Assessment of physical monitoring following rapid tranquillisation: a national survey

Loynes, Benjamin; Innes, James; Dye, Stephen

doi:10.1017/s1742646412000295

Cited by 11 publications

(11 citation statements)

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“…Such variations reflect inconsistency between recommendations from national and international guidelines. Indeed, in national surveys, 97% of RT documents (n = 44) specified monitoring parameters but there was considerable variation with a range of 14 different parameters listed (Innes and Iyeke, 2012;Loynes et al, 2012). Table 6 summarises the key points from guidelines that make pertinent recommendations; the following guidelines make no additional recommendations and are not included: American Association for Emergency Psychiatry (Wilson et al, 2012b); British Association for Psychopharmacology (Barnes et al, 2011); and Austrian Society for Neuropsychopharmacology and Biological Psychiatry (Frey et al, 2015).…”

Section: Physical Health Monitoring and Rtmentioning

confidence: 99%

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation

et al. 2018

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The British Association for Psychopharmacology and the National Association of Psychiatric Intensive Care and Low Secure Units developed this joint evidence-based consensus guideline for the clinical management of acute disturbance. It includes recommendations for clinical practice and an algorithm to guide treatment by healthcare professionals with various options outlined according to their route of administration and category of evidence. Fundamental overarching principles are included and highlight the importance of treating the underlying disorder. There is a focus on three key interventions: de-escalation, pharmacological interventions pre-rapid tranquillisation and rapid tranquillisation (intramuscular and intravenous). Most of the evidence reviewed relates to emergency psychiatric care or acute psychiatric adult inpatient care, although we also sought evidence relevant to other common clinical settings including the general acute hospital and forensic psychiatry. We conclude that the variety of options available for the management of acute disturbance goes beyond the standard choices of lorazepam, haloperidol and promethazine and includes oral-inhaled loxapine, buccal midazolam, as well as a number of oral antipsychotics in addition to parenteral options of intramuscular aripiprazole, intramuscular droperidol and intramuscular olanzapine. Intravenous options, for settings where resuscitation equipment and trained staff are available to manage medical emergencies, are also included.

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Section: Physical Health Monitoring and Rtmentioning

confidence: 99%

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation

et al. 2018

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“…Less frequently occurring themes were debates about CR versus other forms of management, public attitudes to mental health care, staff training, and comparison with national standards, ward indicators, or policies …”

Section: Resultsmentioning

confidence: 99%

International research into 22 years of use of chemical restraint: An evidence overview

Muir‐Cochrane

Oster

Grimmer

2019

Evaluation Clinical Practice

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Background: Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others.Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.Aims: To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.Methods: This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.Results: This review identified 311 relevant primary studies (21 RCTs; 46 noncontrolled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%). Discussion:A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

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“…This proportion was similar for both the baseline audit and re-audit samples. 22 The direct contact required for physical monitoring may be impractical in such cases 17 : patients who are still aroused and disturbed may refuse to cooperate or staff may be wary of approaching them, perceiving that this might be potentially counterproductive and put both the patient and themselves at risk of harm. 6 However, our data provide only very limited evidence that monitoring is less likely to be documented in patients who remain behaviourally disturbed after RT.…”

Section: Discussionmentioning

confidence: 99%

Physical health monitoring after rapid tranquillisation: clinical practice in UK mental health services

Paton

Adams

Dye

et al. 2019

Therapeutic Advances in Psychopharmacology

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Background: We aimed to assess the quality of physical health monitoring following rapid tranquillisation (RT) for acute behavioural disturbance in UK mental health services. Methods: The Prescribing Observatory for Mental Health (POMH-UK) initiated an audit-based quality improvement programme addressing the pharmacological treatment of acute behavioural disturbance in mental health services in the UK. Results: Data relating to a total of 2454 episodes of RT were submitted by 66 mental health services. Post-RT physical health monitoring did not reach the minimum recommended level in 1933 (79%) episodes. Patients were more likely to be monitored (OR 1.78, 95% CI 1.39–2.29, p < 0.001) if there was actual or threatened self-harm, and less likely to be monitored if the episode occurred in the evening (OR 0.79, 95% CI 0.62–1.0, p < 0.001) or overnight (OR 0.57, 95% CI 0.44–0.75, p < 0.001). Risk factors such as recent substance use, RT resulting in the patient falling asleep, or receiving high-dose antipsychotic medication on the day of the episode, did not predict whether or not the minimum recommended level of post-RT monitoring was documented. Conclusions: The minimum recommended level of physical health monitoring was reported for only one in five RT episodes. The findings also suggest a lack of targeting of at-risk patients for post-RT monitoring. Possible explanations are that clinicians consider such monitoring too demanding to implement in routine clinical practice or not appropriate in every clinical situation. For example, physical health measures requiring direct contact with a patient may be difficult to undertake, or counter-productive, if RT has failed. These findings prompt speculation that post-RT monitoring practice would be improved by the implementation of guidance that integrated and refined the currently separate systems for undertaking and recording physical health observations post-RT, determining nursing observation schedules and detecting acute deterioration in physical health. The effectiveness and clinical utility of such an approach would be worth testing.

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Assessment of physical monitoring following rapid tranquillisation: a national survey

Cited by 11 publications

References 2 publications

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation

Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation

International research into 22 years of use of chemical restraint: An evidence overview

Physical health monitoring after rapid tranquillisation: clinical practice in UK mental health services

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