document title - cumbria, northumberland, tyne and wear nhs … · 2017. 1. 9. · ntw(c) 02...

Document Title The Management of Rapid Tranquillisation

Reference Number NTW(C)02

Lead Officer Medical Director

Author(s) (Name and Designation)

Dr Prathibha Rao – Consultant Psychiatrist

Ruth Ayre- Senior Clinical Pharmacist

Ratified by Trust Policy Group

Date ratified February 2016

Implementation Date February 2016

Date of full implementation

August 2016

Review date February 2019

Version number

V04.1

Review and Amendment

Log

Version Type of change

Date Description of change

V04 Review Feb 16

Updated according to NICE MVA guidelines (NG10) May 2015;

Updated sections 2-10;12-14, 21; Appendices 1-6, A, B & C

V04.1 Update Aug 16 IM Aripiprazole as a medication choice for RT

This policy supersedes the following document which must now be destroyed

Reference Number Title

NTW(C)02 – V04 Rapid Tranquillisation Policy

The Management of Rapid Tranquillisation

Section Contents Page No:

1 Introduction 1

2 Purpose 1

3 Definitions of Terms Used 1

4 Duties and Responsibilities 3

5 Use of Rapid Tranquilisation 7

6 Using p.r.n. medication in Rapid tranquillisation 8

7 Parenteral Therapy for Rapid Tranquillisation 9

8 Rapid tranquillisation and seclusion 11

9 Care Post Rapid Tranquillisation 11

10 Capacity to Consent 12

11 Service Users Concerns 13

12 Legal Concerns 14

13 Incident Reporting and Post Incident Reviews 14

14 Training:

Resuscitation

Pulse Oximetry

Rapid Tranquillisation

AVPU

15

15 Implementation 16

16 Monitoring and Compliance 17

17 Fair Blame 17

18 Equality Impact Assessment 17

19 Fraud, Bribery and Corruption 17

20 Associated Documents 17

21 References 18

Standard Appendices – attached to policy

Appendix Title Page No:

Appendix A Equality and Diversity Impact Assessment Form 19

Appendix B Communication and Training Needs Information 21

Appendix C Audit and Monitoring Tool 22

Appendix D Policy Notification Record Sheet - click here

Appendices – listed separate to policy

Appendix No:

Description Issue No:

Issue Date

Review date

Appendix 1 The Management of Rapid Tranquillisation (RT) in relation to pregnant women

2 Sep 16 Feb 19

Appendix 2 RT Monitoring Chart 1 Feb 16 Feb 19

Appendix 3 Flow Chart Violence and Aggression Short Term Management over 18 years

2 Aug 16 Feb 19

Appendix 4 Flow Chart Violence and Aggression Short Term Management 12-18 years

1 Feb 16 Feb 19

Appendix 5 Prescribing Notes over 18 years 2 Aug 16 Feb 19

Appendix 6 Prescribing Notes12-18 years 1 Feb 16 Feb 19

http://nww1.ntw.nhs.uk/services/?id=2550&p=2780&sp=1

NTW(C) 02

Northumberland Tyne and Wear NHS Foundation Trust NTW(C)02 – Rapid Tranquillisation – V04.1 – Reissued Sept16

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1 INTRODUCTION 1.1 With Northumberland, Tyne and Wear NHS Foundation Trust (the Trust/NTW), all

patients, regardless of culture, gender, diagnosis, sexuality, age or religious/spiritual beliefs will be treated with respect and dignity; and where possible will be at the centre of the clinical decision making process ensuring safety is the priority throughout each intervention.

1.2 The purpose of this policy is to outline the use of rapid tranquillisation (RT) within the

context of the prevention and management of violence and aggression. 2 PURPOSE 2.1 This policy covers the safe use of medication in treating service users in a

psychiatric/learning disability inpatient setting and/or service users within a learning disability setting, this includes service users who exhibit disturbed or challenging behaviour and present a real risk of harm to themselves or others.

2.2 Service specific protocols for special populations such as people with acquired brain

injury, children and adolescents, the elderly and a learning disability may supersede the protocol for the general adult population.

2.3 Treatment and care should take account of individual needs and preferences. Service users should have the opportunity to make informed choices about their care and treatment in partnership with their healthcare professional

2.4 Practice Variation: Like all guidance, this is a generalisation of best practice and this policy sets out broad standards for RT, which is intended to inform clinicians in reaching the best treatment decision for individual in-patients at the time and in the current circumstances. There will be occasions when there may need to be some variation from this, and these will require an assessment of the balance of potential benefits and potential harm indicated by the prescribing clinician in consultation with other members of the multi-disciplinary team. If a decision is made to vary from this policy, there must be clear documentation of that decision along with the supporting assessments and related consultations. Before all occasions of variance from this policy, the opinion of the consultant psychiatrist or another senior psychiatrist (e.g. out of hours) should be sought

