Managing acute behaviour disturbance with Rapid Sedation / Rapid Tranquilisation

Publication: 06/02/2007  --
Last review: 14/08/2019  
Next review: 01/08/2022  
Clinical Guideline
CURRENT 
ID: 964 
Approved By: LTH Clinical Guidelines Committee 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Managing acute behaviour disturbance with Rapid Sedation / Rapid Tranquilisation

Summary

Rapid tranquilisation (‘rapid sedation’) is a reactive management strategy that involves the use of medication to calm or sedate a person to reduce the presentation of agitated, violent and/or aggressive behaviours in a situation where there is an immediate risk of harm to self and/or others.

The pharmacological management of violence and aggression should only be used after all other de-escalation management strategies have been considered and where a person’s risk behaviour can no longer be successfully contained by other therapeutic interventions. The use of oral rapid tranquilisation (‘rapid sedation’) should always be considered before the use of intra-muscular (IM) injection.

It may be necessary to physically restrain in order to administer rapid tranquillisation, it is important to ensure that the correct legal authority is in place and that only safe and approved techniques are used.

This document was developed to provide guidance on the use of medication to treat disturbed or aggressive patients who need to be calmed quickly for their own safety or for the safety of others. This document is based on the best evidence available at the current time and its purpose is to aid the safe use and monitoring of the medication used for rapid tranquillisation/sedation. In accordance with NICE Guidance NG10, this guidance also supports staff regarding the monitoring of patients when rapid sedation is used and provides guidance about post incident planning.

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Aims

  • Provide readily accessible, evidence based guidance, on the safe and effective, short term management of adult patients, who are presenting with acute behavioural disturbance in LTHT general hospital settings.
  • Ensure a standard approach to care, based on best available evidence.
  • Provide clarity about staff roles and responsibilities.
  • Ensure staff are aware of their duty to report all incidents where rapid tranquilisation/sedation is used.
  • Minimise risk related to the use of rapid tranquilisation/sedation
  • Clarify when and how rapid tranquilisation/sedation should be used to manage a patient’s aggression/disturbance.

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Objectives

Ensure that all less restrictive alternative strategies have been considered prior to the use of rapid sedation/tranquilisation.
To ensure that the interventions described in this guideline are used in accordance with the legal framework provided by Mental Capacity Act 2005.
To define the parameters for safe and effective use of medication and subsequent aftercare, in line with other relevant procedures.
To reduce suffering for patients and to reduce the risk of harm to others.
To ensure that the right drugs/doses are followed for each patient and that the patient’s health is monitored throughout.

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Scope

To ensure that a Debrief and action plan is formulated after each incident where rapid sedation/tranquilisation is used.
This guideline covers the management of acute behavioural disturbance in the hospital setting.
It includes violence and aggression displayed, or threatened towards the self, which has caused, or has the potential to cause significant harm (significant self-injurious behaviours).
“Violence and Aggression”, refers to a range of behaviours or actions that can result in harm, hurt or injury to another person, regardless of whether the violence or aggression is physically or verbally expressed, physical harm is sustained, or the intention is clear.
“Significant self-injurious behaviours”, refer to a range of actions that could result, or have resulted, in harm, hurt or injury to the patient being cared for.
It does not apply to patients who are displaying antisocial behaviours, which have no link to an underlying clinical cause. Such behaviours are managed under the Trust’s Policy for Conflict Resolution

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Possible causes of acute behavioural disturbance falling within the scope of this guideline

  1. Delirium
  2. Psychotic disorders, or other excited psychiatric states (eg mania)
  3. Drug/alcohol intoxication/withdrawal (please note there are separate LTHT guidelines for withdrawal management)
  4. Withdrawal from prescribe medication (eg benzodiazepines)
  5. Dementia (with or without delirium)
  6. Cognitive impairment e.g. Learning disability or developmental condition (eg autism)
  7. Acute brain injury
  8. Personality disorders

It should however be noted that this list is not exhaustive

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Principles and Stepped approach

The treating team are responsible for showing that they have followed the following principles.

