Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version

Policy No: RM80 Version: 3.0 Name of policy: Policy for the Rapid Tranquilisation (RT) of Adult Patients Displaying Acutely Disturbed or Violent Behaviour Effective from: 11/06/2018 Date ratified 06/04/2018 Ratified Safeguarding Committee Review date 01/04/2020 Sponsor Director of Nursing, Midwifery & Quality Expiry date 05/04/2021 Withdrawn date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues Displaying Acutely Disturbed or Violent Behaviour v3

Version control Version Release Author/Reviewer Ratified by/authorised by Date Changes (Please identify page no.) 1.0 15/05/2014 Dr C Kirkley, Old Age Psychiatry 2.0 21/12/2016 Joanne Coleman Strategic Safeguarding Lead 3.0 11/06/2018 Joanne Coleman Strategic Safeguarding Lead SafeCare Council Safeguarding Committee Safeguarding Committee 09/04/2014 02/12/2016 06/04/2018 Standard operating procedure for completion of Datix Displaying Acutely Disturbed or Violent Behaviour v3 2

Contents Page No. 1. Introduction... 4 2. Policy scope... 4 3. Aim of policy... 4 4. Duties - roles and responsibilities... 4 5. Definition of terms... 5 6. Rapid tranquilisation (RT) of Adult patients displaying acutely disturbed or violent behaviour... 6 6.1 What is RT?... 6 6.2 What is not RT?... 6 6.3 Key priorities... 6 Algorithm 1 (overview)... 8 Reporting 8 6.4 Prediction... 10 6.5 Medication... 10 6.6 Mental Health Act... 11 6.7 Patient monitoring... 11 6.8 Medical Specific Risks... 12 Algorithm 2 (RT in under 65s)... 13 Algorithm 3 (RT in over 65s)... 14 6.9 Consultant advice... 17 6.10 Standard doses... 17 6.11 Further (specialist) Treatments... 17 6.12 Intravenous Therapy... 17 7. Training... 18 8. Diversity and inclusion... 18 9. Monitoring compliance with the policy... 18 10. Consultation and review of this policy... 19 11. Implementation of this policy... 19 12. References... 19 13. Associated documentation... 19 Appendix 1 Physical health monitoring and remedial measures... 20 Appendix 2 Guidelines for use of Flumazenil... 21 Appendix 3 Shortage of Lorazepam injection alternative agents and management options... 22 Appendix 4 Rapid tranquilisation in pregnant women... 23 Appendix 5 Standard operating procedure for reporting in DATIX 24 Displaying Acutely Disturbed or Violent Behaviour v3 3

Policy for the Rapid Tranquilisation (RT) of Adult Patients Displaying Acutely Disturbed or Violent Behaviour 1. Introduction The Trust recognises the importance of good practice in preventing and managing aggressive, violent and potentially violent incidents. Potential behaviour problems should be identified, planned for and defused. However, severe behavioural disturbances will sometimes happen despite all attempts to prevent them. It may become necessary to use pharmacological interventions alongside physical restraint to maintain the safety and physical health of an individual. The administration of medicines under restraint to maintain safety is Rapid Tranquillisation (RT) 2. Policy scope This policy covers all healthcare staff working within inpatient and outpatient settings where RT may be utilised. 3. Aim of policy The aim of this policy is to minimise risk related to the use of RT, ensuring a standard approach to care, based on the best available evidence. The guidance is developed to comply with relevant local and national standards. 4. Duties, roles and responsibilities Trust Board The Trust Board has responsibility for ensuring that a safe and effective policy is in place for RT and that training and facilities are available to support the implementation of the policy. Chief Executive Has responsibility for ensuring the trust has robust and effective policies relating to rapid tranquilisation. Mental Health Committee The Mental Health Committee will be responsible for monitoring the appropriate use and patient monitoring following RT. Safeguarding Lead The Safeguarding lead will be responsible for the regular audit of incidents of RT. Pharmacy Services Provide drug information and advice as required to both staff and patients. Ensure medication to treat disturbed behaviour is available. Displaying Acutely Disturbed or Violent Behaviour v3 4