3 DEFINITION OF TERMS USED 3.1 RT - Rapid Tranquillisation: Rapid tranquillisation in this guideline refers to the use of

medication by the parenteral route (usually intramuscular) if oral medication is not possible or appropriate and urgent sedation with medication is needed. (NICE Clinical Guidance NG10, May 2015). The Code of Practice defines RT as a restrictive intervention

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3.2 The aim of drug treatment in such circumstances is to calm the service user and reduce the risk of violence or harm, so that the necessary care (including cooperation with the Management of Violence and Aggression (MVA) plan) for the underlying psychiatric condition can then be provided/ continued. The aim of rapid tranquilisation is not to treat the individual’s underlying condition. An optimal response would be reduction in agitation or aggression without sedation, allowing the service user to participate in further assessment and treatment. Ideally, the drug should have a rapid onset of action and low levels of side effects. Prescribers should aim to ensure that the degree of sedation arising from rapid tranquillisation does not compromise the patient’s capacity to understand and respond to what is said to them.

3.3 MVA (Management of Violence and Aggression

3.3.1 The Trust recognises the following definition of work related violence: ‘an incident where an individual is abused, threatened or assaulted in circumstances related to their involvement with the Trust, which includes an explicit or implicit challenge to their safety, well-being or health’. (Adapted from DOH 2000).

3.4 IM (Intramuscular) The injection of drugs directly into the muscle

3.5 ILS (Immediate Life Support) Emergency medical care for sustaining life, including defibrillation, airway management, and drugs and medications

3.6 O2 (Oxygen) 3.7 BP (Blood Pressure) 3.8 O (Oral) Administration of a drug via the oral route 3.9 NMS (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 muscular rigidity, pyrexia and confusion; sometimes muscle tremors and a sore throat. If NMS occurs it should be treated as a medical emergency.

3.10 Advance Decisions/Advance Requests: An Advance Decision - is an actual refusal

of all or some specified treatment and the circumstances in which this would apply. Advance Decisions to refuse treatment for mental disorder may not apply if the person who made the Advance Decision is or is liable to be detained under the Mental Health Act 1983

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3.10.1 Advance Statement is a statement of a person’s wishes, views and feelings. Such wishes should be given the same consideration as wishes expressed at any other time. Clinicians must consider advance statements when determining what is in the patient’s best interests if the patient subsequently loses capacity. Some patients will deliberately state their wishes in advance about a variety of issues, including their medical treatment, how families and carers should be involved; the steps that should be taken in emergencies and what should be done if particular situations occur

3.11 p.r.n. (pro re nata): When needed. In this guideline, p.r.n. refers to the use of

medication as part of a strategy to de-escalate or prevent situations that may lead to violence or aggression.

3.12 AVPU scale- Alert, Voice, Pain, Unresponsive Scale.

3.13 ECG- Electro CardioGram. 4 DUTIES AND RESPONSIBILITIES

4.1 The Chief Executive is responsible for ensuring that an appropriate and adequate

infrastructure exists to support the provision of rapid tranquillisation policy amongst staff and patients throughout the organisation.

4.2 The Executive Director of Nursing and Operations in conjunction with the Medical Director and Trust Chief Pharmacist are responsible for the strategic and operational management of the rapid tranquillisation policy.

4.3 The roles and responsibilities of the Clinical Nurse Managers/Service Managers will be to:

Ensure within their area of responsibility the application of the rapid tranquillisation policy is adhered to and where necessary, action is taken to ensure compliance. This will be monitored through the Quality and Performance Groups

Monitor compliance of staff with training requirements and inclusion of rapid tranquillisation in their appraisals in line with the Trust’s policy NTW(HR)09, Staff Appraisal Policy and practice guidance notes (PGN)

Monitor the attendance of staff through their Quality and Performance groups

Undertake monitoring in line with monitoring tool, Appendix C of this policy 4.4 The Unit/Ward manager is required to:

Ensure that all staff are aware of this policy and other policies and guidance which relate to this policy

Ensure that adequate training is given to allow staff to safely implement the guidelines

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Audit the use of guidelines

Inform Clinical Nurse Manager/Service Manager if the guidelines are not being adhered to appropriately

To be involved in the monitoring of the application of this policy

4.5 The Nurse in charge is required to: 4.5.1 Be fully aware of the contents of this policy and supporting policies and guidance

before an incident arises

Assess risk and implement the policy when they feel it is appropriate

Ensure that non-pharmacological (de-escalation) methods are tried first

Ensure that the incident is fully documented

Ensure that the correct monitoring is done (including completing RT vital signs monitoring)

Continue to use de-escalation techniques throughout if appropriate


Must be competent in Immediate Life Support (ILS)

Follow the guidance of Mental Health Act Code of Practice - 2015 in relation to the use of rapid tranquillisation and The Mental Capacity Act 2005 - Code of practice

Complete all relevant Rapid Tranquillisation documentation

4.6 Registered Nurses are required to:

Ensure that they are familiar with the policy and adhere to the protocols and procedures referred to

