1. Rapid Tranquilisation and Patient Safety Andy Cantrell, January 2013

2. Background Rapid tranquilisation poses risks to both staff and patients. Injuries are common in restraint. Medication occasionally contributes to respiratory/cardiac arrest. Ideally all aggression is de-escalated prior to the need for rapid tranquilisation. This has been the focus of other projects. Nevertheless there will always be a small proportion of acutely disturbed, often delusional patients who pose a risk to patients, staff and themselves without intervention. Driven by NICE Guidelines on Violence and Schizophrenia, NHSLA assessment and Serious Incidents, we undertook several years of quality improvement to make this safer…

3. A HQIP Clinical Audit Cycle

4. Key Standards Attempt de-escalation prior to the need for rapid tranquilisation Medication Prescribing Protocol – ‘4 steps of Rapid Tranquilisation Process’ from the Maudsley Prescribing Guidelines including choice of drug, dosage and contra-indications Monitoring of patients’ physical observations following rapid tranquilisation Debriefing with the patient Documentation of all the above

5. Baseline, 2007 Unreliable documentation of incidents in the patient record (48%) Little documentation of attempting de-escalation prior to rapid tranquilisation (10%) Common administration of Haloperidol during rapid tranquilisation (16%) Where given, Haloperidol was usually above the recommended dosage (74%) Physical observations were not recorded following rapid tranquilisation Debriefing with the patient was not recorded

6. Fishbone analysis Injury to staff and patients during RT Aggression Drug interactions Delusions Fear Not all physically suited to restraint Fear Guidelines lacking Local teams sometimes lack de-escalation/ PSTS skills Emergency Team likewise Not covered in everybody’s mandatory training Resus equipment was not 100% correct at start No formal record of observations Often local problems Guidelines perceived as ‘out of touch’ Risk from RT medications Restraint carries risks

7. Improvement Work

8. Physical observations after rapid tranquilisation included in the SLAM Magnet Nursing Competency Framework. Modified Early Warning Scores cards include a prompt on the front page to record observations post-rapid tranquillisation.

9. Improvement Work (contd.) Audit summary findings and recommendations issued in trustwide e- news bulletin and e-mailed to all consultants and ward managers to be given to their teams (March 2010, December 2011). Medication Incident and Error Bulletins produced by the Pharmacy Department have highlighted serious incidents involving rapid tranquilisation and reminders of the mandatory monitoring schedule (e.g. April 2012). A poster of the rapid tranquillisation guidelines has been produced and sent to all wards in March 2011. Inpatient practice visits audit data in May 2012 demonstrated 95% inpatient areas had this poster displayed. The SLaM rapid tranquillisation guidelines were reviewed and re- ratified in October 2011. Amendments to the guidelines included advice on medication for children and older adults.

10. Improvement Work (last of these) Systems have been introduced to scan paper medication and observation charts into the electronic record system. 5 super scanners deployed. Administrators trained. An alert and hyperlink have been added to the DATIXweb incident reporting form where rapid tranquilisation has been used. Encourages recording of physical observations or refusals. A rapid-cycle audit project focused on improving physical observations following rapid tranquillisation (due to start in September 2012)

11. Jim Reason’s Swiss Cheese Model HAZARDS ACCIDENT Cheese = Barriers (good) Holes = Failures (bad)

12. Rapid Tranq. Cheese Model HAZARDS ACCIDENT BARRIERS De-escalation Safe Prescribing PSTS restraint Observations

13. Rapid Tranq. Cheese Model HAZARDS ACCIDENT BARRIERS De-escalation Safe Prescribing PSTS restraint Observations Include RT in PSTS Training MEWS Guidelines Poster CT1 Training, RT

14. Rapid Tranq. Cheese Model HAZARDS ACCIDENT BARRIERS De-escalation Safe Prescribing PSTS restraint Observations Include RT in PSTS Training MEWS Guidelines Poster CT1 Training, RT MEWS RT Cover sheet

15. Rapid Tranq. Cheese Model HAZARDS ACCIDENT BARRIERS De-escalation Safe Prescribing Include RT in PSTS Training MEWS Guidelines Poster CT1 Training, RT MEWS RT Cover sheet PSTS restraint Observations

16. Re-audit - successes By the 2011 audit cycle: Documentation of rapid tranquilisation in the patient electronic notes improved and this was sustained (48% in 2007, up to 96% in 2010, 100% in 2011) Documented attempts to de-escalate the patient prior to rapid tranquilisation became more common (10% up to 66% in 2011) Use of Haloperidol dropped to a minimum (42% in Jan 2008 down to 3.6% in 2011) Recorded debrief with the patient following rapid tranquillisation improved (0% to 43% in 2007) Not so good: Whilst recording of at least one set of observations following rapid tranquilisation improved (0% in 2007 up to 25% in 2011), the requirement to document physical observations at the frequency required (i.e. every 5-10 minutes for one hour and then half-hourly until the patient is ambulatory) has not been met. This is now subject to a focused rapid-cycle audit project.

17. Rapid-Cycle Audit - Observations Cultural change through inclusion in project Frequent observations. Hawthorn effect becomes a real effect  NHS Institute for Innovation and Improvement Deming, 1994

18. 4 Rs of Motivation Responsibilities –Key but disciplinary in nature. Improving ownership by inclusion in quality improvement project Relationships –Team culture is a big factor in RT habits –Negative effect on patient relationship may accumulate from repeated observations? Rewards –Reward to Trust in NHSLA insurance –No such rewards for individual clinicians. Just the knowledge they have avoided the small possibility of physical collapse Reasons –Clinicians not convinced of the value of observations –Need to clarify that risk assessing as unsafe is ok, but to record it –Need to convince clinicians policy writers are not ‘on another planet’ Michael Maccoby (2010) Research Technology Management 53(4) 2010 pp. 60-61

19. Productive Mental Health Ward Good use of ground-up Quality improvement Clinicians are learning and taking ownership

20. Lessons for Patient Safety Best to avoid Rapid Tranquilisation. Consider Relational Security  Staff safety = patient safety Models help you think The clinicians may think your policy writers are living on another planet. Address this. Persevere, small improvements get you there in the end… …If they don’t – change tactics! DoH

21. Thanks for listening Any questions? Anyone achieved rigorous post-RT observations?