Associate Directors /Service Line Managers Ensure within their area of responsibility the application of the rapid tranquillisation policy is adhered to and where necessary take action to ensure compliance. Medical Staff Ensure they are familiar with the policy and adhere to the protocols and procedures. Ensure that an assessment of the patient s physical health is carried out before prescribing and administrating any medication. Complete all relevant RT documentation, update the current medication chart and ensure nurse in charge is fully aware of any decisions regarding medication. The Ward/Department Sister/Charge Nurse Will be fully aware of the contents of this policy and will ensure that all staff in their ward/department are aware of this policy and other policies and guidance which relate to this policy. Ensure that de-escalation methods are tried first and that any incident of RT is fully documented and reported accordingly. Registered Nurses Will ensure they are aware of the policy and adhere to the protocols and procedures and will ensure they attend all relevant training. Security Staff Security staff will support nursing and medical teams in the management of violent/ aggressive behaviour. 5. Definition of terms Rapid Tranquilisation is a reactive management strategy and typically involves physical intervention. It is the administration of medication to calm or sedate an agitated, violent or aggressive patient as quickly as is safely possible: not to treat the individual s underlying condition. Parenteral medication involves administration of medication either via Intramuscular (IM) or Intravenous (IV) routes. IM (intramuscular) is the injection of drugs directly into the muscle. IV (intravenous) is administration of a drug or substance directly into the vein. Advance Decision is an advance refusal of specific medical treatment to be taken into account and adhered to when a person loses the capacity to make the refusal contemporaneously as defined by the Mental Capacity Act 2005. An Advanced Decision relating to medical treatment for mental health disorder may be overruled by Part IV of the Mental Health Act 1983. Neuroleptic malignant syndrome (NMS) is caused almost exclusively by the use of antipsychotic medication. Rapid and large increases in dosage, such as rapid tranquillisation, can also trigger the development of NMS. Signs and symptoms include Displaying Acutely Disturbed or Violent Behaviour v3 5

muscular rigidity, pyrexia and confusion; sometimes muscle tremors and a sore throat. If NMS occurs it should be treated as a medical emergency. 6. Rapid tranquilisation (RT) of adult patients displaying acutely disturbed or violent behaviours 6.1 What is RT? RT is a reactive management strategy and typically involves physical intervention Clinical judgement may be required to distinguish between what is RT and what is administration of as required medical (PRN) within the following definitions RT is the administration of medication to calm or sedate an agitated, violent or aggressive patient as quickly as is safely possible; not to treat the individuals underlying condition The highly aroused condition of the patient during RT may intensify the effect of medicine used. Patients physical health must be monitored after administration (see para 6.7) 6.2 What is not RT? If medication is used proactively as an intervention to prevent a violent or aggressive incident this is not RT. Some patients may have a care plan which required a prescribed medication (usually on an as required (PRN) basis) to be given to prevent them from becoming violent or aggressive this is not RT 6.3 Key Priorities 6.3.1 Drugs for rapid tranquillisation, particularly in the context of restraint, should be used with caution because of the following risks:- Loss of airway Loss of consciousness instead of sedation Respiratory depression or cardiac arrest Over sedation with loss of alertness Cardiovascular collapse Seizures Adverse effects, for example, neuroleptic malignant syndrome Interactions with medication (prescribed or illicit) Underlying coincidental physical disorders 6.3.2 If parenteral (IM or IV) proves necessary then the IM route is preferred over IV from a safety point of view. The service user should be transferred to oral routes of administration at the safest opportunity. Displaying Acutely Disturbed or Violent Behaviour v3 6

