assessment is available to inform


treatment strategy.

For further guidance on measures that do not involve medication, refer to the Trust
Policy for the Prevention and Management of Physical and Non-Physical Assaults

If a satisfactory outcome is not achieved with the above procedure, proceed to STEP
TWO.

Continue to use verbal de-escalation even if other interventions are necessary.

Page 15 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

STEP TWO Oral Medication

Oral medication should only be used after de-escalation techniques alone have
failed to sufficiently calm a service user.

The aim of the management of acute behavioural disturbance with medication is


to achieve light sedation with rapid onset.

Care should be taken to consider whether sedation is the best approach.

This section should be read in conjunction with Appendix 1 - List of preparations


clinicians use in the management of acute behavioural disturbance in HPFT, their
properties and side-effects. Medication for rapid tranquillisation can only be
prescribed by a doctor.

For service users known to services where PRN is an accepted approach to managing
their behaviour within a flexible maintenance dose, a clear management plan must be in
place, which is regularly reviewed by the multidisciplinary team. (This does not constitute
RT). The individuals management plan must specify the monitoring required following
administration of the PRN medication.

Treatment choice should ideally be guided by previous response/adverse


reaction(s) to medication.

Advance decisions made by the service user in relation to medication must be


taken into account.

Any intervention with medication should be tailored to the individual service


user and their clinical situation at any given time.

To support intervention, the Agitation-Calmness Evaluation Scale (ACES) should be


used to generate and develop a score over time, in order to monitor effective
treatment. Refer to Appendix 5c.

Efficacy of intervention should be monitored closely.

Oral medication should be offered before parenteral medication as far as


possible.

Bioavailability differs between routes of administration so prescriptions for oral and


IM medication should be prescribed separately. The abbreviation
O/IM must not be used.

The decision to use oral therapy rather than intramuscular (IM) injection will
generally result in a slower onset of action.

The indication for which oral medication has been prescribed must be specified on
the prescription by the doctor.

Page 16 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Details of the medication administered together with reason(s) for administration


must be clearly documented in the service users notes.

The use of two drugs of the same class e.g. haloperidol and olanzapine
(antipsychotics) for the purpose of RT is not acceptable.

For behavioural disturbance in a non-psychotic context:

Oral lorazepam should be used where the medication history is unknown, the
service user has had no previous exposure to antipsychotics, or has pre-existing
cardiac disease. Refer to Appendix 4.

It is usual to offer oral lorazepam in the first instance. Dose for adults: 1-2mg,
maximum 4mg in 24 hours. Dose for elderly: 0.5-1mg, maximum 2mg in 24 hours.

With oral lorazepam, sedation usually occurs within 30 to 45 minutes,


peaks 2 hours and lasts 4-6 hours.

Oral lorazepam dose may be repeated after a minimum of 30 minutes. However,


since oral lorazepam takes in excess of an hour before achieving full effect, staff
should take such delays into account before administering further doses.

Frequent small doses are safer and more effective than single large doses, but this
may lead to a risk of accumulation.

Always review level of sedation and clinical response prior to repeating


administration of any medication.

If a benzodiazepine is not appropriate, e.g., if a service user has compromised


respiratory function or is known to be sensitive to benzodiazepines, use of oral
promethazine hydrochloride may be considered. Refer to Appendix 1.

Ensure regular reviews of prescription and service user.

Page 17 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

For behavioural disturbance in a psychotic context:

Where there is a confirmed history of previous regular antipsychotic exposure,


consider using an oral benzodiazepine and / or oral antipsychotic. Refer to
Appendix 4.

Always consider any contra-indications to the use of benzodiazepines and


antipsychotics in an individual.

Using a combination of a benzodiazepine and antipsychotic may be beneficial, as


this should allow for a lower dose of antipsychotic to be used.

Benzodiazepines may also counteract the lowering of seizure threshold caused by


antipsychotics.

Oral lorazepam dose for adults: 1-2mg, maximum 4mg in 24 hours. Dose for elderly:
0.5-1mg, maximum 2mg in 24 hours.

Oral lorazepam dose may be repeated after a minimum of 30 minutes. However,


since oral lorazepam takes in excess of an hour before achieving full effect, staff
should take such delays into account before administering further doses.

Haloperidol is best avoided in those who are antipsychotic nave and in those who
have a previous history of extra-pyramidal side-effects.

If haloperidol is used, it is advisable to co-prescribe a prn antimuscarinic. IM


procyclidine or IM benzatropine should be immediately available to reduce the risk of
dystonia or other extra-pyramidal side-effects.

Other oral antipsychotics that may be used include olanzapine and risperidone.

MHRA Warning olanzapine and risperidone are associated with an increased risk
of stroke in elderly patients with dementia. The MHRA has advised:
- olanzapine or risperidone should not be used for treating behavioural symptoms of
dementia;
- for acute psychotic conditions in elderly patients with dementia, risperidone should
be limited to short-term use under specialist advice; olanzapine is not licensed for
acute psychoses;
- the possibility of cerebrovascular events should be considered carefully before
treating any patient with a history of stroke or transient ischaemic attack; risk factors
for cerebrovascular disease should also be considered.

Oral antipsychotic dose may be repeated after a minimum of 45-60 minutes.

Page 18 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

The maximum BNF daily dose must be borne in mind at all times. Any regularly
prescribed benzodiazepines and / or antipsychotics must be taken into
consideration.

Always review level of sedation and clinical response prior to repeating


administration of any medication.

Ensure regular reviews of prescription and service user.

ORAL ANTIPSYCHOTIC OPTIONS


(Refer to Appendix 1 & 4)
Haloperidol

Use of this medicine is associated with the greatest risk of acute dystonias. For this
reason a prn antimuscarinic such as procyclidine should be available and
prescribed.

Recommended RT dose for adults: oral haloperidol 5 to 10 mg. The dose may be
repeated after 45 - 60 minutes. Maximum daily dose is 30mg.

Elderly service users will require much lower doses of antipsychotic medication e.g.
haloperidol 500 micrograms may be enough to sufficiently calm an elderly service
user.

The bioavailability differs between routes of administration so prescriptions for


oral/IM haloperidol must be prescribed separately. The abbreviation O/IM must not
be used.

If deemed necessary, oral haloperidol may be administered with lorazepam, however


service users should be monitored for side-effects.

With haloperidol a baseline ECG is recommended prior to treatment in all service


users, especially in the elderly and patients with a positive personal or family history
of cardiac disease or abnormal findings on cardiac clinical examination. During
therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed
on an individual basis. Whilst on therapy, the dose should be reduced if QT is
prolonged, and haloperidol should be discontinued if the QTc exceeds 500 ms.

Page 19 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Olanzapine
Recommended RT dose for adults: oral olanzapine 10mg. The dose may be
repeated after 45 60 minutes. Maximum daily dose is 20mg.

If deemed necessary, oral olanzapine may be administered with lorazepam,


however service users should be monitored for side-effects.

MHRA Warning olanzapine is associated with an increased risk of stroke in elderly


patients with dementia and should not be used for treating behavioural symptoms of
dementia. Olanzapine is not licensed for acute psychoses in elderly patients.

Risperidone

Recommended RT dose for adults: oral risperidone 1-2mg. The dose may be
repeated after 45 60 minutes. Doses above 10mg daily only if benefit considered
to outweigh risk; maximum daily dose 16mg.

If deemed necessary, oral risperidone may be administered with lorazepam,


however service users should be monitored for side-effects.