Ensure their mandatory training is undertaken in line with policy requirements

Provides support and information to patient, carers and their families as required about the application of rapid tranquillisation

Adhere to the Trust’s policy, NTW(C)17 Medicines Management and the Nursing Midwifery Council Medicine Management Standards

Ensure that they only use clinical procedures which they are competent to administer

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Must be competent in Immediate Life Support (ILS) and remedial measures

Follow the guidance of the Mental Health Act Code of Practice- 2015 in relation to the use of rapid tranquillisation and The Mental Capacity Act 2005- Code of practice


Where appropriate, ensure that the Trust’s practice guidance note within NTW(C)38 – Pharmacological Therapy Policy, PPT-PGN-10 - Guidelines for the Use of High Dose Antipsychotics is followed

4.7 The Medical staff are required to:

Ensure that they are familiar with the policy and adhere to the protocols and procedures referred to

Ensure their mandatory training is undertaken in line with policy requirements

Provides support and information to patient, carers and their families as required about the application of rapid tranquillisation

Adhere to the Trust’s policy, NTW(C)17 Medicines Management

Ensure that they only use clinical procedures which they are competent to administer


Assess the patient and ensure a drug history is available, wherever possible, including ascertaining any past allergies and drug reactions from clinical notes

Conduct a mental state examination, assessment of physical health (including ECG when possible), and ascertain a history of any physical health conditions before prescribing and administrating any medication in line with the Trust’s NTW(C)29 - Trust Standard for the Assessment and Management of Physical Health

Consider any advance decisions/statements before prescribing

Consider if patient intoxicated

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Always refer to the most recent British National Formulary (BNF) to check recommended drugs and dosages

Consider interactions between medications

Must be competent in Immediate Life Support (ILS)

Consider the total daily dose of medications that are being prescribed

Follow the guidance of the Mental Health Act Code of Practice- 2015 in relation to the use of rapid tranquillisation and The Mental Capacity Act 2005- Code of practice


Ensure that the nurse in charge is fully aware of any decisions regarding medication

Ensure the patient’s current medication chart is amended to reflect the administration of ‘Rapid Tranquillisation’


A prescription of RT must be in line with legal requirements (in respect of patients subject to the Act, the rules concerning treatment and emergency treatment powers under the Act)

The person prescribing the injection should state the preferred injection site, having taken account of the need to avoid prone restraint, patient wishes and practicalities of the situation. Consider deltoid administration when possible

4.8 The Pharmacist is required to:

Provide drug information and advice as required for both staff and patients

Ensure medication to treat disturbed behaviour is available on all units where treatment may be carried out

Ensure that medication to treat emergencies is available on all units where treatment may be carried out (as per Trust’s policy NTW(C)01 Resuscitation Policy)


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5 USE OF RAPID TRANQUILLISATION 5.1 Measures to reduce violence and aggression need to be based on comprehensive risk

assessment and risk management. Therefore, mental health service providers must ensure that a full risk management strategy is introduced for all of their service users.

5.2 Rapid tranquillisation, physical interventions and seclusion should only be considered

once de-escalation and other strategies have failed to calm the service users. When determining which of these interventions to employ, clinical need, safety of service users and others, and where possible advanced directives should be taken into account.

5.3 Rapid tranquillisation should only be used where a patient is aroused, agitated, over-

active and aggressive and their actions present serious threat towards themselves or others, or is being destructive to their surroundings and where other therapeutic interventions of managing the behaviour have failed.

5.4 The team should ensure that they provide person-centred, values-based approach to

care, in which personal relationships, continuity of care and a positive approach to promoting health underpin the therapeutic relationship

5.5 Rapid tranquillisation should never be used to manage patients as a substitute for

adequate staffing. 5.6 A multidisciplinary team that includes a psychiatrist and a clinical pharmacist should

develop and document an individualised pharmacological strategy for using routine and p.r.n. medication to calm, relax and tranquillise service users who are at risk of violence and aggression as soon as possible after admission to an inpatient psychiatric unit. They should also document a rapid tranquillisation treatment plan in anticipation of future incidents.

5.7 If rapid tranquillisation is being used, a senior doctor should review all medication at

least once a day including the use of p.r.n. for RT. 5.8 In addition, the multidisciplinary team should review the pharmacological strategy and

the use of medication at least once a week and more frequently if events are escalating and restrictive interventions are being planned or used. The review should be recorded on RiO and include:

clarification of target symptoms

the likely timescale for response to medication

the total daily dose of medication, prescribed and administered, including p.r.n. medication

the number of and reason for any missed doses

therapeutic response

the emergence of unwanted effects

http://www.nice.org.uk/guidance/NG10/chapter/recommendations#terms-used-in-this-guideline

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5.9 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 (loss of airway)

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

Possible damage to the therapeutic partnership between service user and clinician

Specific issues in relation to diagnosis

5.10 Resuscitation equipment must be available and accessible where rapid tranquillisation is used as per the Trust’s NTW(C)01 - Resuscitation Policy

5.11 With growing awareness that involuntary procedures produce traumatic reactions in

service users, following the use of rapid tranquillisation, service user’s should be offered the opportunity to discuss their experiences and should be provided with a clear explanation of the decision to use urgent sedation. This should be in the patient’s record.

