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Short-Term Management of Violence and Aggression The Updated NICE Guidelines (NG10)

Rapid Tranquilisation (Medications) UpdatePeter PrattChief PharmacistSheffield Health & Social Care NHS FT TrustPeter.pratt@SHSC.NHS.UKDisclosure statementSole income from the NHS (Chief Pharmacist)No financial or benefits in kind received from Pharmaceutical industry, its agents or othersNo external influence over contentMember NICE GDG violence ( 2nd class travel expenses to London & one overnight accommodation)

GuidelinesUse of Guidelines by pirates

What are guidelines?Woman Wait you have to take me back to shore The order of the pirates clearly state that PirateFirst.. your return to shore was not part of our negotiations nor our agreement so I MUST do nothingSecondly you must be a pirate for the code to appy..and you are notThirdly.. The code is more of what you would call GUIDELINES than actual rules

NICE guidelinesEvidence-based recommendations for health and care in England.Generally applies toNHS, local authorities & local and national organisations in the private and voluntary sectors.Are suitable for most people with a specific condition or needgroups of peoplepeople in particular circumstances or settings.

Using NICE guidance in the NHSWe [NICE] expect you to take our guidance into account. But you should always base [you] decisions on the person/population you are responsible for.

NICE Medicine recommendationsYou should use a medicine's summary of product characteristics when making decisions with patients.IF medicine doesnt have a UK licence for a particular condition NICE may still recommend it. We NICE only do this when there is good evidence for it.& we mark it with a footnote.You should follow relevant professional guidance and take full responsibility for the decision.The patient - or those with authority to give consent on their behalf - should also give informed consent Make sure you document this.

Using NICE Guidelines Consider: Other Relevant professional guidelines, standards and lawsPerson-centred careSafeguarding children and vulnerable adultsRecommendations are based on:the trade-off between the benefits and harms of an interventionthe quality of the underpinning evidence.Some recommendations are made with more certainty than others. We [NICE] word our recommendations to reflect this. (see NICE guidelines manual) https://www.nice.org.uk/article/PMG20/chapter/9-Developing-and-wording-recommendations-and-writing-the-guidelineCase studies to help with implementation see https://www.nice.org.uk/localPractice/collectionST Andrews Healthcare Overcoming barriers to implementing Updated NICE guidance https://www.nice.org.uk/sharedlearning/addressing-the-barriers-to-the-implementation-of-the-nice-violence-guidelines-in-a-mental-health-organisation

What is good about NICE GuidelinesTransparency

Clarity

Process

EvidenceHigh quality evidence reflects high quality guidelines

Strength of evidence shown by GRADE (Grading of Recommendations Assessment, Development and Evaluation)see ttp://www.gradeworkinggroup.org/intro.htmStandardised way of assessing strength of evidence - high, moderate, low or very low. High strength evidence = strong reccomendations

Wording of NICE guidelinesShould Focus on the actionRecommendations should:Begin with what needs to be done. Be as specific as possible about the exact intervention being recommendedShould use direct instructions wherever possible because they are clearer and easier to follow. NICE Guidelines In practiceGeneral principle for all recommendationspeople using services and the wider public should be informed of their options and be involved in decisions about their care. Reflect the certainty about strength of the recommendationinterventions that should (or should not) be usedinterventions that could be usedinterventions that must (or must not) be used.

Should , could or must (must not)Reflect certainty of balance of benefit harminterventions that should (or should not) be used directive language is used e.g 'offer' (or 'do not offer'), 'advise', 'ask about' or 'commission'.Recommendations with less clear balance between benefits and harmsUse 'consider'.'Consider' indicates that the recommendation is made with less certainty.Consider' should only be used to indicate the strength of a recommendation.Other wording rather than 'consider' should be used for 'be aware of', 'explore' or similar. 'Assess' and 'think about' are other possible alternatives to 'consider'. 'Consider offering' should be avoided because of potential confusionAlso, it might be misinterpreted to mean that a health or social care practitioner may consider offering an intervention without discussing it with the patient or person using services.the recommendation should use 'must' or 'must not' if there isa legal duty to apply a recommendationthe consequences of not following a recommendation are extremely serious

What does NG10 say about medicinesClarity about what is rapid tranquillisation ..in the guideline NICE Violence (NG10)..medicinesClarity about what is meant by rapid tranquillisation ..in the guidelineUse of medication by the parenteral route (usually intramuscular or, exceptionally, intravenous) if oral medication is not possible or appropriate and urgent sedation with medication is needed.about what is meant buy PRN ..in the guideline Use of medication as part of a strategy to deescalate or prevent situations that may lead to violence or aggression - it does not refer to p.r.n. medication used on its own for rapid tranquillisation during an episode of violence of aggression