Principle 1 - Anticipating and reducing the risk:
Knowing the history, personality and behaviour triggers for a patient, and using a current behaviour support plan where available, or making a plan accordingly, will reduce the likelihood of difficult behaviour as well as supporting our appropriate response should it arise.
Sharing information, between professionals as well as family members, is essential to this aim.
Risk assessments should be collated and shared prior to admission when available, or completed on admission in accordance with LTHT policy on use of Restraint

Principle 2 - Consent:
Any interventions and treatment decisions must be taken within the framework of the Mental Capacity Act or, where applicable, the Mental Health Act. Both these frameworks are underpinned by the principle that any intervention for a patient who cannot give valid consent, should be the least restrictive of their rights as possible, whilst maintaining the safety of themselves and others.
Rapid tranquilisation/sedation must not be used on a patient who has mental capacity, at the time, to refuse and who has done so.
When using rapid tranquilisation, evidence must be therefore recorded that the patient lacks capacity to refuse and that the intervention was necessary and proportionate to the risk at the time.

Principle 3 - Person centred Care:
You will find that the more you can tailor the intervention to the person, the more effective it will be.  Talk to as many people who know the person as possible to find out more about their personality, personal history (life story), likes and dislikes.
Such interventions include; de-escalation, distraction, reducing environmental impacts & known triggers, orientation and engagement.

Principle 4 - De-escalation
All clinical staff should know how to apply basic de-escalation techniques.
Staff should be able to confidently approach situations where patients are becoming verbally aggressive or hostile and discuss, in a non-confrontation way, with the patient why this may be occurring.
Staff should be aware that non-hostile body language is important in these situations and that a safe distance should be maintained between them and the patient
Staff should consider whether the patient could be moved to a safe, yet calmer environment.
Consideration should be given to contacting the family or friends of the patient, who may, through experience, know the most successful strategies for calming the patient.
Staff should feel confident in reaffirming boundaries with the patient and explaining what is and what isn’t acceptable in terms of aggressive outbursts.
Staff should feel able to call on senior colleagues/ other expertise, for support in order to develop and implement care plans tailored to the individual patient.

Principle 5 - Proportionate use of restrictive intervention/restraint:
In accordance with LTHT Policy on the use of restrictive intervention / restraint and the Mental Capacity Act; Any restraint used to manage disturbed/aggressive behaviour must comply with the following guidance:

There must be a real possibility of harm to the individual, or to the staff, the public, or others if no action is undertaken;

  • Any restriction/restraint, including medication, cannot be used for a patient who has the mental capacity to refuse it at the time, and is validly refusing.
  • You should take reasonable steps to check that the intervention you are planning is not validly refused by an Advance Decision to Refuse Treatment or a decision by a relevant Lasting Power of Attorney or Court Appointed Deputy.
  • The nature of the restraint used must be proportionate to the risk of harm;
  • Any restraint should be imposed for no longer than absolutely necessary and must only ever be used as a last resort.
  • Staff must do what is practical and reasonable to ensure that the patient’s privacy and dignity are maintained at all times.
  • Staff must explain to the patient, the rationale for using the interventions at the earliest opportunity.
  • Calm, clear and supportive communication should be maintained with the patient throughout the intervention.

STEP ONE:
Includes measures that do not involve medication i.e. de-escalation and distraction
techniques.

  1. Start by treating any known cause/trigger; e.g. pain, sensory overstimulation
  2. consideration of moving the patient to a more appropriately lit room, ensuring sensory aids, communication aids are available and work, involving relatives/carers where possible,
  3. avoiding procedures likely to further upset the patient (eg arguing with patient, catheterisation)
  4. the use of de-escalation skills - leave and return, reduce environmental factors, re-orientation,
  5. one-to-one care (‘enhanced care’)
  6. other less restrictive forms of restriction/restraint, proportionate to the likelihood and seriousness of harm (Please refer to LTHT Policy and Guidance on the use of Restraint)

STEP TWO:
Involves the use of oral medication and should be tried when step one is not feasible and / or does not achieve a satisfactory outcome i.e. to sufficiently calm a patient thereby reducing risk to self and others.

