rapid tranquilisation policy for adult patients within ... · 2 policy title: rapid tranquilisation...
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Policy Title: Rapid Tranquilisation Policy for adult patients within
East Cheshire NHS Trust
Executive Summary: Agitated and aggressive behaviour from patients is common. Such behaviours increase the risk of harm to the patient themselves, other patients, and hospital staff. The clinical practice of restraint and, or rapid tranquilisation is used when psychological and behavioural approaches have failed to deescalate acutely disturbed behaviour. It is essentially a management strategy of last resort.
Supersedes: New Policy
Description of Amendment(s):
N/A
This policy will impact on: All Trust Staff
Financial Implications: None
Policy Area: Document Reference:
Version Number: 1.0 Effective Date: 1st August 2016
Issued By: Review Date: 31s July 2019
Authors: Lead Pharmacist – Urgent Care
Impact Assessment Date:
August 2016
APPROVAL RECORD
Committees / Group Date
Consultation: Medicines Management Group ED Consultants Adult safeguarding Lead
February 2016
Approved by: Medicines Management Group
July 2016
ECT002555
Pharmacy
Pharmacy
3
CONTENTS Page
1.0 Introduction 4
2.0 Managing violence and aggression in emergency departments 4
2.1 Route of administration 4
2.2 Non-drug de-escalation approaches 4
2.3 Physical intervention 4
2.4 Overarching recommendations 5
3.0 Choice of Medication 5
3.1 Rapid Tranquilisation for 18-65 years 8
3.2 Rapid Tranquilisation for over 65 years 9
3.3 Rapid Tranquilisation for 18-65 years when Lorazepam IM Unavailable 10
3.4 Rapid Tranquilisation for over 65 years when Lorazepam IM Unavailable 11
4.0 Monitoring 12
5.0 Assessment 12
6.0 Remedial measures in Rapid Tranquilisation 12
4
1.0 Introduction
Agitated and aggressive behaviour from patients is common. Such behaviours increase the
risk of harm to the patient themselves, other patients, and hospital staff. The clinical practice
of restraint and, or rapid tranquilisation is used when psychological and behavioural
approaches have failed to deescalate acutely disturbed behaviour. It is essentially a
management strategy of last resort.
The policy applies to:
• Inpatients only receiving care and treatment at East Cheshire NHS Trust
• Patients in the A and E department
Other policies to consider:
• ITU tranquilisation policy
• Restraint policy
2.0 Managing violence and aggression in emergency departments
If a patient with a mental health problem becomes aggressive or violent, do not exclude them
from the emergency department. Manage the violence or aggression in line with
recommendations within this policy and do not use seclusion. Regard the situation as a
psychiatric emergency and refer the patient to mental health services urgently for a
psychiatric assessment within 1 hour.
2.1 Route of administration
If possible an oral formulation should always be offered as first line therapy. If oral therapy is
refused or inappropriate medication should be administrated by intramuscular injection (IM)
with appropriate supervision and monitoring, as clarified by the recommendations in this
policy. It may be appropriate to use multiple medications by multiple routes of administration.
2.2 Non-drug de-escalation approaches
• Maintain adequate distance
• Ensure environment is conductive to calmness (e.g. low stimulation levels, noise,
other patients)
• Move to a safe place or seclude
• Explain intentions and be calm and self-assured
• Use non-threatening, non-verbal communication
• Converse and try to develop a therapeutic relationship throughout
2.3 Physical intervention
Where techniques have failed to calm a patient, it may be necessary as a last resort and in the
best interests of the patient to make use of additional interventions, such as physical
intervention, rapid tranquilisation and seclusion to manage the safety of the patient and those
around them. All such interventions should only be considered once all non-physical
interventions have been tried and have not succeeded in calming the patient. The choice of
intervention(s) will depend on a number of factors, but should be guided primarily by:
• Patient preference (if known) i.e. advance directives or lasting power of attorney;
• Management care plans or agreed pathways;
• Duty of care to other patients affected by the disturbed / violent behaviour;
• The protection of staff, patients and visitors;
• The facilities available within the particular setting.