The risk-benefits and strength of evidence aroundChoice of drugs for rapid tranquillisationMonitoring and review post rapid tranquillisationMedication CG 25 vs NG10No longer supported Choice of medication driven by Psychotic/non psychotic contextSuperiority of haloperidol/lorazepam combinationNot supported PRN prescribing of RT in advance for new/unknown patientsWhat the NICE NG10 guidelines say about medicationSee http://www.nice.org.uk/guidance/NG10/chapter/1-recommendationsEncourage the making of advance statements as soon as possible (eg during admission to an inpatient psychiatric unit). Ensure that service users understand the main sideeffect profiles of the medications recommended in this guideline for rapid tranquillisation ..so that they can make an informed choice.

What the NICE NG10 guidelines say about medication..contDevelop an individualised pharmacological strategy to reduce the risk of violence and aggressionA multidisciplinary team should develop and document an individualised pharmacological strategy for using routine and p.r.n. medication to calm, relax, tranquillise or sedate service users who are at risk of violence and aggression as soon as possible after admission to an inpatient psychiatric unit. 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 and include:clarification of target symptomsthe likely timescale for response to medicationthe total daily dose of medication, prescribed and administered, including p.r.n. medicationThe number of and reason for any missed doses therapeutic response the emergence of unwanted effects.If rapid tranquillisation is being used, a senior doctor should review all medication at least once a day.

What the NICE NG10 guidelines say about medication..contWhen prescribing p.r.n. medication as part of a strategy to deescalate or prevent situations that may lead to violence and aggression:do not prescribe p.r.n. medication routinely or automatically on admissiontailor p.r.n. medication to individual need and include discussion with the service user if possibleensure 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 planensure that the maximum daily dose is specified and does not inadvertently exceed the maximum daily dose stated in the (BNF) when combined with the person's standard dose or their dose for rapid tranquillisationonly 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.The multidisciplinary team should review p.r.n. medication at least once a week and, if p.r.n. medication is to be continued, the rationale for its continuation should be included in the review. If p.r.n. medication has not been used since the last review, consider stopping it.

What the NICE NG10 guidelines say about Rapid Tranquilisation for adults Use either intramuscular lorazepam on its own or intramuscular haloperidol combined with intramuscular promethazine for rapid tranquillisation in adults. When deciding which medication to use, take into account:the service user's preferences or advance statements and decisionspreexisting physical health problems or pregnancypossible intoxicationprevious response to these medications, including adverse effectspotential for interactions with other medicationsthe total daily dose of medications prescribed and administered.

If there is insufficient information to guide the choice of medication for rapid tranquillisation, or the service user has not taken antipsychotic medication before, use intramuscular lorazepam.

If there is evidence of cardiovascular disease, including a prolonged QT interval, or no electrocardiogram has been carried out, avoid intramuscular haloperidol combined with intramuscular promethazine and use intramuscular lorazepam instead.

Rapid Tranquilisation in adults .. contIf there is a partial response to intramuscular lorazepam, consider a further dose.If there is no response to intramuscular lorazepam, consider intramuscular haloperidol combined with intramuscular promethazine.If there is a partial response to intramuscular haloperidol combined with intramuscular promethazine, consider a further dose.If there is no response to intramuscular haloperidol combined with intramuscular promethazine, consider intramuscular lorazepam if this hasn't been used already during this episode. If intramuscular lorazepam has already been used, arrange an urgent team meeting to carry out a review and seek a second opinion if needed.When prescribing medication for use in rapid tranquillisation, write the initial prescription as a single dose, and do not repeat it until the effect of the initial dose has been reviewed.

After Rapid tranquilisationMonitor at least every hour until there are no further concerns side effects, pulse, blood pressure, respiratory rate, temperature, level of hydration and level of consciousness Monitor every 15minutes if the BNF maximum dose has been exceeded or the service user:appears to be asleep or sedatedhas taken illicit drugs or alcoholhas a preexisting physical health problemhas experienced any harm as a result of any restrictive intervention

QuestionsWhy didnt NICE include UnameitapineNICE responses to consultation from stakeholdershttp://www.nice.org.uk/guidance/ng10/documentsIn my opinion xxxxxxxxxxxx and yyyyyyy works bestExpert opinion is importantChanging established practice can be difficult Bourne H. The insulin myth. Lancet 1953; 2: 964. makes an interesting read