STEP THREE:
Involves the use of IM medication. The interventions suggested within this step must only be employed when steps one and two are not feasible, or when both steps have been tried and failed to achieve a satisfactory outcome.

STEP FOUR:
Involves the use of IV medication. The interventions suggested within this step must only be employed in very exceptional circumstances. The decision should not be made by junior medical staff in isolation and can only be used following consultation with on-call Consultant.

The use of rapid tranquilisation is a high risk practice which has to be well managed in order to avoid unnecessary harm. The risks associated with rapid tranquilisation have been identified as

  • Over-sedation causing loss of consciousness
  • Over-sedation causing loss of alertness
  • Loss of airway
  • Cardiovascular collapse (problems with arrhythmias, hypotension, sudden death)
  • Respiratory depression (Be Aware acute dystonia’s may compromise respiratory rate)
  • Interaction with medication (prescribed or illicit, including alcohol)
  • Damage to the therapeutic relationship
  • Underlying coincidental physical disorders

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Risks associated with rapid tranquilisation

In certain circumstances prescribing outside the trust guidelines may be appropriate. A risk benefit analysis should be recorded in the medical notes and a rationale in the care plan. Where the risk benefit is unclear, consideration should be given to seeking advice from clinicians who are not directly involved in the care of the patient. There are specific risks associated with the different classes of medications that are used in rapid tranquilisation. The specific properties of the individual drugs should be taken into consideration. When combinations are used, risks may be compounded. Staff need to be aware of the following:

For benzodiazepines

  • Loss of consciousness
  • Respiratory depression or arrests
  • Cardiovascular collapse (in patients receiving both clozapine and benzodiazepines)
  • Paradoxical increases in aggression.

For antipsychotics

  • Loss of consciousness
  • Cardiovascular and respiratory complications and collapse (risk of sudden death)
  • Seizures
  • Subjective experience of restlessness (akathisia)
  • Acute muscular rigidity (dystonia)
  • Involuntary movements (dyskinesia)
  • Neuroleptic malignant syndrome
  • Excessive sedation

Extra care should be taken when implementing rapid tranquilisation in the following circumstances:

  • The presence of congenital cardiac conduction abnormality
  • The concurrent prescription or use of other medication that lengthens QT intervals on ECG both directly and indirectly
  • The presence of certain disorders affecting metabolism, such as, stress and extreme emotions, and extreme physical exertion (hypokalaemia, dehydration).

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Checklist for use of rapid sedation/tranquilisation

Rapid tranquilisation (‘rapid sedation’) refers to the use of medication to calm or lightly sedate a person as quickly and safely as possible, to reduce the presentation of agitated and aggressive behaviour and in a situation where there is an immediate the risk of harm to self and/or others. This does not include the use of medications prescribed pro-actively to support reduction in anxiety/aggression and given ‘as required’

  • Seek advice from senior Doctor / Psychiatry before using IM sedation/tranquilisation.
  • Any Physical restraint required to administer rapid Tranquilisation must be evidenced as proportionate to the likelihood and seriousness of the harm to patient/others.
  • Consider any co-existing medical conditions. Particular caution and raised vigilance when using rapid tranquilisation when a patient has:
    • Any respiratory condition
    • Any cardiac problem (e.g. conduction problems or defects)
    • Metabolic disorders such as Addison’s disease
    • Poorly controlled blood sugar levels
  • If the patient is detained under the Mental Health Act, take reasonable steps to check for any treatment Certificate which sets out which psychiatric medications can be given. This can be done by checking E-meds alerts and searching in PPM+; type ‘MHA’ into the search function and look at the list for any current ‘T’ Form or Section 62 Form.
  • If the patient is not detained under MHA, then you must first be clear that the patient lacks capacity under the Mental Capacity Act 2005 to refuse the medication and that it is in their best interests to proceed on the balance of probabilities.
  • Check NEWS2 score and/or refer to previous physical examinations where available in the medical notes.
  • Review medication already received in last 24 hours.
  • Preferably restrict to using one medication (usually Lorazepam). If the patient has not taken antipsychotic medication before, use Lorazepam alone, to avoid the risks associated with combining antipsychotics.
  • 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. IM and oral routes must be prescribed separately. Oral and IM doses are not always equivalent; ensure that the daily maximum dose is not exceeded when prescribing for use with more than one route.
  • Offer oral medication first. Only if this does not work or patient refuses should you consider IM route.
  • Allow sufficient time for clinical responses between doses. Medicines given by oral route may take between 30-60 mins to work, IM route may take 15-45 mins.
  • If giving haloperidol, ensure that procyclidine is immediately available. If an acute dystonic reaction occurs, then give IV Procyclidine 5 - 10mg (or IM) (these are more common with IM Haloperidol and in antipsychotic naïve patients).