5
2.4 Overarching recommendations
Rapid tranquilisation, physical intervention and seclusion should only be considered once de-
escalation and other strategies have failed to calm the patient. These interventions are
emergency management strategies and are not regarded as primary treatment techniques.
When determining which interventions to employ, clinical need, safety of patients and others,
and, where possible, advance statements should be taken into account. The intervention
selected must be a reasonable and proportionate response to the risk posed by the patient.
3.0 Choice of Medication
Rapid tranquillisation is defined in this guideline as the administration of sedative medication,
although a number of effective agents are available for sedation, there is no evidence showing
clear superiority for any one agent. Therefore individualised treatment needs to be
emphasised, taking into account the patient's view, pre-existing physical health problems,
previous response to medications including adverse effects, the potential for interactions with
other medications, and the total daily dose of medications prescribed and administered.
Intramuscular lorazepam is recommended for patients who have not taken antipsychotic
medication before because it is an effective intervention that is likely to be acceptable to the
majority of patients. Prescribing the initial dose of rapid tranquillisation as a single dose will
ensure that any subsequent treatment options can be individualised, taking account of both
response and any emergent adverse effects of the initial treatment choice. When considering
rapid tranquilisation therapy medication should not routinely or automatically on admission,
there should be clarity about the rationale and circumstances in which medication should be
given. The maximum daily dos, appropriate interval and maximum daily dose should be
included on the prescription and different routes of administration of the same medication
should be prescribed separately.
Intramuscular olanzapine has been withdrawn from the UK market but it remains a licensed
product in the European Union (EU) and can therefore be imported from other countries.
Care must be taken when giving IM injections to patients who are highly aroused or
distressed and pose serious concerns to the safety of others or themselves. The provision of
adequate staff trained in approved care and responsibility techniques should always be on
standby even when patients agree to IM treatment, as there are the inadvertent risks of intra-
arterial injection, bolus dosing, nerve damage, bruising, needle breakage in patients who may
struggle or are resistive, and also a higher than expected absorption rate due to the increased
blood flow to the muscles in a highly aroused individual.
All staff should be aware of the “DO NOTS” involved in rapid tranquilisation:
• DO NOT mix medications in the same syringe;
• DO NOT use two or more antipsychotics at the same time;
• DO NOT use IM diazepam, which is erratically absorbed;
• DO NOT use IM chlorpromazine, which crystallises in the tissues and causes a
precipitous drop in blood pressure, especially in older patients;
• DO NOT administer IM olanzapine and IM benzodiazepines at the same time, leaving a
one hour gap after administering IM olanzapine;
6
Table 1: Medicines used in rapid tranquilisation – their properties, cautions and advice notes
Medicine Route Pharmacokinetics Major Side
Effects
Notes
Lorazepam Oral or
IM
Onset 10 to 30 mins
Peak 60 to 90 mins
Half-life 12 to 16
hrs
- Respiratory
Depression
- Disinhibition
- IM absorption is as slow as oral absorption, but is rapid
in an active patient.
- The injection should be diluted 50:50 with water for
injections preinjection.
- There is no accumulation of lorazepam with repeated
doses or in impaired liver function- this makes it
advantageous over diazepam.
- A wide therapeutic index & respiratory depression is
readily reversed with the specific antagonist flumazenil.
- Disinhibition is more likely to occur in those with
organic brain disease, including learning disabilities, the
under 18s & the over 65s, & perhaps those with impulse
control problems.
- Simultaneous injection of parenteral benzodiazepines
and IM olanzapine is not recommended due to the
potential for excessive sedation, cardiorespiratory
depression and in very rare cases, death.
Haloperidol Oral Onset 1 to 2 hrs
Peak 4 hrs
Half-life 1 to 36 hrs
- EPSE
- Hypotension
- NMS
- Increased
QTc
or arrhythmias
- Seizures
- Sudden death
- The bioavailability of both formulations is different and
this must be
taken into account when considering the total dose per
24 hr period.