6.3.3 Sufficient time should be allowed for clinical response between IM doses of medications. 6.3.4 The use of two drugs of the same class for the purpose of RT is not recommended. 6.3.5 Medications should never be mixed in the same syringe. 6.3.6 When using IM Haloperidol as a means of managing disturbed/violent behaviour, an antimuscarinic agent such as Procyclidine should be immediately available to reduce the risk of dystonia and other extrapyramidal side effects. This should be given as per manufacturers recommendations. 6.3.7 IV administration of Diazepam should not be used (due to the high risk of respiratory depression) except in exceptional circumstances, which should be specified and recorded. 6.3.8 Rapid tranquilisation should only be considered once de-escalation and other strategies have failed to calm the patient. The intervention (along with physical intervention) should be considered a management strategy and not be regarded as a primary treatment technique. When determining which intervention to employ, clinical need, the safety of service users and others and, where possible, any advance decisions should be taken into account. The intervention selected must be a reasonable and proportionate response to the risk posed by the patient at that particular time; this follows guidance given under the Mental Capacity Act 2005. 6.3.9 The reasons for using Rapid Tranquilisation (and any other intervention) must be explained to the patient at the earliest opportunity. 6.3.10 Resuscitation In the event of a need for resuscitation in Cragside or Sunniside - dial 999 for attendance by the ambulance service For all other areas within the trust where rapid tranquilisation might be used a crash trolley must be available. Equipment available must include an automatic external defibrillator, a bag valve mask, oxygen and suction equipment. All equipment must be properly maintained and checked as discussed in the Trust Resuscitation policy RM27a. 6.3.11 All prescribers and staff involved in rapid tranquilisation must be familiar with and have access to the Trust Resuscitation Policy RM27a. 6.3.12 Any incident requiring rapid tranquilisation (or physical intervention or seclusion) must be contemporaneously recorded. All appropriate staff should be trained to ensure that they are aware of how to correctly record any incident using the appropriate documentation. Displaying Acutely Disturbed or Violent Behaviour v3 7

6.3.13 All events of rapid tranquilisation must be reported as an incident on the Datix Incident Reporting system see appendix 5 for standard operating procedure. 6.3.14 A post-incident review should take place as soon as possible and at least within 72 hours of an incident ending. Wherever possible, a person not directly involved in the incident should lead the review. The review should address the following factors: What happened during the incident? Trigger factors. Each person s role in the incident. Their feelings at the time of the incident, at the review and how they may feel in the near future. What can be done to address their concerns? 6.3.15 Legal considerations: When considering RT it is essential that the clinician is clear under what legal authority the treatment will be administered. Legal authority could come from either the capable/ competent patient s valid consent (common law) or the Mental Health Act (see section 6.6). Alternatively, the Mental Capacity Act, if there is reasonable belief that the patient lacks capacity and that there is reasonable evidence that the treatment is in the patient s best interests then the Mental Capacity Act can be used. Any restraint required should be proportionate and necessary to prevent harm to the patient. The entry made into the patient s notes should make it clear which authority was used at the time of RT. 6.3.16 If a patient has underlying alcohol dependency & has alcohol withdrawal symptoms please refer to the Alcohol pathway policy & detoxification guideline 2011 Displaying Acutely Disturbed or Violent Behaviour v3 8

Algorithm 1 Overview algorithm for the short-term management of disturbed/violent behaviour PREDICTION Risk assessment Searching Continuous risk reassessment and use of de-escalation techniques PREVENTION De-escalation techniques Observation INTERVENTIONS FOR CONTINUED MANAGEMENT Consider, in addition to above, one or more of the following Rapid Tranquilisation Seclusion Physical Intervention Used to avoid prolonged physical intervention Use to avoid prolonged physical intervention Medication is required to calm a psychotic or non-psychotic behaviourally disturbed service user When service user has taken previous medication CONTRA-INDICATED AS AN INTERVENTION Should be terminated when rapid tranquillisation, if given, has taken effect When other interventions not yet explored Better if service user responds quickly Can be used to enable rapid tranquillisation to take effect Prolonged physical intervention POST-INCIDENT REVIEW Reference: The short-term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departments. (National Institute for Clinical Excellence February 2005) Displaying Acutely Disturbed or Violent Behaviour v3 9