5.12 Service users will be given the opportunity to write up their account of the intervention.

This may necessitate the assistance of advocates and relatives. The written account will be filed in the patient’s record. Service users will be engaged in discussion with staff to learn and share lessons.

5.13 Older people, the elderly and other groups may require smaller doses of medication.

Particularly consider:

a) Altered levels of metabolism b) Existence of physical illness c) Use of concurrent medications

6 USING P.R.N MEDICATION IN RAPID TRANQUILLISATION

6.1 When prescribing p.r.n. medication as part of a strategy to de-escalate or prevent

situations that may lead to violence and aggression: do not prescribe p.r.n. medication routinely or automatically on admission. Only prescribe p.r.n. medications for purposes of RT if there are good reasons to anticipate that this may be required.

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6.2 When prescribing, ensure that the medicines chart is annotated to reflect

administration of rapid tranquillisation e.g. ‘use for RT’ as the indication for use.

6.3 Tailor p.r.n. medication to individual need and include discussion with the service user if possible and ensure there is clarity about the rationale and circumstances in which p.r.n. medication may be used and that these are included in the care plan.

6.4 A single dose should be prescribed and not repeated until the effects of the initial dose

has been reviewed. It should be remembered that peak plasma concentrations occur approximately 60-90 minutes following intramuscular administration.

6.5 Ensure that the maximum daily dose is specified and does not inadvertently exceed the maximum daily dose stated in the British national formulary (BNF) when combined with the person's standard dose or their dose for rapid tranquillisation.

6.6 Only exceed the BNF maximum daily dose (including p.r.n. dose, the standard dose

and dose for rapid tranquillisation) if this is planned to achieve an agreed therapeutic goal, documented, and carried out under the direction of a senior doctor. Ensure that the interval between p.r.n. doses is specified.

6.7 If p.r.n. medication has not been used since the last review, consider stopping it. 7 PARENTERAL THERAPY FOR RAPID TRANQUILLISATION 7.1 If parenteral (I/M) treatment proves necessary, the service user should be transferred

to oral routes of administration at the safest opportunity. 7.2 Where oral therapy for management of violence and aggression is refused, is not

indicated by previous clinical response, is not a proportionate response, or is ineffective, a parenterally (I/M) administered rapid tranquillisation agent is recommended (see Appendix 3 -Prescribing flowchart >18 years, Appendix 4 – Prescribing flowchart 12-18 years, Appendix 5 - Prescribing notes >18 years, Appendix 6 - Prescribing notes 12-18 years.

7.3 Sufficient time should be allowed for clinical response between intramuscular doses of

medications for rapid tranquillisation. (See local rapid tranquillisation notes in Appendix 3).

7.4 The use of two drugs of the same class for the purpose of rapid tranquillisation is not

recommended. 7.5 Medications should never be mixed in the same syringe. 7.6 When using I/M 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 intramuscularly as per manufacturer’s recommendations.

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7.7 All staff should be appropriately trained (see section 13 14 - Training) to recognise symptoms of respiratory depression, dystonia or cardiovascular compromise (such as palpitations, significant changes in blood pressure, reduction or sudden drop in respiratory rate or level of consciousness.

7.8 If intramuscular medication is used the service user should never be left unattended,

and if in seclusion should be monitored on eye sight observations. Intramuscular administration should never occur without access to full support and resuscitation equipment that should be immediately available. This equipment should be maintained and checked weekly as per the Trust’s NTW(C) 01 – Resuscitation Policy.

7.9 NICE Guidelines state that zuclopenthixol acetate injection is not recommended in

rapid tranquillisation due to long onset and duration of action. However, it may be used in certain specified circumstances:

When disturbed/violent behaviour over an extended period of time is expected

There is a history of good and timely response

There is a history of requirement for repeated parenteral (I/M) administration

An advance directive has been made indicating that this is a treatment of choice

RT monitoring/patient observations should be completed as per Section 9 – Care Post Rapid Tranquillisation

7.10 NICE guidelines do not recommend the use if aripiprazole injection in rapid tranquilisation. However, clinical trials have demonstrated the efficacy and safety of aripiprazole injection in acutely disturbed patients with schizophrenia, schizoaffective disorder, schizophreniform disorder or bipolar mania. The reported incidence of extrapyramidal side-effects was less with IM aripiprazole compared to IM haloperidol. Aripiprazole is also classed as lower risk in cardiovascular disease compared to Haloperidol. Aripiprazole injection can be considered for use when an antipsychotic is required and there is/are:

a history of significant extrapyramidal side-effects

pre-existing cardiac problems where lorazepam is of limited use

7.11 Particular care needs to be taken, if the patient is struggling and not held securely in an appropriate hold to ensure needlestick injuries, damage to nerves or accidental intra-arterial injection do not occur.