See table 2 for advice on this.
- Note risk of acute dystonias and ensure that an
appropriate antimuscarinic is available.
IM Onset 20 mins
Peak 1 hrs
Half-life 21 hrs
Olanzapine Oral Onset 5 to 8 hrs
Peak 5 to 8 hrs
Half-life 32 to 50
hrs
- Hypotension
- Bradycardia
- Syncope
- IM Olanzapine is only available as an unlicensed
formulation
- Less likely to cause EPSE than haloperidol.
- IM administration results in initial maximum plasma
concentration 5 times higher than same dose given
orally.
- Parenteral benzodiazepines should not be administered
until at least 1 hour after IM olanzapine administration
IM Onset 15 to 45 mins
Peak 15 to 45 mins
Half-life 30 hrs
Promethazine IM Onset 20 mins
Peak 2 to 8 hrs
Half-life 7 to14 hrs
- Prolonged
sedation
- Seizures
-
Cardiorespirat
ory
depression
- It is an antihistamine that is derived from
phenothiazines.
- Phenothiazines can cause QT interval elongation
therefore a baseline ECG measurement would be
recommended as good practice prior to administration
- Use of IM promethazine for rapid tranquilisation is off-
label.
- It has a slow onset of action, but is an effective
sedative.
- Dilution is not required before IM injection.
- Smaller doses will be required in severe renal
impairment.
- Use with caution in hepatic impairment, respiratory
disease and congestive heart failure.
- As promethazine is NOT a benzodiazepine, flumazenil
is not an antidote to reverse its effects.
Midazolam IM Onset 15 mins
Peak 30 to 60 mins
Half-life
1.5to2.5hrs
- Respiratory
Depression
- Disinhibition
- Amnesia
- Use of midazolam IM for rapid tranquilisation is off-
label.
- Simultaneous injection of parenteral benzodiazepines
and IM olanzapine is not recommended due to the
potential for excessive sedation, cardiorespiratory
depression and in very rare cases, death. (Schedule 3
CD)
7
Table 2: Haloperidol administration – oral and intramuscular equivalent doses
As the parenteral and oral bioavailability differ, the maximum daily dose for both
routes are not the same
Maximum dose in 24 hours :
Haloperidol Oral 20mg
Haloperidol IM 12mg
Please use the conversion chart below, if a patient has received both haloperidol IM and oral
in the last 24 hours, to calculate how much the patient has received in total:
Approximate Equivalent Doses of Haloperidol (mg)
Oral 0.5 1 1.5 2.5 4.2 5 7.5 8.3 10 12.5 16.7
IM 0.3 0.6 0.9 1.5 2.5 3 4.5 5 6 7.5 10
For example:
Patient has been given 1 x 4mg haloperidol IM, followed 30 minutes later by 5mg orally, then
30 minutes later by another 5mg orally.
Convert to all oral doses, i.e. 6.6mg + 5mg + 5mg = 16.6mg oral equivalent or
Convert to all IM doses, i.e. 4mg + 3mg + 3mg = 10mg IM equivalent
Therefore the patient may receive a further 3mg oral equivalent or 2mg IM equivalent
haloperidol within the 24 hour period.
8
3.1 Rapid Tranquilisation for 18-65 years
This algorithm should be used in conjunction with the Rapid Tranquilisation Policy – it is not
a stand-alone Algorithm.
For known patients or patients under the influence of alcohol or illicit substances use lower
end of doses range. If known patients consider what has worked before.