MHRA Warning risperidone is associated with an increased risk of stroke in


elderly patients with dementia and should not be used for treating behavioural
symptoms of dementia. For acute psychotic conditions in elderly patients with
dementia, risperidone should be limited to short-term use under specialist advice.

If STEP TWO is not feasible or fails to achieve a satisfactory outcome, proceed to


STEP THREE.

Page 20 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Supportive Observations and Escorting following rapid tranquilisation Refer to Appendix 5.


Procedure for Physical Observations following medication administered orally
Physical observations to be carried out following the schedule below and recorded.
Where it is difficult to undertake these observations due to service user unwillingness, a
more subjective assessment is required. Refer to Appendix 5.
Procedure
Alertness using
ACES
Respiratory rate
Pulse
Blood Pressure

Duration

1. At 15 minute intervals for 45 minutes.


2. Then continue to monitor alertness, mental state and
behaviour. Restart physical observation if there are any
concerns.

Ensure fluid intake is maintained. Fluid intake and output should be monitored.

Seek urgent medical advice if any signs show deterioration.


The following should be available immediately:
 Antimuscarinic if service user develops dystonia
 Oxygen if breathing becomes compromised
ECG should be performed at earliest opportunity, especially if higher doses of
antipsychotics are used.
If unconscious (ACES 8 and above) seek urgent medical advice and nurse in the
recovery position.
.

Page 21 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

STEP THREE Intramuscular (IM) Medication

Use of IM medication should be considered where RT through oral therapy has


failed, is refused, is not indicated by previous response, or is not expected to be
effective quickly enough.

This section should be read in conjunction with Appendix 1 - List of preparations


clinicians use in the management of acute behavioural disturbance in HPFT, their
properties and side-effects. Medication for rapid tranquillisation can only be
prescribed by a doctor.

For cautions when administering IM medication refer to the Trust Policy for the
Management of Needlestick Injuries and Incidents Involving Exposure to Blood
and Body Fluids.

Treatment choice should ideally be guided by previous response/adverse


reaction(s) to medication.

Advance decisions made by the service user in relation to medication must be


taken into account.

Any intervention with medication should be tailored to the individual service


user and their clinical situation at any given time.

To support intervention, the Agitation-Calmness Evaluation Scale (ACES) should be


used to generate and develop a score over time, in order to monitor effective
treatment. Refer to Appendix 5c.

Efficacy of intervention should be monitored closely.

The indication for which IM medication has been prescribed must be specified on
the prescription by the doctor.

Details of the medication administered together with reason(s) for administration


must be clearly documented in the service users notes.

The use of two drugs of the same class e.g. haloperidol and olanzapine
(antipsychotics) for the purpose of RT is not acceptable.

The service user should be switched to oral medication at the earliest opportunity.

Page 22 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

For behavioural disturbance in a non-psychotic context:

Where oral lorazepam is not considered to be appropriate or is refused, consider IM


lorazepam in the first instance. Refer to Appendix 4.

IM lorazepam should be used where the medication history is unknown, the service
user has had no previous exposure to antipsychotics, or has pre-existing cardiac
disease.

IM lorazepam dose for adults: 1-2mg, maximum 4mg in 24 hours. Dose for elderly:
0.5-1mg, maximum 2mg in 24 hours.

Sedation usually occurs within 30 to 45 minutes, peaks 60 - 90 minutes, lasts 4-6


hours.

IM lorazepam dose may be repeated after a minimum of 30 minutes. However,


since IM lorazepam can take in excess of an hour before achieving full effect, staff
should take such delays into account before administering further doses.

Always review level of sedation and clinical response prior to repeating


administration of any medicine.

Lorazepam injection must be stored in a refrigerator and be diluted 1:1 with water
for injection prior to IM administration.

If a benzodiazepine is not appropriate, e.g., if a service user has compromised


respiratory function or is known to be sensitive to benzodiazepines, use of IM
promethazine hydrochloride may be considered. Refer to Appendix 1.

Ensure regular reviews of prescription and service user.

Page 23 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

For behavioural disturbance in a psychotic context:

Where there is a confirmed history of previous regular antipsychotic exposure,


consider using an IM benzodiazepine and / or IM antipsychotic. Refer to
Appendix 4.

Always consider any contra-indications to the use of benzodiazepines and


antipsychotics in an individual.

Short acting benzodiazepines are generally preferred for rapid tranquillisation as


they are associated with fewer serious side-effects than antipsychotics. Caution is
required if a service user has already received an agent with a respiratory
depressant effect, e.g. someone who has taken opiates or large amounts of alcohol.
Respiratory depression may be reversed with flumazenil.

Using a combination of a benzodiazepine and antipsychotic may be beneficial, as


this should allow for a lower dose of antipsychotic to be used.

IM haloperidol is best avoided in those who are antipsychotic nave and in those
who have a previous history of extra-pyramidal side-effects.

If IM haloperidol is used, it is advisable to co-prescribe a prn antimuscarinic. IM


procyclidine or IM benzatropine should be immediately available to reduce the risk of
dystonia or other extra-pyramidal side-effects.

The dose of IM haloperidol may be repeated after a minimum of 60 minutes. For IM


olanzapine and IM aripiprazole, a second dose may be repeated two hours
after the first dose.

IM haloperidol and IM aripiprazole may be administered together with IM lorazepam.


IM olanzapine must not be administered within an hour of IM lorazepam. (For further
details refer to pages 23 & 24).

Do not mix two medications in the same syringe.

Always review level of sedation and clinical response prior to repeating


administration of any medication.

Ensure regular review of prescription and service user.

Page 24 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

IM ANTIPSYCHOTIC OPTIONS
(Refer to Appendix 1 & 4)
IM Haloperidol

Use of this medicine is associated with the greatest risk of acute dystonias. For this
reason a prn antimuscarinic such as procyclidine should be available and
prescribed.

Recommended RT dose for adults: IM haloperidol 3 to 6 mg. The dose may be


repeated after 60 minutes.

Elderly service users will require much lower doses of antipsychotic medication e.g.
haloperidol 500 micrograms may be enough to sufficiently calm an elderly service
user.

The bioavailability differs between routes of administration so prescriptions for


oral/IM haloperidol must be prescribed separately. The abbreviation O/IM must not
be used.

The maximum daily dose of haloperidol is either 30mg orally or 18mg IM. Maximum
doses will need to be adjusted if a combination of both routes is used. Oral
haloperidol 5mg may be considered to be approximately bioequivalent to IM
haloperidol 3mg.

If deemed necessary, IM haloperidol may be administered with lorazepam, however


service users should be monitored for side-effects.

With haloperidol a baseline ECG is recommended prior to treatment in all service


users, especially in the elderly and patients with a positive personal or family history
of cardiac disease or abnormal findings on cardiac clinical examination. During
therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed
on an individual basis. Whilst on therapy, the dose should be reduced if QT is
prolonged, and haloperidol should be discontinued if the QTc exceeds 500 ms.

Page 25 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

IM Olanzapine

Recommended dose: Adults: initially 5-10mg (usual dose 10mg) as a single dose
followed by 5-10mg after 2 hours if necessary.
Elderly: initially 2.5- 5mg as a single dose followed by 2.5-5mg after 2 hours if
necessary. Maximum 3 injections daily for 3 days. Maximum daily combined oral
and parenteral dose 20mg.

MHRA Warning olanzapine is associated with an increased risk of stroke in elderly


patients with dementia and should not be used for treating behavioural symptoms of
dementia. Olanzapine is not licensed for acute psychoses in elderly patients.

IM olanzapine must not be administered within an hour of IM lorazepam due to


an increased risk of sedation and cardiorespiratory depression. The combination of
oral lorazepam and IM olanzapine should be used with caution.