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8 RAPID TRANQUILLISATION AND SECLUSION 8.1 The use of seclusion (see the Trust’s NTW(C)10 - Seclusion Policy) with rapid

tranquillisation is not absolutely contraindicated. However, the following advice should be carefully considered and followed in conjunction with the patient’s MVA care plan: -

If the service user is secluded, the potential complications of rapid tranquillisation should be taken particularly seriously

The service user should be monitored ‘within eyesight’ observation by an appropriately trained individual (see the Trust’s NTW(C) 19 - Observation Policy) and vital signs monitored (see section 8). These physical health recordings must be documented:

o either on a printed version of Appendix 2- RT monitoring chart immediately AND then the recordings transferred onto the electronic RT monitoring chart on RiO within 24 hours

o or enter the recordings directly onto the electronic RT monitoring chart on RiO

The electronic RT monitoring chart can be found on RiO under core clinical documents>physical health monitoring>link to IP rapid tranq chart

The trust in addition recommends the use of The National Early Warning Score (NEWS) for monitoring any signs of physiological deterioration.

Once rapid tranquillisation has taken effect, consider terminating the seclusion as soon as reasonably possible

9 CARE POST RAPID TRANQUILLISATION

9.1 After parenteral (IM) rapid tranquillisation is administered, vital signs should be monitored, (See Appendix 2 –RT Monitoring Chart) and pulse oximeters should be used.

9.2 Blood pressure, pulse, temperature, respiratory rate, oxygen saturations, level of

consciousness and hydration should be recorded as per monitoring chart initially, then at least every hour or at intervals agreed by a multi-disciplinary team, until the service user becomes alert again/ there are no concerns about their physical health.

9.3 These physical health recordings must be documented -

either on a printed version of Appendix 2- RT monitoring chart immediately AND then the recordings transferred onto electronic RT monitoring chart on RiO within 24 hours

or enter the recordings directly onto the electronic RT monitoring chart on RiO

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The electronic RT monitoring chart can be found on RiO under core clinical documents>physical health monitoring>link to IP rapid tranq chart The trust in addition recommends the use of The National Early Warning Score (NEWS) for monitoring any signs of physiological deterioration

9.4 Where oral medication is used, no additional physical observation is required. 9.6 In the following circumstances, more frequent and intensive monitoring (at least every

15 minutes) by appropriately trained staff is required and should be recorded in the care plan and on the monitoring chart as above. Particular attention should be paid to the service user’s respiratory effort, airway and level of consciousness:

If the service user appears to be, or, is asleep/sedated. Ensure to maintain service user on eyesight observation during the 1st hour due to the risk of cardiac respiratory collapse

If the British National Formulary (BNF) limit is exceeded

In high risk situations e.g. clinically unwell patient, frail, known physical conditions/complications

Where the service user has been using illicit substances or alcohol

Where the service user has a relevant medical disorder or concurrently prescribed medication

Where the service user has experienced any harm as a result of any restrictive intervention

9.7 If a patient becomes acutely unwell where physical observations are showing a deterioration, the Trust’s NTW(C)01 - Resuscitation Policy must be followed. Also refer to the Trust’s NTW(C)29 – Trust standard for the assessment and management of physical health policy, practice guidance note AMPH-PGN-03 - National Early Warning Score (NEWS).

10 CAPACITY TO CONSENT 10.1 The principals of the Mental Capacity Act 2005 (MCA 2005) and Supplementary Code

of Practice for Deprivation of Liberty Safeguards must be followed in relation to consent to treatment. The five statutory principles are:

A person must be assumed to have capacity unless it is established that they lack capacity

A person is not to be treated as unable to make a decision unless all practicable steps to help him/her to do so have been taken without success

A person is not to be treated as unable to make a decision merely because he/she makes an unwise decision

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An act done or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his/her best interests

Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action

10.2 The assessment of the individual’s ‘capacity to consent’ should be taken by the staff team who carry out the intervention required to manage the situation. Whether the person has the capacity to consent is incident specific and time specific, this means there may be parts of treatment a person may have capacity to consent to; and at times they may have capacity to consent. An assessment may draw upon the expertise of other healthcare professionals, family, carers and advocates who are close to that person.

10.3 The assessment should follow the 2 stage test as outlined in the MCA 2005 Code of

Practice and the Trust’s NTW(C) 34 – Mental Capacity Act 2005 Policy. Namely this means establishing if the person has;

a) An impairment of the mind or brain, or some sort of disturbance affecting the way their mind or brain works (It doesn’t matter whether the impairment or disturbance is temporary or permanent.)

b) If so, does that impairment or disturbance mean that the person is unable to make the decision in question at the time it needs to be made?

10.4 A person may be said to lack capacity if they can’t understand the treatment, explain

consequences of having/not having the treatment; can’t retain, use or weigh up the information relevant to the treatment; or can’t communicate their decision in relation to the treatment (by whatever means).