Consider this route for
patients with:
Epilepsy/seizure
disorder
Older people –
organic disorder
TIA/CVA/CVD
Pregnancy
Narrow angle
glaucoma
Non-urgent tranquilisation
Offer oral therapy
Lorazepam 2-4mg
(with or without Haloperidol 5mg)
OR Olanzapine 10mg
Lorazepam IM 1 to 4mg
(dilute 50:50 with water for
injection)
AND/OR
Haloperidol IM 5mg
Wait 1 hour
If successful continue or
initiate oral therapy
If unsuccessful, refuses oral therapy or urgent
rapid tranquilisation
Consider this route for
patients with:
Previous dystonic reaction
to antipsychotics
1st episode/ neuroleptic
naïve
Bipolar Affective
Disorder – sensitive to
extrapyramidal side
effects
Not suitable for patients
with:
Liver impairment
CVD/TIA/CVA/ pervious
stroke
Lorazepam IM 1 to 4mg
(dilute 50:50 with water for
injection)
OR
Olanzapine IM 10mg
*For 60+ patients use over
65 chart
Consider Mental Health Act status before
and during use of Rapid Tranquilisation
Regular medicines continue throughout, where
possible and appropriate to do so.
Maximum doses (BNF limits)
Max of 4mg Lorazepam PO/IM in
24 hours
If on regular haloperidol max 20mg
PO/ 12mg IM in 24 hours
If on regular Olanzapine max dose
of 20mg / 24 hours ( in max 3
injections)
Repeat up to the BNF limits
Dose based on initial
response Lorazepam IM
(max 4mg/24hrs)
AND/OR
Haloperidol IM (Max 12mg/
24hrs) Wait at least 1 hour
Alternate Olanzapine &
Lorazepam
Maximum doses in 24 hours
Lorazepam up to 4mg (do not
repeat within 1 hour of
previous Olanzapine IM)
Olanzapine up to 20mg in
max 3 injections (do not
repeat within 2 hours of
previous Olanzapine IM)
Have available
Procyclidine PO/IM for acute dystonic
reactions – 5mg three times a day
Flumazanil IV for benzodiazepine induced
respiratory depression
Do not mix any drugs in the same syringe
9
3.2 Rapid Tranquilisation for over 65 years
This algorithm should be used in conjunction with the Rapid Tranquilisation Policy – it is not
a stand-alone Algorithm.
For known patients or patients under the influence of alcohol or illicit substances use lower
end of doses range. If known patients consider what has worked before.
Avoid use of antipsychotics if patient has a dementing illness
DONOT USE ANTIPSYCHOTIC FOR PATIENTS WHO MAY HAVE LEWY BODY
DEMENTIA OR PARKINSONS DISEASE
Consider this route for
patients with:
Epilepsy/seizure disorder
organic disorder
TIA/CVA/CVD
Narrow angle glaucoma
Non-urgent tranquilisation
Offer oral therapy
Lorazepam 500micrograms to 2mg
Lorazepam IM
500micrograms to 2mg
(dilute 50:50 with water for
injection)
AND/OR
Haloperidol IM 2.5mg
Wait 1 hour
If successful continue or
initiate oral therapy
If unsuccessful, refuses oral therapy or urgent
rapid tranquilisation
Consider this route for
patients with:
Previous dystonic reaction
to antipsychotics
1st episode/ neuroleptic
naïve
Bipolar Affective
Disorder – sensitive to
extrapyramidal side
effects
Not suitable for patients
with:
Liver impairment
CVD/TIA/CVA/ pervious
stroke
Lorazepam IM
500micrograms to 2mg
(dilute 50:50 with water for
injection)
OR
Olanzapine IM 2.5-5mg
Lorazepam IM 500micrograms to 2mg
(Dilute 50:50 with water for injection)
Regular medicines continue throughout, where
possible and appropriate to do so.
