Rapid Tranquilisation and Patient Safety Andy Cantrell, January 2013 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… Clinical Audit Cycle A HQIP 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 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 Fishbone analysis Local teams Guidelines sometimes lack Aggression lacking de-escalation/ Fear PSTS skills Drug Risk from RT interactions medications Emergency Team Delusions Not all physically likewise Restraint Fear suited to restraint carries risks Injury to staff and Resus equipment patients was not 100% during RT correct at start Not covered in Often local everybody’s No formal record problems Guidelines perceived mandatory of observations as ‘out of touch’ training Improvement Work Improvement Work • 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. 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. 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) Jim Reason’s Swiss Cheese Model HAZARDS Cheese = Barriers (good) Holes = Failures (bad) ACCIDENT Rapid Tranq. Cheese Model BARRIERS De-escalation HAZARDS Safe Prescribing PSTS restraint Observations ACCIDENT Rapid Tranq. Cheese Model BARRIERS De-escalation HAZARDS Safe Prescribing PSTS restraint Observations CT1 Training, RT Guidelines Poster Include RT in PSTS Training ACCIDENT MEWS Rapid Tranq. Cheese Model BARRIERS De-escalation HAZARDS Safe Prescribing PSTS restraint Observations CT1 Training, RT Guidelines Poster Include RT in PSTS Training ACCIDENT MEWS MEWS RT Cover sheet Rapid Tranq. Cheese Model BARRIERS De-escalation HAZARDS Safe Prescribing PSTS restraint Observations CT1 Training, RT Guidelines Poster Include RT in PSTS Training ACCIDENT MEWS MEWS RT Cover sheet 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. Rapid-Cycle Audit - Observations • Cultural change through inclusion in project • Frequent observations. Hawthorn effect becomes a real effect ã NHS Institute for Innovation and Improvement Deming, 1994 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 Productive Mental Health Ward • Good use of ground-up Quality improvement • Clinicians are learning and taking ownership Lessons for Patient Safety • Best to avoid Rapid Tranquilisation. Consider Relational Security à • Staff safety = patient safety • Models help you think DoH • 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! Thanks for listening Anyone achieved Any questions? rigorous post-RT observations?
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