10.5 A treatment can only be given to a person if they have capacity and consent; or lack

capacity to consent and it is in their best interests; or they are subject to the Mental Health Act 1983 where consent would not normally be required, any assessment and decision to treat must be recorded in the person’s records.

10.6 If someone does not have capacity to make decisions, healthcare professionals should

follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards

10.7 Rapid tranquillisation must not be used to treat an informal patient who has the capacity

to refuse treatment and who has done so. 11 SERVICE USER CONCERNS 11.1 When using interventions such as restraint, rapid tranquillisation or seclusion, steps

must be taken to try to ensure that such treatment has the least impact on privacy and dignity as possible.

http://www.justice.gov.uk/protecting-the-vulnerable/mental-capacity-act

http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085476

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11.2 The reasons for using rapid tranquillisation; physical interventions or seclusion should be explained to the service user at the earliest opportunity.

11.3 After the use of rapid tranquillisation, physical interventions or seclusion, the service

user’s care plan should be reassessed, if required, and the service user should be helped to reintegrate into the ward milieu at the earliest safe opportunity.

11.4 Service users will be given the opportunity to write up their account of the intervention

wherever possible, this will be managed at the service user’s communication level, for example documentation of a verbal account or facilitated using talking mats / symbols etc; and may be part of a post incident support scenario. This may necessitate the assistance of advocates and relatives. The written account will be filed in the service user notes. Service users will be engaged in discussion with staff to learn and share lessons.

12 LEGAL CONCERNS 12.1 Regard must be made to any advance decisions and/or advance statements which the

person may have made in relation to rapid tranquilisation as detailed in the Trust’s NTW(C)34 – Mental Capacity Act Policy, practice guidance note, MCA-PGN-02 – Advance Decision to Refuse Treatment and Advance Statement PGN.

12.2 All staff must be aware of the legal framework that authorises the use of rapid

tranquillisation, physical intervention and seclusion. The guidance of the Mental Health Act 1983 Code of Practice 2015 should be followed, with any departures from that guidance clearly recorded and justified as being in the service user’s best interest. CYPS staff should be familiar with the Children Act 1989 and 2004 and the Mental Health Act 1983, as well as the Mental Capacity Act 2005 and the Human Rights Act 1998. They should also be aware of the United Nations Convention on the Rights of the Child.

12.3 The service should provide easy access to competent legal advice in relation to the

management of any contentious aspect of disturbed/violent behaviour as detailed in the Trust’s policy, NTW (O) 16 - Access to Legal Advice.

12.4 Prescription of RT must be in line with legal requirements (in respect of patients

subject to the Act, the rules concerning treatment and emergency treatment powers under the Act.

13 INCIDENT REPORTING AND POST INCIDENT REVIEWS 13.1 Incident Reporting 13.1.1 Any incident requiring intramuscular (I/M) rapid tranquillisation, physical restraint or

seclusion should be reported by staff to their line manager, in line with the Trust’s NTW(O)05 Incident Policy, which follows the principles of the guidance issued by the Security Management Service (SMS) and the National Patient Safety Agency (NPSA): Seven Steps to Patient Safety: Step 4: Promote Reporting.

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13.2 Post-Incident Reviews 13.2.1 Following administration of Rapid Tranquillisation, an immediate post-incident review

that includes at least a doctor and a nurse to identify and address any physical harm to service users and to develop further medication plans and RT plans should be conducted

13.2.2 As soon as possible, but no later than 72 hours, a post incident review that includes

the service user will need to happen in order to evaluate what could have been done differently, determine alternatives and record management plan for future RT incidents that are tailor made for the service user.

13.2.3 For anyone (to include service users and staff) that has witnessed rapid

tranquillisation, consideration should be given to offering support and further help as appropriate.

14 TRAINING – See Standard Appendix B 14.1 The Trust will ensure that all staff has access to appropriate levels of training, it is the

responsibility of each Group Director to ensure staff attend. Levels of training are identified in the training needs analysis (see Appendix B) and are included within the Essential Training Guide which forms part of NTW(HR)09 – Staff Appraisal Policy and Practice Guidance Notes.

14.1.1 Levels of training are identified in the training needs analysis and are included within

the Training Guide which can be accessed via this link

http://nww1.ntw.nhs.uk/services/index.php?id=3796&p=2780 14.2 Resuscitation

14.2.1 All staff involved in administering or prescribing rapid tranquillisation, or monitoring service users to whom parenteral rapid tranquillisation has been administered, will receive annual competency based resuscitation training. This will be provided by the Trust, detailed in the Trust’s NTW(C)01 – Resuscitation Policy.