Maximum doses (BNF limits)
Max of 2mg Lorazepam PO/IM in
24 hours
If on regular haloperidol max 20mg
PO/ 12mg IM in 24 hours
If on regular Olanzapine max dose
of 20mg / 24 hours ( in max 3
injections)
Repeat up to the BNF limits
Dose based on initial
response Lorazepam IM
(max 2mg/24hrs)
AND/OR
Haloperidol IM (Max 12mg/
24hrs)
Wait at least 1 hour
Alternate Olanzapine &
Lorazepam
Maximum doses in 24 hours
Lorazepam up to 2mg (do not
repeat within 1 hour of
previous Olanzapine IM)
Olanzapine up to 15mg in
max 3 injections (do not
repeat within 2 hours of
previous Olanzapine IM)
Have available
Procyclidine PO/IM for acute dystonic
reactions – 5mg three times a day
Flumazanil IV for benzodiazepine induced
respiratory depression
Do not mix any drugs in the same syringe
If unsuccessful but accepting
oral therapy offer
Haloperidol 500micrograms
to 1.5mg OR Olanzapine
2.5mg
Consider Mental Health Act status before
and during use of Rapid Tranquilisation
10
3.3 Rapid Tranquilisation for 18-65 years when Lorazepam IM Unavailable
This algorithm should be used in conjunction with the Rapid Tranquilisation Policy – it is not
a stand-alone Algorithm.
For known patients or patients under the influence of alcohol or illicit substances use lower
end of doses range. If known patients consider what has worked before.
Consider this route for
patients with:
Epilepsy/seizure
disorder
Older people –
organic disorder
TIA/CVA/CVD
Pregnancy
Narrow angle
glaucoma
Non-urgent tranquilisation
Offer oral therapy
Lorazepam 2-4mg
(with or without Haloperidol 5mg)
OR Olanzapine 10mg
Promethazine IM 25 to 50mg
(if Promethazine IM is
unsuitable consider
Midazolam IM 5 to 7.5mg)
AND/OR
Haloperidol IM 5mg
Wait 1 hour
If successful continue or
initiate oral therapy
If unsuccessful, refuses oral therapy or urgent
rapid tranquilisation
Consider this route for
patients with:
Previous dystonic reaction
to antipsychotics
1st episode/ neuroleptic
naïve
Bipolar Affective
Disorder – sensitive to
extrapyramidal side
effects
Not suitable for patients
with:
Liver impairment
CVD/TIA/CVA/ pervious
stroke
Promethazine IM 25 to
50mg (if Promethazine IM
is unsuitable consider
Midazolam IM 5 to 7.5mg)
OR
Olanzapine IM 10mg
*For 60+ patients use over
65 chart
Consider Mental Health Act status before
and during use of Rapid Tranquilisation
Regular medicines continue throughout, where
possible and appropriate to do so.
Maximum doses (BNF limits)
Max of 4mg Lorazepam PO/IM in
24 hours
Max of 100mg Promethazine IM in
24 hours
(Midazolam IM max 15mg in 24
hours)
If on regular haloperidol max 20mg
PO/ 12mg IM in 24 hours
If on regular Olanzapine max dose
of 20mg / 24 hours PO/IM
combined ( in max 3 injections)
Repeat up to the BNF limits
Dose based on initial
response Promethazine IM
(max 100mg/24hrs)
(Midazolam IM max
15mg/day)
AND/OR
Haloperidol IM (Max 12mg/
24hrs)
Wait at least 1 hour
Repeat up to BNF limits
Maximum doses in 24 hours
Promethazine 100mg
(Midazolam 15mg, do not
repeat within 1 hour of
previous Olanzapine IM)
Olanzapine up to 20mg in
max 3 injections (do not
repeat within 2 hours of
previous Olanzapine IM
Have available
Procyclidine PO/IM for acute dystonic
reactions – 5mg three times a day
Flumazanil IV for benzodiazepine induced
respiratory depression
Do not mix any drugs in the same syringe
11
3.4 Rapid Tranquilisation for over 65 years when Lorazepam IM Unavailable
This algorithm should be used in conjunction with the Rapid Tranquilisation Policy – it is not
a stand-alone Algorithm.
For known patients or patients under the influence of alcohol or illicit substances use lower
end of doses range. If known patients consider what has worked before.