6.4 Prediction Certain factors can indicate an increased risk of aggressive or physically violent behaviour. A comprehensive clinical risk assessment must be completed including demographic or personal history, clinical and situational variable. A risk management plan must be developed on admission if it is felt there may be the need for RT. This management plan, where possible, should be agreed with the patient and their carer s, friends and/or relative. Employing RT should only be considered once de-escalation and other strategies have failed in line with the Physical Control and Restraint Policy (RM73) 6.5 Medication 6.5.1 Treatment Aims 6.5.2 Doses To reduce suffering for the patient: psychological or physical (through self-harm or accidents). To reduce risk of harm to others by maintaining a safe environment. To do no harm (by prescribing safe regimes and monitoring physical health). It is recognised that clinicians may decide that the use of medication outside of the Summary of Product Characteristics (SPC) is occasionally justified, bearing in mind the overall risks. However, where the regulatory authorities or manufacturer issues specific warning that this may result in an increased risk of fatality, the medication should only be used strictly in accordance with the current marketing authorisation. In certain circumstances, current British National Formulary (BNF) uses and limits, and the manufacturers SPC, may be knowingly exceeded e.g. Lorazepam. This decision should not be taken lightly or the risks underestimated, and a risk-benefit analysis should be recorded in the case notes and a rationale in the care plan. Where the risk-benefit is unclear, consideration should be given to seeking advice from clinicians who are not directly involved in the care of the patient. If current BNF doses or SPC are exceeded it is particularly important to undertake frequent and intensive monitoring of a calmed patient. Particular attention must be given to regular checks of the airway, level of consciousness, pulse, blood pressure, respiratory effort, temperature and hydration. Doses of medication should be individualised for each patient. This will be dependent on several factors including the patient s age (older patients will generally require lower doses), concomitant physical disorders (e.g. renal, Protocol/Policy for the Rapid Tranquillisation (RT) of Patients Displaying Acutely Disturbed or Violent Behaviour version 1

6.6 Mental Health Act hepatic, cardiovascular, neurological), and concomitant medication. Particular attention must be given to any psychotropic medication administered to the patient in the past 24 hours and how rapid tranquilisation treatment might need to be adjusted as a result. 6.5.2 Discontinuation Rapid tranquilisation should be discontinued at the point of response. Thereafter, the patient must continue to be closely monitored, and future medication (both regular and as required) should be reviewed. Patients detained under the Mental Health Act are subject to consent to Treatment (MHA part 4). If they have been detained for more than 3 months, they will require consent under Section 58 (3) with a current T2 or T3 form, or be treated under Section 62 urgent treatment to prevent harm to self or others. All information relevant to MHA status must be fully documented in the medical notes. The patients legal status should be reviewed whenever parenteral medication is considered. The enforced administration of medication by injection in an informal patient may necessitate use of the Mental Health Act 6.7 Patient Monitoring Where possible, baseline measurements of the following should be recorded before any parenteral drug administration: - Temperature - Pulse - Respiratory Rate - Blood Pressure The measurements above must also be recorded every 5 10 minutes for 1 hour following the parenteral administration of any drug. Thereafter, they should be recorded at the half hourly intervals until the patient is fully ambulatory. In addition, staff should closely monitor for signs of extra-pyramidal side effects in response to the administration of antipsychotic medication. The patient must be monitored by within eyesight observation. Where the patient is unconscious or asleep, the same monitoring should take place so far as is possible, and pulse-oximetry should also be used. Where possible, and where facilities exist, ECG and haematological monitoring are also strongly recommended when parenteral anti-psychotics are administered, 11

especially where high doses have been used. High stress levels, agitation, and hypokalemia all place the patient at high risk of developing cardiac arrhythmias. The observations must be recorded on the EWS chart. Ref. Enhanced Care Policy and Supportive Engagement (observation) (Related to Mental Health & Advanced Physical Care) 6.8 Medication Specific Risks There are specific risks with different classes of medication and these risks may be compounded when medication is used in combination. Close monitoring of the patient is essential. Benzodiazepines Loss of Consciousness, Respiratory Depression or Cardiac Arrest, Cardiovascular Collapse (particularly in Clozapine patients). Antipsychotics Loss of Consciousness, Cardiovascular / respiratory complications and collapse, seizures, akathisia, Dystonia, Dyskinesia, neuroleptics malignant syndrome, excessive sedation. 12