14.3 Pulse Oximetry 14.3.1 Prescribers and those who administer rapid tranquillisation should have received

training in the use of pulse oximeters (see Appendix B: Training Needs Analysis). This will be updated annually, be provided by the Trust and include: -

The basic principles of pulse Oximetry

Physiological risk factors in relation to physical intervention rapid tranquillisation

Changes that can occur in an individual during control and restraint/rapid tranquillisation

http://nww1.ntw.nhs.uk/services/index.php?id=3796&p=2780

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Reasons for monitoring service users when control and restraint/rapid tranquillisation is used

Potential difficulties in achieving accurate pulse oximetry readings

Responsibilities in using pulse Oximetry

Knowledge assessment

14.4 Rapid Tranquillisation 14.4.1 All staff involved in administering or prescribing rapid tranquillisation, or monitoring

service users to whom parenteral rapid tranquillisation has been administered, will receive rapid tranquillisation training every three years (see Appendix B: Training Needs Analysis). This will be provided by the Trust and will include: -

The properties of Benzodiazepines; their antagonist, Flumazenil; Antipsychotics; Antimuscarines and Antihistamines

The risks associated with rapid tranquillisation, including cardio-respiratory effects of the acute administration of these drugs, particularly when the service user if highly aroused and may have been misusing drugs; is dehydrated or possibly physically ill

The need to titrate doses to effect

Will include alternative approaches to rapid tranquillisation and the importance of staged interventions

14.5 All staff involved in monitoring service users to whom parenteral rapid tranquillisation has been administered will need to be familiar with interpreting the AVPU Scale modified in assessing the level of consciousness and seeking help as required

15 IMPLEMENTATION 15.1 An awareness of the policy, its content and implementation will be undertaken 6

months post implementation to establish the level of embedding of the policy and plan any remedial action needed.

16 MONITORING COMPLIANCE – See Appendix C 16.1 As part of Post-Incident Reviews there will be a Review of documentation (as detailed

in Appendix C) by Ward Manager, following each incident of rapid tranquillisation. Compliance with training requirements will be monitored via dashboards and by the provision of regular reports to workforce and development group

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17 FAIR BLAME 17.1 The Trust is committed to developing an open learning culture. It has endorsed the

view that, wherever possible, disciplinary action will not be taken against staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be taken.

18 EQUALITY IMPACT ASSESSMENT 18.1 In conjunction with the Trust’s Equality and Diversity Officer this policy has undergone

an Equality and Diversity Impact Assessment which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner.

19 FRAUD, BRIBERY and CORRUPTION 19.1 In accordance with the Trust’s policy NTW (O) 23 – Fraud, Bribery and Corruption

Policy, all suspected cases of fraud and corruption should be reported immediately to the Trust’s Local Counter Fraud Specialist or to the Executive Director of Finance.

20 ASSOCIATED DOCUMENTS:

NTW(C)01 - Resuscitation Policy

NTW(C)03 – Leave, absent without leave and missing person policy

o LP-PGN-02 – Entry and Exit from wards practice guidance note

NTW(C)05 - Consent to Examination or Treatment Policy

NTW(C)10 - Seclusion Policy

NTW(C)16- Recognition, Prevention, MVA Policy

NTW(C)17 - Medicines Management Policy

NTW(C)19 - Observation Policy

NTW(C)34 - Mental Capacity Act 2005 Policy

o MCA-PGN-02 – Advance Decision to refuse treatment and advance statements

NTW(C)38 – Pharmacological Therapy Policy, PGN

o PPT-PGN-10 - Guidelines for the Use of High Dose Antipsychotics

NTW(O)01 - Development and Management of Procedural Documents

NTW(O)05 - Incident Policy (including management of serious incidents) and practice guidance notes

NTW(O)16 - Access to Legal Advice

NTW(O)21 – Security Management Policy, PGN

o SM-PGN-06 – Police Liaison PGN

o SM-PGN-06.1 – Missing Persons PGN

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NTW(HR)09 – Staff Appraisal Policy and Practice Guidance Notes

o SA-PGN-01 – Training/Development Needs Analysis Process and attendance management

o SA-PGN-02 - Appraisal and Annually Earned Pay Points for Bands 8c,d and 9

21 REFERENCES:

Mental Health Act 1983 Code of Practice

Mental Health Act 2007 Code of Practice 2015 - in relation to the use of rapid tranquillisation

Mental Capacity Act 2005 (MCA 2005)

Mental Capacity Act 2005 – Code of Practice and Supplementary Code of Practice in relation to Deprivation of Liberty safeguards

Security Management Service (SMS) and the National Patient Safety Agency (NPSA): Seven Steps to Patient Safety: Step 4: Promote Reporting.

Immediate Life Support (ILS) – Resuscitation Council UK

Basic Life support (BLS) – Resuscitation Council UK)

NICE Clinical Guideline May 2015 NG10

Children Act 1989 and 2004

Human Rights Act 1998

United Nations Convention on the Rights of the Child. Current lists should be retained in the front of policy file.

Andrezina R et al Psychopharmacological 2006 188 (3) 282-292

Tran-Johnson TK et al Journal of Clinical Psychiatry 2007 68 111-119

Product Characteristics (SPC) http://www.medicines.org.uk/ - for all medications included in the policy. Accessed Sept 2015 and April 2016

Taylor D, Paton C, Kapur S. (2015). The Maudsley Prescribing Guidelines. 12th ed. London: Wiley-Blackwell.