Avoid using antipsychotics if patient has a dementing illness
DO NOT USE ANTIPSYCHOTICS FOR PATIENTS WHO MAY HAVE LEWY BODY
DEMENTIA OR PARKINSONS DISEASE
Consider this route for
patients with:
Epilepsy/seizure
disorder
Older people –
organic disorder
TIA/CVA/CVD
Narrow angle
glaucoma
Non-urgent tranquilisation
Offer oral therapy
Lorazepam 500micrograms - 2mg
Promethazine IM 12.5 to
25mg (if Promethazine IM is
unsuitable consider
Midazolam IM 2.5 to 5mg)
AND/OR
Haloperidol IM 2.5mg
Wait 1 hour
If successful continue or
initiate oral therapy
If unsuccessful, refuses oral therapy or urgent
rapid tranquilisation
Consider this route for
patients with:
Previous dystonic reaction
to antipsychotics
1st episode/ neuroleptic
naïve
Bipolar Affective
Disorder – sensitive to
extrapyramidal side
effects
Not suitable for patients
with:
Liver impairment
CVD/TIA/CVA/ pervious
stroke
Promethazine IM 12.5 to
25mg (if Promethazine IM
is unsuitable consider
Midazolam IM 2.5 to 5mg)
OR
Olanzapine IM 2.5-5mg
Regular medicines continue throughout, where
possible and appropriate to do so.
Maximum doses (BNF limits)
Max of 2mg Lorazepam PO/IM in
24 hours
Max of 50mg Promethazine IM in
24 hours
(Midazolam IM max 7.5mg in 24
hours)
If on regular haloperidol max 20mg
PO/ 12mg IM in 24 hours
If on regular Olanzapine max dose
of 15mg / 24 hours PO/IM
combined ( in max 3 injections)
Repeat up to the BNF limits
Dose based on initial
response Promethazine IM
(max 50mg/24hrs)
(Midazolam IM max
7.5mg/day)
AND/OR
Haloperidol IM (Max 12mg/
24hrs)
Wait at least 1 hour
Repeat up to BNF limits
Maximum doses in 24 hours
Promethazine 50mg
(Midazolam 7.5mg, do not
repeat within 1 hour of
previous Olanzapine IM)
Olanzapine up to 15mg in
max 3 injections (do not
repeat within 2 hours of
previous Olanzapine IM)
Have available
Procyclidine PO/IM for acute dystonic
reactions – 5mg three times a day
Flumazanil IV for benzodiazepine induced
respiratory depression
Do not mix any drugs in the same syringe
Consider Mental Health Act status before
and during use of Rapid Tranquilisation
12
4.0 Monitoring
A number of adverse effects are associated with the medicines used in RT including,
extrapyramidal side effects (EPSE), respiratory depression, seizures, over-sedation or loss of
consciousness, hypotension and neuroleptic malignant syndrome. Of particular concern, is the
possibility of sudden cardiac death and arrhythmias. After RT is administered, nursing staff
should monitor physical observations on the VitalPAC system. Prescribers should be aware of
actions to be taken if a patient’s physical condition deteriorates as a result of RT (see remedial
measures in Rapid Tranquilisation). If a patient is unconscious then close observation of
physical well-being with 1:1 nursing is recommended.
5.0 Assessment
If rapid tranquilisation is used then an Airway, Breathing, Circulation, Disability, (ABCD)
approach to assess and treat the patient should be used. If possible the patient should be
reviewed by a senior doctor such as at year 2 senior house officer, registrar or consultant to
assess the patient for monitoring, administration of reversal agents and need for critical care.
A senior review should also be sought if the intervention does not work and a second
intervention is required. As soon as possible a capacity assessment/DoLS (linking into the
Mental Capacity Policy) or a mental health assessment may be required as well as a best
interests meeting if enforced medication will continue to be required.