IM Aripiprazole

Recommended dose: Adults: initially 9.75mg as a single dose. Effective dose range
is 5.25 -15mg as a single injection. Lower dose of 5.25mg may be given on the
basis of individual clinical status. A second injection may be administered two hours
after the first injection. No more than 3 injections should be given in any 24 hour
period. Maximum daily dose is 30mg (including all formulations of aripiprazole).
Elderly: the effectiveness in people 65 years or older has not been established. A
lower starting dose should be considered when clinical factors warrant.

IM Aripiprazole is not approved for the treatment of dementia-related


psychosis.

If IM aripiprazole is deemed necessary in addition to IM lorazepam, service users


should be monitored for excessive sedation and for orthostatic hypotension.

(For further information refer to the BNF and relevant SPCs).

NB: There is not sufficient evidence with regards to the safety of the combination of IM
haloperidol with IM promethazine or IM midazolam, hence these combinations are not
recommended for routine psychiatric practice in the UK.
In very exceptional circumstances, which must be specified and recorded, IM
haloperidol with IM promethazine or IM midazolam may be considered as an alternative
to intravenous administration of benzodiazepines or haloperidol. Junior medical staff in
isolation must not make this decision.

Page 26 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Supportive Observations and Escorting following rapid tranquilisation - refer to


Appendix 5b .
Procedure for Physical Observations following medication administered by IM
injection
Physical observations to be carried out following the schedule below and recorded.
Where it is difficult to undertake these observations due to service user unwillingness, a
more subjective assessment is required. Refer to Appendix 5c.
Procedure
Alertness using
ACES
Respiratory rate
Pulse
Blood Pressure
Oxygen Saturation
Levels SpO2 (Where
2
available)

Duration

1. Every five to 10 minutes for one hour


2. Then every 30 minutes until service user is ambulatory
3. Then continue to monitor alertness, mental state and
behaviour. Restart physical observation if there are any
concerns.

Ensure fluid intake is maintained. Fluid intake and output should be monitored.

Seek urgent medical advice if any signs show deterioration.


The following should be available immediately:

Antimuscarinic if service user develops dystonia


Oxygen if breathing becomes compromised

ECG should be performed at earliest opportunity, especially if higher doses of


antipsychotics are used.
If unconscious (ACES 8 and above) seek urgent medical advice and nurse in the
recovery position.
.

SpO2 Saturation of Peripheral Oxygen

Page 27 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

STEP FOUR - Intravenous (IV) medication

IV administration of benzodiazepines or haloperidol should not normally be carried


out except in very exceptional circumstances i.e. a VERY hostile and disturbed
service user.

The decision to use IV medication should not be made by junior medical staff in
isolation and can only be used in consultation with the on-call Consultant
Psychiatrist. Medication for rapid tranquillisation can only be prescribed by a doctor.

Reasons for using the IV route must be clearly specified and recorded in the service
users notes.

The IV route of administration can lead to high concentrations of drug at the heart
muscles and should always be avoided in older patients.

Nursing staff working within the Trust are not trained to administer medication via
the IV route and hence administration would need to be carried out by a doctor if
necessary.

If immediate tranquillisation is essential then IV administration may be required. If it


is used, medical and nursing staff must be appropriately trained to recognise and
manage symptoms of respiratory depression, dystonia or cardiovascular
compromise (such as palpitations, significant changes in blood pressure and
cardiovascular collapse).

If IV medication is used, the service user must be managed on continuous


observation for at least three hours following tranquillisation.

Page 28 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Procedure for Physical Observations following medication administered by IV


injection
Physical observations to be carried out following the schedule below and recorded.
Where it is difficult to undertake these observations due to the service user
unwillingness, a more subjective assessment is required. Refer to Appendix 5c.
Procedure
Alertness using
ACES scale
Respiratory rate
Pulse
Blood Pressure
Oxygen Saturation
SpO2 (Where available)

Duration

1. Every five to 10 minutes for one hour


2. Then every 30 minutes until service user is ambulatory
3. Then continue to monitor alertness, mental state and
behaviour. Restart physical observation if there are any
concerns.

Ensure fluid intake is maintained. Fluid intake and output should be monitored.

Seek urgent medical advice if any signs show deterioration.


The following should be available immediately:
Antimuscarinic if service user develops dystonia
Oxygen if breathing becomes compromised
ECG should be performed at earliest opportunity.
If unconscious (ACES 8 and above) seek urgent medical advice and nurse in the
recovery position.
.
If IV medication is used, the service user must be managed on continuous observation
for at least three hours following rapid tranquillisation.

Page 29 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

7. MEDICATIONS NOT RECOMMENDED FOR RAPID TRANQUILLISATION


The following medications are not recommended for rapid tranquillisation:

Chlorpromazine oral or IM
Diazepam IM
IM depot anti-psychotics
Olanzapine and risperidone should not be used for behavioural disturbance in service
users with dementia.

Zuclopenthixol acetate (Acuphase) is NOT an appropriate drug for use in RT


due to both its delayed onset of action and long duration of action.

I t may have a role in the ongoing management of a risk of violence once


tranquillisation has been satisfactorily achieved. It is important to consider the
pharmacokinetics of other drugs when prescribing it. For example, caution is
necessary in a patient who has recently received a dose of depot antipsychotic
which has not yet reached peak levels.

It should only be given after calming has been achieved and in those situations
when it is likely that repeated doses of intramuscular antipsychotics would be
necessary.

I t should never be used in those who are struggling, who are sensitive to
extrapyramidal side-effects (EPSE), those with cardiac disease, hepatic or renal
impairment or in pregnancy.
The BNF and manufacturers SPC must be consulted regarding the use of
Zuclopenthixol acetate (Acuphase).

The onset of sedation with zuclopenthixol acetate starts at 1 to 4 hours, peaks


at 8 to 36 hours and is mainly complete by 48 to 72 hours. A second dose should
not be given within 24 hours of the first dose.

The usual effective dose used in acute adult psychiatry is 100mg. 25mg is an
appropriate starting dose in the elderly, service users with low body weight and
in those who are dehydrated. 50 mg is an appropriate starting dose in younger
adults with little previous experience of antipsychotic treatment. The maximum
dose is 400mg in 2 weeks.

If in doubt contact a senior member of medical staff for further advice

Page 30 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

NICE suggests that zuclopenthixol acetate (Acuphase) injection MAY be


considered as an option for medium term management of disturbed behaviour
when any of the following apply:

It is clearly expected that the service user will be disturbed/violent over an


extended period of time.

A service user has a past history of good and timely response to zuclopenthixol
acetate injection.

A service user has a past history of repeated parenteral administration.

An advance decision has been made indicating that this is the treatment of
choice.

Note: Zuclopenthixol acetate (Acuphase) must NEVER be administered to those


without any previous exposure to antipsychotic medication.
8.

DOSES FOR RAPID TRANQUILLISATION

8.1 When using rapid tranquillisation there may be certain circumstances in which the
current BNF uses, maximum recommended daily dose and manufacturers licence may
be knowingly exceeded (e.g. for lorazepam). The rationale must be recorded in the care
plan, and monitoring of the service users condition must be specified. For further
information refer to section 11.5 Cautions.
8.2 In all circumstances of rapid tranquillisation, the prescriber and person
administering medication must pay attention to issues of consent, BNF requirements
and physical and mental status of the service user.
In considering the dose, if it is above the BNF maximum recommended dose YOU
MUST contact medical staff on the On-Call Consultant Rota for confirmation of this
dose.
8.3 The dose of antipsychotic medication should be individualised for each service user.
8.4 If current BNF doses are exceeded it is particularly important that frequent and
intensive monitoring of a calmed service user is undertaken. This must be specified and
recorded in the notes. Pay particular attention to regular checks of airway, level of
consciousness, pulse, blood pressure, respiratory effort, temperature and hydration.