Bazire S. (2014). Psychotropic Drug Directory 2014. London: Lloyd Reinhold Communications.

http://www.medicines.org.uk/

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Appendix A

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Directorate

Chris Rowlands V04 Oct 18

Policy to be analysed Is this policy new or existing?

Management of Rapid Tranquillisation-V04 Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

This policy covers the safe use of medication in treating service users in a psychiatric/learning disability inpatient setting and/or service users within a learning disability setting (residential and day care), this includes service users who exhibit disturbed or challenging behaviour and present a real risk of harm to themselves or others

Trust Policy NTW(C)05 Incident Policy (including management of serious incidents) which follows the principles of the guidance issues by the Security Management Service (SMS) and the National Patient Safety Agency (NPSA): Seven Steps to Patient Safety: Step 4: Promote Reporting. Consent, Advanced Decisions.

Who will be affected? e.g. staff, service users, carers, wider public etc

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability Consent issues

Sex

Race

Age Older People - Consent issues

Children and Young People - Use the Trust protocol with reference to age and weight of the child/ young person.

Gender reassignment

(including transgender)

N/A

Sexual orientation.

Religion or belief

Marriage and Civil Partnership

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Pregnancy and maternity

Carers

Other identified groups

How have you engaged stakeholders in gathering evidence or testing the evidence available?

Through standard policy process procedures

How have you engaged stakeholders in testing the policy or programme proposals?

Through standard policy process procedures

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

Appropriate review by author/team

Summary of Analysis Considering the evidence and engagement activity you listed above, please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

This policy does not unlawfully discriminate against equality target groups

Advance equality of opportunity N/A

Promote good relations between groups N/A

What is the overall impact?

Addressing the impact on equalities

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010?

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Date: November 2015

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Appendix B

Communication and Training Check list for policies

Key Questions for the committees’ accountable designing, reviewing or agreeing a new Trust policy

Is this a new policy with new training requirements or a change to an existing policy?

This is an amendment to the previous policy.

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

No

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHSLA etc.

Please identify the risks if training does not occur.

NICE guidelines, CQC, Royal College of Psychiatrists

It could have a detrimental impact of patient safety and care.

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

All clinicians within an in-patient setting require awareness and training.

Is there a staff group that should be prioritised for this training / awareness?

Nursing and medical staff.

Please outline how the training will be delivered. Include who will deliver it and by what method.

Management cascade E Learning Team brief Local Induction Training Awareness sessions for those affected by the new policy Medicines Management Committee Newsletter

Shared learning – NICE website NICE -usingguidance/sharedlearningimplemention

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus,

Administration needs etc.

Prathibha Rao Ruth Ayre

http://www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/examplesofimplementation/eximpresults.jsp?o=184

http://www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/examplesofimplementation/eximpresults.jsp?o=184

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Appendix C Audit and Monitoring Tool

Statement

The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, policy authors are required to include how monitoring of this policy is linked to auditable standards/key performance indicators will be undertaken using this framework.

NTW(C)02 – Rapid Tranquillisation Policy - Monitoring Framework

Auditable Standard/Key Performance Indicators

Frequency/Method/Person Responsible

Where Results and Any Associate Action Plan Will Be Reported To, Implemented and Monitored; (this will usually be via the relevant Governance Group).

1 Staff in in-patient settings receive training in Rapid Tranquillisation and Pulse Oximetry in line with training standards (Appendix 1&2)

Line manager to ensure training is updated 3 yearly (rapid tranquillisation) and annually for pulse oximetry. Monitored via dashboard. and performance report

Monitored monthly at individual Group Q+P via performance report

2 Arrangements for post rapid tranquillisation monitoring are clearly documented on patients records

This will also be captured within the seclusion audit.

Additional audits as decided by the groups plus national POMH audits

Seclusion and additional audits are reviewed by the Group Q+P and safe subgroup

3 For parenteral (I/M) Rapid Tranquillisation only – all seven key elements of monitoring have been conducted – BP, Pulse, Respiratory rate,temperature hydration, O2 Saturation and level of consciousness

Seclusion audit reported to Groups (frequency of reporting to be determined by GBM and the Groups).

Additional audits as decided by the groups plus national POMH audits

Seclusion audits are reviewed by the Group Q+P and GBM

Additional audits reviewed by Q&P safe subgroup

4 NTW Prescribing standards are followed on prescription cards

Review of documentation by clinical staff (nurses, medical and pharmacy).

6 monthly full prescribing standards audit completed on every ward.

Findings to be to be resolved by clinical team. Repeated issues to be raised through the appropriate management.

Prescribing standards audit reported to Group Q+P 6 monthly

The Author(s) of each policy is required to complete this monitoring template and ensure that these results are taken to the appropriate Quality and Performance Governance Group in line with the frequency set out.