Rapid Tranquilisation of the Acutely Disturbed / Violent Patient Under 65s Algorithm 2 Step 1 NON-PHARMACOLOGICAL MEASURES De-escalation, distraction, seclusion etc Consult any Advance Directives Step 2 Oral Treatment [a, b] Lorazepam 1 2mg 1 st line, non psychotic context or if already prescribed regular antipsychotics and/or Olanzapine 10mg Or Haloperidol 5mg If psychotic context ALLOW AT LEAST 45 MINUTES FOR ORAL MEDICATION TO WORK IF INEFFECTIVE, REPEAT ORAL MEDICATION AT SAME DOSES ALLOW AT LEAST 45 MINUTES FOR REPEATED ORAL MEDICATION TO WORK IF ORAL MEDICATION IS REFUSED CONSIDER COVERT ADMINISTRATION Prior to proceeding to step 3 (i/m treatment) consider using Buccal Midazolam 10 20mg (Unlicensed) Step 3 I/M Treatment [c, d] Ensure baseline measurements are recorded on the EWS chart: TEMPERATURE, PULSE, BP, RESPIRATORY RATE before IM administration, and repeat every 5-10 minutes for 1 hour, then half-hourly until patient is ambulatory. Use pulse oximetry if patient asleep or unconscious. MONITOR PATIENT CLOSELY! Lorazepam 1-2mg I/M [d][e] 1 st line non psychotic context AND and /or [b] Haloperidol 5mg I/M [f] ALLOW AT LEAST 30 MINUTES FOR I/M HALOPERIDOL and/or I/M LORAZEPAM TO WORK. IF INEFFECTIVE, REPEAT AT SAME DOSES AND ALLOW A FURTHER 30 MINUTES FOR EFFECT. DO NOT PROCEED FURTHER WITHOUT ADVICE FROM CONSULTANT (see Section 6.9) IF INEFFECTIVE, SEEK SPECIALIST ADVICE FROM CONSULTANT 13

Notes for Algorithm 2 a. Choice depends on current treatment. It patient is established on antipsychotics, Lorazepam may be used alone. If the patient uses street drugs or already receives regular benzodiazepines, an antipsychotic may be used alone. For the majority of patients, best response will be with combination therapy. b. Ensure Procyclidine injection is available. Antipsychotic may cause acute dystonic reaction. c. As in (a), either antipsychotic or benzodiazepine may be used alone, but best results are likely with combination therapy. d. Ensure Flumazenil injection is available to reverse effects of Lorazepam injection. e. Lorazepam should be mixed 1:1 with water before injecting. Shortage of Lorazepam injection see Appendix 3. f. Haloperidol (5mg) can also be used but should be the last drug considered because of the relatively high incidence of acute Dystonia and the recommendation that patients should have a pre-treatment ECG & IM Procyclidine available. 14

Algorithm 3 Rapid Tranquilisation of the Acutely Disturbed / Violent Patient - Patient Aged Over 65 Years - Step 1 NON-PHARMACOLOGICAL MEASURES De-escalation, distraction, seclusion etc Consult any advance directives Step 2 Oral Treatment [a,b] Lorazepam 0.5-1mg 1 st line, non psychotic context or if already prescribed regular antipsychotics AND/OR Olanzapine 2.5-5mg Haloperidol 0.5-2.5mg (Unless previously tolerated higher doses ) In patients with Parkinson s disease or dementia, especially those with a history of vascular disease or Lewey body dementia, antipsychotics should be used with caution or not at all. [b, f] ALLOW AT LEAST 45 MINUTES FOR ORAL MEDICATION TO WORK IF INEFFECTIVE, REPEAT ORAL MEDICATION AT SAME DOSES ALLOW AT LEAST 45 MINUTES FOR REPEATED ORAL MEDICATION TO WORK IF ORAL MEDICATION IS REFUSED CONSIDER COVERT ADMINISTRATION Prior to proceeding to step 3 (i/m treatment) consider using Buccal Midazolam 10 20mg (Unlicensed) Step 3 I/M Treatment [c,d] Ensure baseline measurements are recorded on the EWS chart: TEMPERATURE, PULSE, BP, RESPIRATORY RATE before IM administration, and repeat every 5-10 minutes for 1 hour, then half-hourly until patient is ambulatory. Use pulse oximetry if patient asleep or unconscious. MONITOR PATIENT CLOSELY! Lorazepam 1-2mg I/M [d] [e] 1 st line non psychotic context AND/ AND/ OR Haloperidol 1 2.5mg I/M [f] ALLOW AT LEAST 45 MINUTES FOR I/M HALOPERIDOL and/or I/M LORAZEPAM TO WORK. IF INEFFECTIVE, REPEAT AT SAME DOSES AND ALLOW A FURTHER 45 MINUTES FOR EFFECT. DO NOT PROCEED FURTHER WITHOUT ADVICE FROM CONSULTANT (see Section 6.9) IF INEFFECTIVE, SEEK SPECIALIST ADVICE FROM CONSULTANT 15