Page 31 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

8.5 The total dose of medication prescribed for an acutely disturbed service user must
be reviewed:
- regularly by a member of the medical team responsible for the service user or the
duty doctor out of hours, in conjunction with the multidisciplinary team
- at least every 24 hours (or more often in a rapidly changing situation)
8.6 Oral and intramuscular medications should be prescribed separately and the
abbreviation of o/im should not be used.

Note previous medications and response.

Look for any previous records of adverse reactions to medication which might
inform your choice.

Consider any antipsychotics taken recently (note doses taken in last 24 hours) or
depot antipsychotic injections given in the past six weeks and any illicit drug
intoxication (especially alcohol, opiates and benzodiazepines).

Remember that elderly and physically ill people will require lower doses than
healthy adults. Review physical health and drug status (elderly, thin or frail,
cardiac or respiratory disease, service users with learning disability.)

Ensure regular review of prescriptions and service user.

9. PLAN FOR THE NEXT 24 HOURS AND AFTERWARDS:

Medical and nursing staff should jointly review the care plan four hours after
rapid tranquillisation.

The service users care plan should be reassessed and the service user helped
to reintegrate in to the ward.

If the service user is transferred to another unit a full history must be available to
the receiving team.

Review and monitor physical and mental health status

Where language barriers are seen to be a factor which is preventing a response


by the service user to interventions/treatment, this can lead to an escalation of
acute behaviour disturbance by the service user. Staff should be mindful of this
and seek the support of the interpreting service as soon as possible.

Seek advice from senior doctor if necessary.

Review Mental Health Act status.

Page 32 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Review any when required medication.

Consider increasing or start regular (oral) antipsychotics (if haloperidol used


consider switching to an alternative and possibly better tolerated antipsychotic)
or starting a longer acting regular benzodiazepine, e.g. diazepam.

Post incident support made available in line with the Trust policy on the
Prevention and Management of Non-Physical and Physical Assaults.

10. Common or serious side effects and their management

If there are serious concerns about the service users physical wellbeing at any point
then the doctor on call or the emergency services should be contacted immediately.

Page 33 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

11. Consultation, Approval and Ratification Process


This guidance has been written by a dedicated working group of healthcare
professionals and circulated for comments within Trust services via the Heads of
Services and Lead Clinicians. This guidance will be approved by the Trust Drugs and
Therapeutics Committee.
The guidance will be ratified by the Risk Management and Patient Safety Committee
and will be accepted as an organisation-wide guidance by the Trust Executive
Committee.
12. Dissemination, Implementation and Access to this document
This guidance is implemented and disseminated throughout the Trust following
ratification via the policy guardians. And will be published on the HPFT staff website.
Access to this document is open to all via the Trust public website.
This guidance must be discussed within operational management teams to ensure that
awareness of this guidance, the training needs of relevant staff and clearly defined
responsibilities for its implementation.
13. Process for monitoring compliance with this document
The organisations objective is to demonstrate monitoring as a minimum in relation to:

prescribing guidelines with regard to rapid tranquilisation

arrangements for monitoring service users having received rapid tranquilisation.

The Risk Management department will commission monitoring for evidence


demonstrating compliance with this guidance and an outcome A report will be made to
the Risk Management and Patient Safety group on an annual basis.
14. Process for reviewing, approving and archiving this document
14.1 This document will be reviewed annually or whenever national policy or guideline
or changes to the NHSLA standards require to be considered (whichever occurs first),
by the Trust Drugs and Therapeutic Committee, following which it will be subject to reratification by the organisation-wide Risk Management and Patient Safety Committee.
14.2 All procedural documents must be retained for a period of 10 years from the date
the document is superseded as set out in the Trust Business and Corporate (NonHealth) Records Retention Schedule, which is part of the Records Management Policy
(non-clinical).
14.3 A database of archived procedural documents is kept as an electronic archive by
the Director of Workforce and Organisational Development. This archive is held on a
central server.
Page 34 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

15. References
Clinical Guideline for the short-term management of disturbed/violent) behaviour in inpatient psychiatric settings and emergency departments.
National Institute for Clinical Excellence, February 2005
Core interventions in the treatment and management of schizophrenia in primary and
secondary care, National Institute for Clinical Excellence, December 2002
Management of imminent violence: quick reference guide, Royal College of
Psychiatrists
Interim Guidelines for Management of Acutely Disturbed Adults, Norfolk Mental Health
Care NHS Trust
th

Psychotropic-related QT prolongation, 2003 Prescribing Guidelines, 7 Edition, The


South London and Maudsley NHS Trust, Martin Dunitz
Use of Psychotropics in special service user groups Drug choice in pregnancy, 2003
Prescribing Guidelines, 7th Edition, The South London and Maudsley NHS Trust,
Martin Dunitz
The Royal Marsden Hospital Manual of Clinical Nursing Procedures 7th Edition,
th

The Maudsley Prescribing Guidelines 8 Edition, 2007


16. Associated Documentation
This guidance to be read in conjunction with the following Hertfordshire Partnership
NHS Foundation Trust Policies:

Prevention and Management of Non-Physical and Physical Assaults


Medicines Policy
Supportive Observation Policy
Management Of Needlestick Injuries And Incidents Involving Exposure To Blood And
Body Fluids
Advance Decisions Policy
Clinical Risk Assessment Policy
Single Equalities Scheme

Page 35 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Appendix 1
Prescribing Guidelines - List of preparations clinicians may use in RT, their
properties and side effects
Drug

Route

Pharmacokinetics

Major side effects

Peak 5-8 hours


t 32-50 hours

Hypotension
Bradycardia
Syncope

Notes

Short-acting antipsychotics
Less likely to cause EPSE than haloperidol
Olanzapine

Oral

Intramuscular

Peak 15-45 minutes


t 30 hours

IM administration results in initial


maximum plasma concentration 5 times
higher than same dose given orally.
IM olanzapine must not be administered
within one hour of IM lorazepam.
Not approved for use in dementia related
psychosis/behavioural disturbance.
Limited clinical experience or trial data.

Risperidone

Quetiapine

Haloperidol

Aripiprazole

Levomepromazine

Oral

Peak 2 hours
t 18 hours

EPSE
? Hypotension

Peak 1.5 - 1.8 hours


t 6-7 hours

? QT prolongation
? Hypotension

Oral

Peak 4 hours
t 21 hours

Intramuscular

Peak 20 minutes
t 21 hours

EPSE
Hypotension
NMS
Increased QTc
Arrhythmias
Seizures
Sudden death

Intramuscular

Peak 1 - 3 hours
t 75 146 hours

Oral

Oral

Peak 1 4 hours
t 30 hours

Intramuscular

Peak 30 90 minutes

Orthostatic
hypotension
Tachycardia
Dry mouth

Hypotension
Arrhythmias
EPSE
Seizures
Increased QTc
Severe drowsiness

Not recommended for the treatment of


behavioural symptoms of dementia.
Limited clinical experience or trial data.
This drug was not considered by NICE in
the violence guideline, but its short half-life
justifies its inclusion in this list.
The SPC requires an ECG.
Note risk of acute dystonias and ensure that
an appropriate antimuscarinic is to hand.
Not recommend for I.V. use because of
increased risk of arrhythmias.
The bioavailability of oral & IM
haloperidol is different and this must be
taken into account when considering the
total dose per 24 hour period. 5mg oral = 3
mg IM.
Those receiving IM aripiprazole should be
observed for orthostatic hypotension.
If parenteral benzodiazepine therapy is
deemed necessary in addition to
aripiprazole IM, monitor for excessive
sedation and for orthostatic hypotension.
Not approved for the treatment of
dementiarelated psychosis
There is little published evidence available.
It is likely to have similar drawbacks and
complications to chlorpromazine.
Oral to be used cautiously titrate dose
extremely slowly.
The injection is not licensed for
psychosis. If used intramuscularly, it is as
a last resort. It must be prescribed only
by a Consultant Psychiatrist and the
patient must be in a secure environment
to receive treatment.
The justification for its use, although not
considered by NICE, is that it works
quickly and has low incidence of
neuroleptic malignant syndrome.
ECG monitoring is required if it is used

Page 36 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

with other antipsychotics.