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Monitoring of patient after administration of rapid sedation/tranquilisation

  • Record and monitor the patient’s observations and levels of sedation every 5-10 mins for first hour and then every 15mins for the following hour. If patient observations are stable after 2 hours perform 4 hourly observations thereafter.
  • NEWS2 score (which includes ACVPU) should be recorded with every set of observations in line with the Trusts Physical Observations guidelines.
  • Escalate any deterioration in physical observations / NEWS2 to a registered practitioner, and document interventions in the medical notes/eObs.
  • Patient observations must be increased if there is deterioration in the patients NEWS2 / conscious level.
  • If physical observations cannot be completed as prescribed the reason for this must be documented in the patient’s notes. In this event an assessment of the patients conscious level using ACVPU should be recorded.
  • An adult resuscitation trolley stocked in accordance with the LTHT Resuscitation and Training Department’s Standard Adult Resuscitation Equipment List should be available including a reliable source of oxygen to deliver face-mask or nasal oxygen in the event of patient deterioration.

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Post incident Plan

  • In accordance with NICE guidance (NG10) a post-incident Debrief must take place as soon as possible after the use of rapid tranquilisation and at least within 4 hours. This should include staff involved and wherever possible the patient and family/carers.
  • The Debrief should be led by a senior medical professional
  • The Debrief should address:
    • What happened during the incident
    • Any trigger factors
    • Each person’s role in the incident
    • Their feelings at the time of the incident/after wards, any support they may need
    • What can be done to address their concern?
    • Patients should be given the opportunity to document their own account of the intervention. This should be filed in their medical notes.
    • Effectiveness of medications
  • The Debrief should inform the development of a written Rapid Tranquilisation Care Plan which attempts to identify triggers, de-escalation strategies and an agreed plan of enhanced care where necessary.
  • In addition to the above debrief a senior clinician, preferably somebody not involved in the incident, must complete a Rapid Tranquilisation Monitoring Review to check compliance with these guidelines. This must evidence:
    • Adherence to prescribing guidelines
    • Adherence to patient observations
    • Assurance that all alternatives were considered before using Rapid tranquilisation
    • Debrief has taken place in accordance with guidance above.
  • The ‘Rapid Tranquilisation Care Plan’ and ‘Rapid Tranquilisation Monitoring Review’ must be uploaded to PPM within 7 days of the incident.
  • They must be uploaded as an Attachment using ‘Rapid Tranquilisation’ in the Caption box - this is essential for auditing and monitoring purposes
  • All use of rapid tranquilisation must reported on Datix by the Doctor authorising its use immediately after the event, using the coding category ‘incident or requirement causing restraint to be used’

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Maximum doses / Information about the drugs used

Do not exceed these maximum doses;

  • Lorazepam:  maximum by any route is 4 mg / 24 hours
  • Lorazepam: in patients aged over 65, maximum by any route is 2mg / 24 hours
  • Haloperidol: maximum oral dose 20mg / 24 hours Haloperidol: maximum intramuscular dose 10mg /24 hours
  • Haloperidol: in patients aged over 65, maximum by any route is 3mg/24 hours
  • If a combination of Haloperidol oral and IM is used, transfer sum of oral doses into IM dose by multiplying with 0.6, add to it all IM doses and ensure max dose of 18mg is not exceeded in 24 hour period.