Notes for Algorithm 3: a. Choice depends on current treatment. If patient is established on antipsychotics, Lorazepam may be used alone. If the patient uses street drugs or already receives regular benzodiazepines, an antipsychotic may be used alone. For the majority of patients, best response will be with combination therapy. b. Ensure Procyclidine injection is available. Antipsychotic may cause acute dystonic reaction. c. As in (a), either antipsychotic or benzodiazepine may be used alone, but best results are likely with combination therapy. d. Ensure Flumazenil injection is available to reverse effects of Lorazepam injection. e. Lorazepam should be mixed 1:1 with water before injecting. Shortage of Lorazepam injection see below. f. Haloperidol (5mg) can also be used but should be the last drug considered because of the relatively high incidence of acute Dystonia and the recommendation that patients should have a pre-treatment ECG & IM Procyclidine available. 16

6.9 Consultant Advice Advice must be sought from the Consultant, (or Consultant on-call), at any stage of rapid tranquilisation if any doubt exists regarding how best to proceed. 6.10 Standard Doses (BNF) Standard doses of medication used in rapid tranquilisation are listed below. Whenever possible doses prescribed should be within these limits. However, prescribing outside recommended standard doses may occasionally be justified. (See section 6.5.2) 6.10.1 Haloperidol: oral = 30mg / 24 hours, I/M = 18mg / 24 hours (i.e. 3mg haloperidol I/M is approximately equivalent to 5mg oral) 6.10.2 Lorazepam: oral = 4mg / 24 hours, I/M = 30mcg / kg / 6 hours (i.e. I/M maximum is approximately 6-8mg / 24 hours) 6.10.3 Olanzapine: oral = 20 mg/24 hours, this dose should not be exceeded without obtaining specialist advice 6.11 Further (specialist) Treatments The following treatments are rarely used, have a minimal evidence base and are unlicensed. They may only be prescribed by or under guidance of a senior clinician or consultant who has previous experience of their use. Any decision to use these treatments must only be taken when more conventional treatments have failed and must be fully documented in the patient s notes. 6.11.1 Midazolam I/M Flumazenil must be available 6.11.2 Promethazine I/M Can be used in patients who are benzodiazepine tolerant. Slow onset of action but highly sedating. 6.11.3 Diazepam I/V (Diazemuls) Flumazenil must be available. Produces very rapid response. 6.11.4 Haloperidol I/V Dose as per I/M route. (see section 6.12) 6.12 Intravenous Therapy 6.12.1 The intravenous administration of benzodiazepines or haloperidol should not normally be used except in very exceptional circumstances, which should be specified and recorded. This decision should only be taken by a consultant or senior clinician who has had previous experience of its use. 17