Drug

Route

Chlorpromazine

Pharmacokinetics

Major side effects

Notes
Should never be given parenterally because
of the risk of severe hypotension and
prolonged unconsciousness, as well as the
reported association of high doses with
sudden death.
It is also extremely painful when given
parenterally.
NOT RECOMMENDED FOR USE IN RT.

Oral

Peak 2-4 hours


t 16 30 hours

Hypotension
Arrhythmias
Seizures
Prolonged sedation
Cardiac arrest
Sudden death

Oral

Peak 2 hours
t 12 hours

Respiratory depression

Benzodiazepines
Lorazepam

Disinhibition

Diazepam

Intramuscular

Peak 60 90 minutes
t 12 16 hours

Oral

Peak 60 minutes
t 24 48 hours

Benzodiazepines have a wide therapeutic


index & respiratory depression is readily
reversed with the specific antagonist
flumazenil.
IM lorazepam must not be administered
within one hour of IM olanzapine. Oral
lorazepam and IM olanzapine should be
used with caution.
Disinhibition is more likely to occur in
those with organic brain disease,
including learning disabilities, the under
18s and the over 65s, and perhaps those
with impulse control problems.

Longer acting antipsychotics


Zuclopenthixol
acetate
(Acuphase)

Intramuscular

Onset 2 8 hours
Peak 24 36 hours
t 60 hours

EPSE
Sudden Death
Cardiac arrest
Arrhythmias

This is not an appropriate drug for use


in RT due to its delayed onset and long
duration of action. NICE suggest that
this drug maybe used for medium term
management of disturbed behaviour
under four explicit circumstances (see
section 7 of this guidance for detail).
It should never be used in those who are
neuroleptic nave, who are struggling,
who are sensitive to EPSE, or those with
cardiac disease, hepatic or renal
impairment or in pregnancy.

Antihistamines
Promethazine

Oral

Peak 2 - 3 hours
t 7 15 hours

Prolonged sedation
Seizures
Cardiorespiratory
depression

Limited evidence for efficacy but may be


of use in patients who are known to be
sensitive/tolerant to benzodiazepines.

Intramuscular

Onset 1 2 hours
t 7 15 hours
Note: The pharmacokinetics of lorazepam is similar whether given orally or parenterally, therefore the only reason to give
lorazepam parenterally is if the patient refuses oral.
Note: It is recognised that clinicians may decide that the use of medication outside of the manufacturers Summary of Product
Characteristics (SPC) is occasionally justified, bearing in mind the overall risks. However, where the regulatory authorities or
manufacturer issues a specific warning that this may result in an increased risk of fatality, the medication should only use used
strictly in accordance with the current marketing authorisation.

Page 37 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Appendix 2
Psychotopic-related QT Prolongation
th
(Taken from the Maudsley Prescribing Guidelines 9 Edition 2007)
Introduction
Many psychotropic drugs are associated with ECG changes and it is probable that
certain drugs are causally linked to serious ventricular arrhythmia and sudden cardiac
death. Specifically, some antipsychotics block cardiac potassium channels and are
linked to prolongation of the cardiac QT interval, a risk factor for the ventricular
arrhythmia torsades de pointes, which is occasionally fatal. Recent case-control studies
have suggested that the use of some antipsychotics (mainly haloperidol) is associated
with an increase in the rate of sudden cardiac death. Overall risk however remains
extremely low. Tricyclic antidepressants are sodium channel antagonists which prolong
QRS interval and QT interval, but this is usually evident only following overdose.
ECG monitoring of drug induced changes in a mental health trust is complicated by a
number of factors;
- Psychiatrists may have limited expertise in ECG interpretation. For example self
reading, computerised ECG devices are available and to some extent
compensate for some lack of expertise
- ECG machines may not be as readily available in all clinical areas as they are in
general medicine
- Time for ECG determination may not be available in many areas e.g. outpatients
- ECG determination may be difficult to perform in acutely disturbed, physically
unco-operative patients.
ECG monitoring of all patients is therefore impractical and, given that risks are probably
very small, of dubious benefit. The Maudsley Guideline has set out a pragmatic
strategy of risk reduction and should be seen as general guidance on minimising the
possible risk associated with some drugs.
QT Prolongation
The cardiac QT interval (usually cited as QTc-QT corrected heart rate) is a useful, but
imprecise indicator of risk of torsade de pointes and of increased cardiac mortality.
Different correction factors and methods may give markedly different values.
There is some controversy over the exact association between QTc and risk of
arrhythmia. Very limited evidence suggests that risk is exponentially related to the
extent of prolongation beyond normal limits (440ms for men and 470ms) though there
are exceptions to disprove this theory. Rather stronger evidence links QTc values over
500ms to a clearly increased risk of arrhythmia. Despite these uncertainties QTc
determination remains an important measure in estimating risk of arrhythmia and
sudden death.
QTc measurements and evaluation are complicated by:
- Difficulty in determining the end of the T wave, particularly where U waves are
present (this applies both to manual and self-reading ECG machines.)
Page 38 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Normal physiological variation in QTc interval: QT varies with gender, time of


day, food intake, alcohol intake, menstrual cycle, ECG lead etc.
Variation in the extent of drug-induced prolongation because of changes in
plasma levels . QTc prolongation is most prominent at peak drug plasma levels
and least obvious at trough levels.

Other ECG Changes


Tricyclics and other antidepressants may prolong the QRS interval, particularly in
overdose. Other reported antipsychotic-induced changes include atrial fibrillation,
giant P-waves, T-wave changes and heart block.
Quantifying risk
Drugs are categorised by The Maudsley Guideline according to data available on
their effects on the cardiac QTc interval (as calculated by Bazetts correction
formula).
Psychotropics effect on QTc
No effect drugs
Those with which QTc prolongation has not been reported either at therapeutic
doses or in overdose.
Aripiprazole
SSRIs
(except
citalopram)

Reboxetine
Mirtazapine

MAOIs
Carbamzaepin
e

Gabapentin
Lamotrigine

Valproate
Benzodiazepine
s

Low effect drugs


Those for which severe QTc prolongation has been reported only following overdose
or where only small average increases (less than 10ms) have been observed at
clinical doses.
Amisulpride
Fluphenzaine Risperidone
Citalopram
Trazadone
Clozapine
Perphenazine Sulpiride
Moclobemide Lithium
Flupentixol
Olanzapine*
Bupropion
Venlafaxine
* Isolated cases of QTc prolongation but all other data suggest no effect
Moderate effect drugs
Those which have been observed to prolong QTc by more than 10ms on average
when given at normal clinical doses or where ECG monitoring is officially
recommended in some circumstances
Chlorpromazin
e
Melperone