Other important information about the drugs used;

Lorazepam: can cause loss of consciousness; respiratory depression or arrest; and can cause cardiovascular collapse in patients also receiving clozapine.  
On rare occasions Lorazepam can paradoxically cause an increase in aggression; it is important to be aware of this potential in advance so that safety is maintained. 
Haloperidol: can cause loss of consciousness, cardiovascular/respiratory complications and collapse; seizures; dystonia including oculogyric crisis, dyskinesia & akathisia (restlessness); neuroleptic malignant syndrome.

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Flowchart

Provenance

Record: 964
Objective:

Aims

  • Provide readily accessible, evidence based guidance, on the safe and effective, short term management of adult patients, who are presenting with acute behavioural disturbance in LTHT general hospital settings.
  • Ensure a standard approach to care, based on best available evidence.
  • Provide clarity about staff roles and responsibilities.
  • Ensure staff are aware of their duty to report all incidents where rapid tranquilisation/sedation is used.
  • Minimise risk related to the use of rapid tranquilisation/sedation
  • Clarify when and how rapid tranquilisation/sedation should be used to manage a patient’s aggression/disturbance.

Objectives

Ensure that all less restrictive alternative strategies have been considered prior to the use of rapid sedation/tranquilisation.

To ensure that the interventions described in this guideline are used in accordance with the legal framework provided by Mental Capacity Act 2005.

To define the parameters for safe and effective use of medication and subsequent aftercare, in line with other relevant procedures.

To reduce suffering for patients and to reduce the risk of harm to others.

To ensure that the right drugs/doses are followed for each patient and that the patient’s health is monitored throughout.

To ensure that a Debrief and action plan is formulated after each incident where rapid sedation/tranquilisation is used.

Clinical condition:

Acute behaviour disturbance in adults

Target patient group: This guideline applies to all adult patients (aged 17 years and above)
Target professional group(s): Secondary Care Doctors
Secondary Care Doctors
Allied Health Professionals
Secondary Care Nurses
Adapted from:

Evidence base

  1. NICE NG 10 (2015) - Violence and aggression: short-term management in mental health, health and community settings
  2. Leeds and York Partnership NHS Foundation Trust (2015) Guidelines for the Pharmacological Management of Psychiatric Emergencies/Behavioural Disturbances using Rapid Tranquillisation (RT)
  3. The National Institute for Health and Care Excellence guideline on violence and aggression: short-term management in mental health, health and community settings (2015)

 

  1. American Psychiatric Association (1999).  Practice Guideline for the Treatment of Patients with Delirium.
  2. British National Formulary (BNF).  BMJ Publishing Group, Royal Pharmaceutical Society of Great Britain and RCPCH Publications 2005.
  3. Cook , I A (2004). Guideline Watch. Practice Guideline for the Treatment of Patients with Delirium.  American Psychiatric Association.
  4. Macpherson, R., Dix, R. & Morgan, S. (2005) Revisiting: Guidelines for the management of acutely disturbed psychiatric patients. Advances in Psychiatric Treatment , 11, 404-415.
  5. National Institute for Clinical Excellence (2005) The Short- term Management of Disturbed/Violent Behaviour in In-patient Psychiatric Settings and Emergency Departments. (Clinical Guideline 25). London: NICE.
  6. Royal College of Psychiatrists (2003) The psychological care of medical patients.  A practical guide. Second edition (Council Report CR108). London: Royal College of  Psychiatrists.
  7. Taylor, D., Paton, C. & Kerwin, R. (2005) The Maudsley 2005– 2006  Prescribing Guidelines. London: Taylor & Francis
  8. British Geriatric Society (2006). An abstract of the guidelines fot the prevention,  diagnosis and management of delirium in older people in hospital. https://www.bgs.org.uk/

Approved By

LTH Clinical Guidelines Committee

Document history

LHP version 1.0

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