7 Training 6.12.2 If immediate tranquilisation is essential then intravenous administration may be considered necessary. If so, it is essential that attending staff have been appropriately trained to recognise symptoms of respiratory depression, acute dystonia and cardiovascular compromise. 6.12.3 If intravenous medication is used, the patient must never be left unattended. Intravenous administration must not take place without full access to support and resuscitation services. 7.1 All staff involved in administering or prescribing rapid tranquilisation, or monitoring patients to whom parenteral rapid tranquilisation has been administered, must receive ongoing competency training to a Trust recognised standard which includes maintenance of airway, cardio-pulmonary resuscitation (CPR), the use of defibrillators, and the use of pulse oximeters. This must include training to ensure that they are aware of how to correctly record any incident using the appropriate documentation. 7.2 All prescribers, and those staff who administer medicines for rapid tranquilisation, should be familiar with and have received training which includes the following The properties of benzodiazepines, the benzodiazepine antagonist flumazenil, antipsychotics, antimuscarinics and antihistamines. Associated risks, including cardio-respiratory effects of the acute administration of the drugs, particularly when the patient is highly aroused and may have been misusing drugs, is dehydrated, or is possibly physically ill. The need to titrate doses to effect. 8 Diversity and Inclusion The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat staff reflects their individual needs and does not unlawfully discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). This policy aims to uphold the right of all staff to be treated fairly and consistently and adopts a human rights approach. This policy has been appropriately assessed. 9 Monitoring compliance with the policy Standard/process/issue Audit of incidents of RT against case notes to ensure appropriate use and monitoring following RT Monitoring and audit Method By Audit of Safeguarding all lead incidents reported on Datix Committee Frequency Mental 6 monthly Health Committee and SafeCare 18

10 Consultation and review There has been significant consultation on the policy including the Associate and Divisional Directors, Service Line Managers, Modern Matrons, Medical & Nursing staff within Old Age Psychiatry and Accident & Emergency, CMH Nursing staff, relevant Ward sisters, pharmacy and operational staff. 11 Implementation of policy (including raising awareness) The policy will be implemented in line with OP27 Policy on the Development, implementation and management of policies and through departmental meetings and brought to the attention of relevant staff through team meetings. 12 References 12.1 Violence the short term management of disturbed / violent behaviour in psychiatric in-patient settings and emergency departments. National Institute for clinical Excellence, February 2005. 12.2 The South London and Maudsley NHS Trust and Oxleas NHS Trust Prescribing Guidelines (1oth edition) 12.3 Antenatal and Postnatal mental health. National Institute for Clinical Excellence, February 2007. 12.4 Mental Health Act 1983 Code of Practice 12.5 Mental Capacity Act 2005 Code of Practice 12.6 NICE Clinical Guideline 25 February 2005 13. Associated documentation RM73 Restrictive Interventions Policy RM27a Resuscitation Policy RM04 Incident reporting policy Medicines Management Policy RM32 Policy and Procedure for the Care of Individuals who are Violent or Abusive 19

Physical health monitoring and remedial measures Appendix 1 Rapid Tranquilisation monitoring After any parenteral drug administration, monitor the following: Temperature Pulse Blood Pressure Respiratory Rate Every 5 10 minutes, for one hour, then half-hourly until patient is ambulatory. If the patient is asleep or unconscious, the use of pulse oximetry to continuously measure oxygen saturation is desirable. A nurse should remain with the patient until they are ambulatory again and observation should be re-assessed at this stage. ECG and haematological monitoring are also strongly recommended when parenteral antipsychotics are given, especially when higher doses are used. Hypokalaemia, stress, and agitation place the patient at risk of cardiac arrhythmias. Remedial measures in rapid tranquilisation Problem Acute dystonia (Including oculogyric crises) Remedial measures Give Procyclidine 5 10mg IM Reduced respiratory rate Give oxygen; raise legs; ensure patient is not lying face down. (<10/min) or oxygen saturation Give flumazenil if benzodiazepine-induced respiratory depression (<90%) suspected (see Appendix 2). If induced by any other sedative agent, ventilate mechanically. Irregular or slow (<50/min) pulse Fall in blood pressure (>30mmHg orthostatic drop or <50mmHg diastolic) Increased temperature Refer to specialist medical care immediately. Lie patient flat, tilt bed towards head. Monitor closely Withhold antipsychotics (risk of NMS and perhaps arrhythmias). Check creatinine kinase urgently. 20