Quetiapine

Zotepine

Ziprasidone

Tricyclic
antidepressant

Page 39 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

s
High effect drugs
Those for which extensive average QTc prolongation (usually more than 20mg at
normal clinical doses) has been noted or where ECG monitoring is mandated by the
manufacturers data sheet.
Any
Haloperidol
Methadone
Pimozide
Sertindole
intravenous
antipsychotic
Any drug or combination of drugs used in doses exceeding recommended
maximum
Unknown effect drugs
Loxapine

Pipothiazine

Trifluoperazin
e

Zuclopentixol

Anticholinergi
c drugs
(procyclidine,
benzhexol,
etc)

Note
The effect on QTc may not necessarily equate directly to risk of torsade de pointes
or sudden death, although this is often assumed. Note also that categorisation is
inevitably approximate given the problems associated with QTc measurement.
Other risk factors
Physiological/pathological risk factors for QTc prolongation and arrhythmia
Cardiac
Long QT syndrome
Bradycardia
Ischaenic heart disease
Myocarditis
Myocardial infarction
Left ventricular hypertrophy

Metabolic
Hypokalaemia
Hypomagnesaemia
Hypocalcaemia
Others
Extreme physical exertion
Stress or shock
Anorexia nervosa
Extremes of age children and elderly may be more susceptible to QT changes
Female gender
Page 40 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Note: Hypokalaemia- related QTc prolongation is more commonly observed in


acute psychotic admissions. Also be aware that there are a number of physical and
genetic factors which may not be discovered on routine examination but which
probably predispose patients to arrhythmia.
Non-psychotropic drugs associated with QT prolongation
Antibiotics
Erythromycin
Clarithromycin (and some other 4-quinolones)
Ampicillin
C-trimoxazole
Pentamidine
Antimalarials
Chloroquine
Mefloquine
Quinine
Antiarrhythmics
Quinidine
Disopyramide
Procainamide
Sotalol
Amiodarone
Bretylium
Others
Amantadine
Ciclosporin
Diphenhydramine
Hydroxyzine
Nicardipine
Tamoxifen
Note:
B2 agonists and sympathomimetics may provoke torsade de pointes in
patients with prolonged QTc.
Metabolic inhibition
The effect of drugs on the QTc interval is plasma level dependent. Drug interactions
are therefore important, especially when metabolic inhibition results in increased
plasma levels of the drug affecting QTc. Commonly used metabolic inhibitors
include fluvoxamine, fluoxetine, paroxetine and valproate.
Other cardiovascular risk factors

Page 41 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

The risk of drug-induced arrhythmia and sudden cardiac death with psychotropics is
very small with a few drugs and probably non-existent with many others. Of much
greater concern are other patientrelated risk factors to cardiovascular disease.
These include smoking, obesity and impaired glucose tolerance, and present a much
greater risk to patient mortality than the uncertain outcome of QT changes.
ECG monitoring recommendations
Generally, prescribing should be such that the need for ECG monitoring is
minimised. This can be achieved by prescribing drugs with the lowest effect on QT
at their minimum effective dose and by avoiding polypharmacy or other QTprolonging drugs and hepatic enzyme inhibitors.
ECG monitoring recommendations
No other risk
factors

Physiological/pathological
risk factors*

No-effect drugs

None

None

Low effect
drugs

None

None

Moderate effect
drugs

None

High effect
drugs

Baseline ECG, then


after dose change,
consider referral to a
cardiologist
None

Correct risk factors if possible, if


not baseline ECG, then after
dose change, consider referral
to a cardiologist
Correct risk factors if possible, if
not - avoid

Unknown effect
drugs

Correct risk factors if possible if


not baseline ECG, then after
dose change, consider referral
to a cardiologist

When
co-administered
with other QTprolonging
drugs**
None
Baseline ECG,
then after dose
change, consider
referral to a
cardiologist
Avoid or refer to a
cardiologist

Avoid

Avoid or refer to a
cardiologist

Many conditions necessitate close cardiac monitoring, regardless of drugs


prescribed. Recommendations in this column therefore represent additional
requirements to those already mandated by the patients condition.
** Defined as any non-psychotropic drug associated with QT prolongation or
psychotropics of moderate or high effect. The use of these drugs may necessitate
cardiac monitoring. Recommendations in this column therefore represent additional
requirements to those already mandated by the use of these drugs alone.
*

Actions to be taken
QTc less than 440ms (men) or less than 470 ms (women)
No action required unless abnormal T-wave morphology consider referral to
cardiologist if in doubt.
Page 42 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

QTc more than 440ms (men) or more than 470 ms (women) but less than
500ms
Consider switch to drug of lower effect: re-perform ECG and consider referral to a
cardiologist
QTc more than 500ms
Stop suspected causative drug(s) and switch to a drug of lower effect; refer to
cardiologist immediately
Abnormal T-wave morphology
Review treatment. Consider switch to drug of lower effect. Refer to cardiologist
immediately.

Page 43 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Appendix 3
Drug Choice in Pregnancy
Clinicians should check with an up-to-date source of information before
prescribing in pregnancy.
Obtain advice from a specialist Consultant Psychiatrist, local medicines
information service or medicines information services listed on the front cover of
the BNF or directly with manufacturers databases.
Specialist drugs in pregnancy advice can be obtained from National Teratology
Information Service (NTIS) on 0191-2321525 (Mon to Friday 8.30 am to 5.00 pm
Urgent enquiries which arise outside office hours are dealt with via the National
Poisons Information Service (NPIS) Newcastle Centre 0191-2231307 (17.00 to
20.00 Monday to Friday). Outside the above hours contact NPIS 0870-6006266 (24
hours)
Website for National Teratology Information Service (NTIS) (www.nyrdtc.nhs.uk)
The safety of psychotropics in pregnancy cannot be clearly established because robust,
prospective trials are unethical. Individual decisions are dependent upon an imperfect
retrospective database and an assessment of the risks and benefits associated with
withdrawal or continuation of drug treatment. The service uses view of risks and
benefits will have paramount importance. Possible effects on the unborn child should
be discussed if possible with a mother who requires acute or maintenance treatment.
Risks should be weighed up against possible benefits.
General principles of prescribing in pregnancy

Only treat when absolutely necessary (potential benefit outweighs potential harm),
but remember that mentally ill women who are pregnant are very likely to require
treatment

Ensure that the prospective parents are as fully involved as possible in all
discussions

Always consider the risk of relapse when discontinuing psychotropics relapse may
ultimately be more harmful to the mother and child than continued, effective drug
therapy.

Try to avoid all drugs in the first trimester when major organs are being formed

Use an established drug at the lowest effective dose and avoid polypharmacy
whenever possible

Page 44 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Be prepared to adjust doses as pregnancy progresses and drug handling is altered.


Be aware of potential problems with individual drugs around the time of delivery

Ensure adequate foetal screening during pregnancy and monitor the neonate for
withdrawal effects after birth.

Document all decisions

Page 45 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT)
V2 Oct 08.doc

Appendix 4
Algorithm for Rapid Tranquillisation
RAPID TRANQUILLISATION BY ORAL AND INTRA-MUSCULAR ROUTES

Rapid tranquillisation by ORAL ROUTE


(Intended for service users aged 18-65 years)
BEHAVIOURAL DISTURBANCE IN A
NON-PSYCHOTIC CONTEXT
(Diagnosis unknown)

Disturbed behaviour
unresponsive to
de-escalation

BEHAVIOURAL DISTURBANCE IN A
PSYCHOTIC CONTEXT
(Diagnosis psychotic illness)

Disturbed behaviour
unresponsive to
de-escalation
Lorazepam 1 2 mg
and/or either
Haloperidol 510 mg or
Olanzapine 10 mg
(orodispersible)
or
Risperidone 12 mg
(liquid/orodispersible)

Lorazepam
1 2 mg

Wait 30 mins

Lorazepam wait 30mins


Antipsychotic wait 4560mins

Patient settled?