6.0 Remedial measures in Rapid Tranquilisation
Problem Remedial Measure
Acute Dystonia (including
oculogyric crisis)
Give intramuscular (IM) procyclidine 5-10mg
Reduced Oxygen saturation (less than 90%) or respiratory
rate (less than 10 breaths/
minute)
Give oxygen; raise legs, ensure patient is not lying face down
Give 200micrograms intravenously over 30 seconds of flumazenil
if benzodiazepine-induced respiratory depression suspected. A
further dose of 300 micrograms can be given if no response after 30
seconds. Consult BNF for further management
Irregular or slow (50bpm)
pulse or drop in blood pressure
(more than 30mmHg diastolic)
Lie patient flat, tilt bed towards head or raise legs on pillows.
Monitor blood pressure closely
Policy written using the following resources:
Cheshire and Wirral Partnership NHS Foundation Trust. Rapid Tranquilisation (RT) Policy.
Issue Number 8 September 2014. Available at http://www.cwp.nhs.uk/
Oxford University Hospitals NHS Foundation Trust. Management of Acutely Disturbed
Behaviour for adults (including Rapid Tranquilisation). Volume 9, Number 6. September
2015
National Institute for Health and Clinical Excellence (NICE) (2015) Violence and aggression:
short-term management in mental health, health and community settings. [Online]. Available
at: https://www.nice.org.uk/guidance/ng10. [Accessed: 15 January 2016].
13
Equality Analysis (Impact assessment)
1. What is being assessed?
Rapid Tranquilisation Policy for Adult Patients within East Cheshire NHS Trust
Details of person responsible for completing the assessment:
Name: Kashif Haque
Position: Chief Pharmacist
Team/service: Pharmacy
State main purpose or aim of the policy, procedure, proposal, strategy or service:
(usually the first paragraph of what you are writing. Also include details of legislation,
guidance, regulations etc which have shaped or informed the document)
Agitated and aggressive behaviour from patients is common. Such behaviours increase the risk of harm to
the patient themselves, other patients, and hospital staff. The clinical practice of restraint and, or rapid
tranquilisation is used when psychological and behavioural approaches have failed to deescalate acutely
disturbed behaviour. It is essentially a management strategy of last resort.
2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who
use the service and the staff that provide it
2.1 Give details of RELEVANT information available that gives you an understanding
of who will be affected by this document
Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West &
Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people
resided in CE and 329,608 people resided in CWAC.
Age: East Cheshire and South Cheshire CCG’s serve a predominantly older population than the
national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700
people).
Vale Royal CCGs registered population in general has a younger age profile compared to the
CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people).
Since the 2001 census the number of over 65s has increased by 26% compared with 20%
nationally. The number of over 85s has increased by 35% compared with 24% nationally.
Race:
In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British
5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK – Poland
and India being the most common
3% of CE households have members for whom English is not the main language (11,103
people) and 1.2% of CWAC households have no people for whom English is their main
language.
Gypsies & travellers – estimated 18,600 in England in 2011.
Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51%
female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be
transgender and for CWAC 1,500 transgender people will be living in the CWAC area.
14
Disability:
In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health
problem or disability
In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with
dementia in CWAC. 1 in 20 people over 65 has a form of dementia
Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or
deafness.
C. 2 million people in the UK have visual impairment, of these around 365,000 are
registered as blind or partially sighted.
In CE, it is estimated that around 7000 people have learning disabilities and 6500 people
in CWAC.
Mental health – 1 in 4 will have mental health problems at some time in their lives.
Sexual Orientation:
CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE
was estimated at18,700, based on assumptions that 5-7% of the population are likely
to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The
Lesbian & Gay Foundation).
CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there
were c. 20,000 LGB people in the area and as many as 1,500 transgender people
residing in CWAC.
Religion/Belief:
The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001
to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying
they had no religion doubled in both areas from around 11%-22%.
Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester
Sikh: 0.07% of Cheshire East and 0.1% of Cheshire West & Chester
Buddhist: 0.24% of Cheshire East and 0.2% of Cheshire West & Chester
Hindu: 0.36% of Cheshire East and 0.2% of Cheshire West & Chester
Jewish: 0.16% of Cheshire East and 0.1% of Cheshire West & Chester
Muslim: 0.66% of Cheshire East and 0.5% of Cheshire West & Chester
Other: 0.29% of Cheshire East and 0.3% of Cheshire West & Chester
None: 22.69%of Cheshire East and 22.0% of Cheshire West & Chester
Not stated: 6.66% of Cheshire East and 6.5% of Cheshire West & Chester
Carers: In 2011, nearly 11% (40,000) of the population in CE are unpaid carers and just
over 11% (37,000) of the population in CWAC.
2.2 Evidence of complaints on grounds of discrimination: (Are there any complaints or
concerns raised either from patients or staff (grievance) relating to the policy, procedure,
proposal, strategy or service or its effects on different groups?)
No
2.3 Does the information gathered from 2.1 – 2.3 indicate any negative impact as a
result of this document?
No
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3. Assessment of Impact
Now that you have looked at the purpose, etc. of the policy, procedure, proposal, strategy
or service (part 1) and looked at the data and research you have (part 2), this section asks you
to assess the impact of the policy, procedure, proposal, strategy or service on each of the
strands listed below.
RACE:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, racial groups differently? Yes
Explain your response: If there is a patient whose first language is not English, then staff
need to be aware of how to access interpretation facilities.
___________________________________________________________________________
_________
GENDER (INCLUDING TRANSGENDER):
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, different gender groups differently? No
Explain your response: If the patient takes medication as part of the transgender process,
staff would check with pharmacy for any interaction.
DISABILITY
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, disabled people differently? Yes
Explain your response: When providing information, the Trust is required to provide it in a
format that is relevant to the applicant’s and this that could mean in audio/braille for the
visually impaired for example.
___________________________________________________________________________
_________
AGE:
From the evidence available does the policy, procedure, proposal, strategy or service,
affect, or have the potential to affect, age groups differently? Yes
Explain your response: Policy applies equally regardless of age, however, staff need to be
mindful that older people can be more vulnerable and therefore more at risk.
LESBIAN, GAY, BISEXUAL:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, lesbian, gay or bisexual groups differently? No
Explain your response: Policy applies equally regardless of sexuality
___________________________________________________________________________
_________
RELIGION/BELIEF:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, religious belief groups differently? No
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Explain your response: If the patient is unable to consume vertain substances due to their
religion/belief, staff would check with pharmacy for any interaction.
___________________________________________________________________________
__________
CARERS:
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect, carers differently? No
Explain your response: Carers would be kept informed as appropriate.
___________________________________________________________________________
__________
OTHER: EG Pregnant women, people in civil partnerships, human rights issues.
From the evidence available does the policy, procedure, proposal, strategy or service
affect, or have the potential to affect any other groups differently? Yes
Explain your response: The choice of drug used may be affected if the patient is either
pregnant or breast feeding. Specialist advice from the medivines information centre should be
sought.
-
___________________________________________________________________________
__________
4. Safeguarding Assessment - CHILDREN a. Is there a direct or indirect impact upon children No
b. If yes please describe the nature and level of the impact (consideration to be given to all
children; children in a specific group or area, or individual children. As well as consideration of
impact now or in the future; competing / conflicting impact between different groups of children
and young people:
c. If no please describe why there is considered to be no impact / significant impact on children
Policy applies to adults only
5. Relevant consultation Having identified key groups, how have you consulted with them to find out their views and
that the made sure that the policy, procedure, proposal, strategy or service will affect them
in the way that you intend? Have you spoken to staff groups, charities, national organisations
etc?
Staff groups and national data and recommendations for safeguarding taken into account.
6. Date completed: 05.09.2016 Review Date: Sept 2018
7. Any actions identified: Have you identified any work which you will need to do
in the future to ensure that the document has no adverse impact?
Action Lead Date to be Achieved
8. Approval – At this point, you should forward the template to the Trust Equality
and Diversity Lead [email protected]
Approved by Trust Equality and Diversity Lead: Date: 7.9.16