Guidelines for use of Flumazenil Appendix 2 Guidelines for use of flumazenil Indication for use Contra-indications Caution Dose and route of administration Time before dose can be repeated Maximum dose Side effects Management If respiratory rate falls below 10/minute after the administration of Lorazepam, Midazolam or diazepam. Patients with epilepsy who have been receiving long-term benzodiazepines. Dose should be carefully titrated in hepatic impairment. Initial 200mcg intravenously over 15 seconds if required level of consciousness not achieved after 60 seconds the, Subsequent dose: 100mcg over 10 seconds 60 seconds 1mg in 24 hours (one initial dose and eight subsequent doses). Patients may become agitated, anxious or fearful on awakening. Seizures may occur in regular benzodiazepine users. Side effects usually subside. Monitoring What to monitor? Respiratory rate How often? Continuously until respiratory rate returns to baseline level. Flumazenil has a short half life. Respiratory function may recover then deteriorate again. Note: If respiratory rate does not return to normal or patient is not alert after initial doses assume sedation due to some other cause. 21

Shortage of Lorazepam injection Alternative agents and management options. Appendix 3 Buccal Midazolam (10-20mg) may be considered initially (although unlicensed) to avoid the need to move on to an intramuscular injection. If oral / buccal treatment is not appropriate, or if two doses fail (with 45-60 minute gap between doses), consider if antipsychotic therapy is appropriate Haloperidol Adults under 65, 5mg I/M. Adults over 65, 1 2.5mg I/M If a benzodiazepine is indicated Diazepam, (can be painful if given by the intramuscular route). Adults under 65, 10mg I/M, Adults under 65, 5mg I/M. Alternatively Midazolam i.m. can be used. Flumazenil must be available. Adults under 65, 70 100mcg / Kg, maximum dose 5mg. Adults over 65, 25 50mcg / Kg usual dose range 1 2.5mg max dose 5mg. Promethazine 25 50mg can be prescribed by or under guidance of a senior clinician or consultant who has had previous experience of its use see section 6.12.2 22

Appendix 4 Rapid Tranquilisation in Pregnant Women A pregnant woman requiring rapid tranquillisation should be treated using the Protocol/Policy for the Rapid Tranquilisation (RT) of Adult Patients Displaying Acutely Disturbed or Violent Behaviour except Do not seclude the woman following rapid tranquillisation. Adapt restraint procedures to avoid possible harm to the foetus. When choosing an agent for rapid tranquillisation, consider an anti psychotic (e.g. haloperidol) or benzodiazepine (e.g. lorazepam) with a shorter half life. If an antipsychotic is used it should be at the minimum effective dose to minimise the risk of neonatal extrapyramidal symptoms. If a benzodiazepine is used the risks of floppy baby syndrome should be taken into account. Manage the woman s care during the perinatal period in close collaboration with a paediatrician and an anaesthetist. Adapted from: NICE clinical guideline 45 Antenatal and postnatal mental health Published: February 2007 23

Appendix 5 Rapid Tranquilisation Due to V&A Rapid Tranquilisation SOP Incident occurs; First step is to report and this incident (see below) and then the date, Datix number and details of the person reporting must be detailed in the relevant patient records. These are the only details needed to avoid duplication as the incident documentation will be added to the patient s notes at the end of the process. All relevant details will be within this documentation. 1) Select the Category & Sub Category of Incident (e.g. assault on staff) 2) Select physical assault requiring control & restraint of patient 3) Select Chemical restraint 4) This will make the Rapid Tranquilisation section appear 24

Rapid Tranquilisation Disruptive due to Patients Medical Condition (e.g. 1) Select Category & Sub Category of Incident 2) Complete Rapid Tranquilisation section as step 4 above. Pulling Document from Datix for Medical Notes 25

1) Go into the incident and go to the Documents tab 2) Select Rapid Tranquilisation Form from the templates then click generate 3) You will see a pop up saying choose a contact, select the patient then click confirm 4) Click on the generated document and it will open in word, you will now be able to print 5) The document will need to be printed off and added into the relevant Patient records for completeness. 26