Yes

No

Patient settled?

Yes

No

BNF maximum daily doses:


Lorazepam: 4mg daily
Haloperidol: 30mg daily
Olanzapine: 20mg daily
Risperidone: 16mg daily (doses above 10mg daily only if benefit considered to
outweigh risk)

Page 46 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2 Oct 08.doc

Rapid tranquillisation by INTRAMUSCULAR ROUTE


(Intended for service users aged 18-65 years)
B BEHAVIOURAL DISTURBANCE IN A
NON-PSYCHOTIC CONTEXT
(Diagnosis unknown)

Disturbed behaviour
unresponsive to
de-escalation

Lorazepam 1 2 mg

Wait 30 mins

BEHAVIOURAL DISTURBANCE IN A
PSYCHOTIC CONTEXT
(Diagnosis psychotic illness)

Disturbed behaviour
unresponsive to
de-escalation
*Lorazepam 1 - 2 mg
and/or either Haloperidol
3 6 mg
or *Olanzapine 5 10 mg
or Aripiprazole 9.75 mg

Lorazepam wait 30 mins


Haloperidol - wait 60 mins
Olanzapine - wait 2 hours
Aripiprazole - wait 2 hours

Patient settled/accepting
oral treatment?
Patient settled/accepting
oral treatment?
Yes

No
Yes

No

* IM olanzapine must not be given within 1 hour of IM lorazepam

BNF maximum daily doses:


Lorazepam: No maximum daily dose specified in BNF. Usual maximum daily dose is 4mg
Haloperidol: 18mg daily
Olanzapine: 20mg daily
Aripiprazole: 30mg daily

Page 47 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2 Oct
08.doc

Appendix 5a
Nursing Observations Pre and Post Rapid Tranquillisation
1. Nursing Observations
1. 2 Aim

The physical assessment is to help you identify and report medical problems that affect a
service users health.

The expectation of staff is that they will maintain the wellbeing of the service user in a
realistic, appropriate and safe manner.

1.3 During physical interventions observe respiratory rate and colour looking for signs of
cyanosis or distress every five minutes.(Refer to the Trust Policy on the Management of
Physical and Non-Physical Assaults)
1.4 Skilled nursing observation is essential following rapid tranquillisation and nurses should be
advised by the following guides.
The monitoring schedule is set out in the stepped approach, Section 6.
The attending doctor should state in the care record any further specific monitoring
requirements.
1.5 In the following circumstances, more frequent and intensive monitoring is required.
If the service user appears to be or is asleep/sedated
If intravenous administration has taken place
If BNF limit is exceeded
Where the service user has been using illicit substances or alcohol
Where the service user has a relevant medical disorder or concurrently prescribed medication
If verbal responsiveness is lost as a consequence of administration of medication
2. Implementing Nursing Observations

Carry out supportive observations as set out in the observation matrix in Appendix 5b.

Follow the physical monitoring schedule set out in Step 2-4. Seek urgent medical advice
if any of the signs show deterioration.
If the service user is barely rousable or if verbal responsiveness is lost, nurse in the
recovery position with continuous observation. See medical advice.
Look for signs of cyanosis, vomiting or distress.
If there is any vomiting, remember the service users airway must be kept clear.
Page 48 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2 Oct
08.doc

Ensure fluid intake and output is maintained. Ensure adequate fluid intake and toilet
visits. Assess electrolytes if not done in last 3-4 days - daily if emergency persists.
Ensure pressure areas are dry and clean

Grade and record levels of consciousness. Use the ACE scale (Appendix 5c) for this
purpose.

Maintain the dignity and privacy of the service user

Use opportunities to establish rapport and empathy with the service user

Seek urgent medical assistance if the service user complains of pain in the chest and
numbness or tingling in arm or legs.

All monitoring activity must be recorded in the care record and appropriate observation
and vital signs recording chart.

If there are serious concerns about the service users physical wellbeing at any point
then the doctor on call should be called urgently or the emergency services. If cardiac
arrest occurs summon the emergency services or resuscitation team dependent on local
policy and institute basic life support.

Page 49 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2 Oct
08.doc

Appendix 5b
Observation / Escort Procedure Following Medication
Staff should ensure that these minimum standards of observation and escorting procedures are
part of a comprehensive approach to the management of risks associated with responding to
disturbed / aggressive behaviour involving medication and physical interventions. The
observation time frames are based on the drug titration levels. (If the minimum intervention is
not felt to be appropriate re-evaluate accordingly). Record on the HPFT observation recording
forms ( refer to the HPFT Supportive observation policy).
ORAL MEDICATION WITH NO PHYSICAL INTERVENTIONS

DRUG CHOICE

Benzodiazepines

MEDICATION PREVIOUSLY
USED WITH SERVICE USER

Service user to remain in unit for a


minimum of 2 hours under general
observations

KNOWN HISTORY OF
COMPLICATIONS WITH
MEDICATION
Intermittent Observations for 2 hours

Escorted leave only during these 2 hours


as per HPFT Policy.
(Clear & robust rational for leave must
be documented)

Antipsychotics

Service user to remain in unit for a


minimum of 4 hours under general
observations

Intermittent Observations for 4 hours

Escorted leave only during these 4 hours


as per HPFT Policy.
(Clear & robust rational for leave must
be documented)

Combination

Service user to remain in unit for a


minimum of 4 hours under general
observations

Intermittent Observations for 4 Hours

Escorted leave only during these 4 hours


as per HPFT Policy.
(Clear & robust rational for leave must
be documented)

Page 50 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2 Oct 08.doc

ORAL MEDICATION WITH PROTECTIVE PHYSICAL INTERVENTIONS

DRUG CHOICE

MEDICATION PREVIOUSLY
USED WITH SERVICE USER

KNOWN HISTORY OF
COMPLICATIONS WITH
MEDICATION

Benzodiazepines

Intermittent Observations for 2 hours

Continuous Observations for 2 hours

Antipsychotics

Intermittent Observations for 4 hours

Continuous Observations for 4 hours

Combination

Intermittent Observations for 4 hours

Continuous Observations for 4 hours

ORAL WITH RESTRICTIVE PHYSICAL INTERVENTIONS

DRUG CHOICE

MEDICATION PREVIOUSLY
USED WITH SERVICE USER

KNOWN HISTORY OF
COMPLICATIONS WITH
MEDICATION

Benzodiazepines

Continuous Observations for 2 hours

Continuous Observations for 4 hours

Antipsychotics

Continuous Observations for 4 hours

Continuous Observations for 4 hours

Combination

Continuous Observations for 4 hours

Continuous Observations for 4 hours

Page 51 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2 Oct
08.doc

INTRAMUSCULAR MEDICATION WITH PROTECTIVE / RESTRICTIVE


PHYSICAL INTERVENTIONS

DRUG CHOICE

MEDICATION PREVIOUSLY
USED WITH SERVICE USER

KNOWN HISTORY OF
COMPLICATIONS WITH
MEDICATION

Benzodiazepines

Continuous Observations for 3 hours

Continuous Observations for 6 hours

Antipsychotics

Continuous Observations for 3 hours

Continuous Observations for 6 hours

Combination

Continuous Observations for 3 hours

Continuous Observations for 6 hours

INTRAVENOUS MEDICATION WITH PROTECTIVE / RESTRICTIVE


PHYSICAL INTERVENTIONS

DRUG CHOICE

MEDICATION PREVIOUSLY
USED WITH SERVICE USER

KNOWN HISTORY OF
COMPLICATIONS WITH
MEDICATION

Benzodiazepines

Continuous Observations for 3 hours

Continuous Observations for 6 hours

Antipsychotics

Continuous Observations for 3 hours

Continuous Observations for 6 hours

Combination

Continuous Observations for 3 hours

Continuous Observations for 6 hours

Page 52 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2 Oct
08.doc

Agitation-Calmness Evaluation Scale (ACES) are defined as follows:


Appendix 5c
1 Marked Agitation:
High levels of physical activity, may demonstrate markedly increased levels of verbal expression, may be
physically violent, cannot control signs of agitation if requested to do so, may require continuous nursing
care/supervision and/or physical restraint.
2 Moderate Agitation:

Moderately increased levels of physical activity, demonstrates increased levels of verbal expression and may
be verbally threatening, is not physically violent, can partly control signs of agitation if requested to do so,
requires standard nursing care/supervision.

3 Mild Agitation:

Slightly increased levels of physical activity, may demonstrate slightly increased levels of verbal expression
(e.g. may raise his or her voice volume), is not threatening or violent, can control signs of agitation if
requested to do so, requires standard nursing care/supervision.

4. Normal:

Normal levels of physical activity, normal levels of verbal expression, awake with eyes continuously open.

5 Mild Calmness:

Slightly reduced levels of verbal and physical activity, eyes continuously open, remains aware of and
responsive to his or her environment

6 Moderate Calmness:

Moderately reduced levels of verbal and physical activity, eyes may be intermittently open, easily aroused or
responsive to mild verbal (e.g. calling of name) or physical stimulation (e.g. a gently touch), remains awake
when stimulus removed.

7 Marked Calmness:

Greatly reduced verbal or physical activity, sleeping lightly, aroused by mild to moderate verbal (e.g. calling
of name) or physical stimulation (e.g. a touch).

8. Deep Sleep:

No verbal or physical activity, sleeping deeply, awakened only with great difficulty by vigorous verbal (e.g.,
loud repeated calling of name) and/or physical stimulation (e.g. vigorous, repeated shaking of service user's
shoulder), returns to sleep immediately when stimulus is removed.

9. Unrousable:

Sleeping deeply, cannot be aroused by either vigorous verbal or physical stimulation (e.g. vigorous, repeated
shaking of service user's shoulders).

Page 53 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2 Oct 08.doc

Hertfordshire Partnership NHS Foundation Trust


Equality Impact Assessment Stage One
P Policy or service being assessed: The Management of Acute Behavioural Disturbance

in Adults (including rapid tranquillisation)


Summary of Policy: These guidelines and procedures are to be used for adults (16
years and over) requiring rapid tranquillisation in Trust Mental Health Services
inpatient units and Specialist Learning Disability inpatient, treatment and
assessment units
Rapid tranquillisation is the administration of medication to calm or sedate an
agitated, aggressive service user. The aim is to reduce patient suffering, allow
improved communication, reduce risks to the service user and others, and to do no
harm.
Lead Person: Practice Standards Facilitator
Date of Assessment: 18th June 2008
1. Is this a new or existing policy or
service?
2. What is the expected outcome of the
service/policy (e.g. aims, objectives and
purpose of the service/policy, standards for
practice)

New:

Existing: X

The standards for clinicians,


pharmacists, nursing staff and other
health care professionals involved in
the management of acute behaviour
disturbance and the prescribing,
administration and monitoring of rapid
tranquillisation.
Yes: X
No:

3. Does this policy/service link to others? If


yes please state link below:
Links to the HPFT Medicines policy, Clinical Risk Assessment and Management of
Violence and Aggression
4. Does the Policy/Service show that the 11
Yes:
principles of mental health recovery have
been taken into account?
If yes, please give evidence: Rapid tranquillisation is part of the therapeutic duty of care
to aid the development of personal responsibility and self-determination.
Staff have a framework in which to
5. Who is intended to benefit from the
work and service users are assured
policy/service: In what way.
that correct procedure for the use of
rapid tranquillization is followed.
6. How is the policy/service to be put into
These guidelines are applicable to
practice? Who is responsible?
all Trust medical, nursing and other

health care professionals and


support staff who could be involved
in the prescribing, administration or
monitoring of service users
receiving rapid tranquillisation.
7. How and where is information about the
policy/service publicised?
8. What regular consultation do you carry out
with different communities and groups re the
policy/service?
9. Are there concerns that the policy/service
could have an adverse impact* because of:
Age
Disability
Gender

The policy is available on the Trust


website.
All Medicine policies are agreed by the
HPFT Drugs and Therapeutic
Committee which includes a lay
member
Yes:
No:
X
X
X

Page 54 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2
Oct 08.doc

Ethnicity
Sexual Orientation
Religion/Belief
10. If YES to one or more of the above please
state evidence.

11. Do the differences amount to


discrimination?*
12. If YES could it still be justifiable e.g. on
grounds of promoting equality of opportunity
for one group?
I.e. Indirect discrimination can be justifiable
sometimes when a service is being provided for
a particular target group E.g. Asian womens
breast screening, Gay mens sexual health clinic,
Mental Health Services for Older People etc.
If Yes: Please give reasons below:
N/A
13. Do you think this policy/service
specifically contributes to promoting equality
and diversity in Hertfordshire? If so, in what
way? Please note any examples of good
practice.
14. What approaches will you take to get
feedback on your assessment?
15. How will the assessment link to other
mainstream service planning or review
processes?
16. Should there now be a Full Impact
Assessment and if so what are the reasons?

X
X
X
In common with most drugs authorised
for use by the MHRA there are cautions
for specific uses. Caution has to be
taken in the use of rapid tranquilisation
with service users who are elderly,
pregnant or who have learning
disabilities.
Yes:
No: X
Yes:

No: N/A
This is a caution
to protect the
service users not
discriminate
against them.

The policy does not specifically


contribute to promoting equality and
diversity.

Feedback from HPFT EIA Scrutiny


Group.
The management of acute behavioural
disturbance is linked to the national
NICE requirements for the treatment of
schizophrenia and NICE Management
of Violence.
The stage one assessment does not
indicate that a Full Impact Assessment
is required.
N/A

17. What further data, information or


assistance do you need to carry out a full
assessment?
June 2008
Date of Assessment
What feedback was given about Stage 1?
The following feedback was given by the EIA scrutiny group on 27/06/08:
Section 9 of the assessment there is a concern that due to language
requirements those service users who have poor or no English could be more at
risk of needing to be rapidly tranquilised. The reason for this is that they may not
respond to other methods of treatment due to a need for staff to communicate with
them. Whilst this cannot be prevented, services should be mindful of this fact and
where possible involve interpreters as soon as possible in the process.
The Following changes have been made to the policy:
Section 9. Plan For The Next 24 Hours And Afterwards:
Where language barriers are seen to be a factor which is preventing a response by
the service user to interventions/treatment, this can lead to an escalation of acute
behaviour disturbance by the service user. Staff should be mindful of this and seek
the support of the interpreting service as soon as possible.

Page 55 of 55
Hertfordshire Partnership NHS Foundation Trust
October 2008
Z:\Governance\RM\FOI\2010-2011 Requests\(338) Baker\Management of Acute Behavioural Disturbance(RT) V2
Oct 08.doc