Rapid Tranquilisation and
Patient Safety
Andy Cantrell, January 2013
Background
Rapid tranquilisation poses risks to both staff and patients.
Injuries are common in restraint. Medication occasionally
contributes to respiratory/cardiac arrest.
Ideally all aggression is de-escalated prior
to the need for rapid tranquilisation. This
has been the focus of other projects.
Nevertheless there will always be a small proportion of
acutely disturbed, often delusional patients who pose a risk
to patients, staff and themselves without intervention.
Driven by NICE Guidelines on Violence and Schizophrenia,
NHSLA assessment and Serious Incidents, we undertook
several years of quality improvement to make this safer…
Clinical Audit Cycle
A
HQIP
Key Standards
• Attempt de-escalation prior to the need for rapid
tranquilisation
• Medication Prescribing Protocol – ‘4 steps of
Rapid Tranquilisation Process’ from the
Maudsley Prescribing Guidelines including
choice of drug, dosage and contra-indications
• Monitoring of patients’ physical observations
following rapid tranquilisation
• Debriefing with the patient
• Documentation of all the above
Baseline, 2007
• Unreliable documentation of incidents in the
patient record (48%)
• Little documentation of attempting de-escalation
prior to rapid tranquilisation (10%)
• Common administration of Haloperidol during
rapid tranquilisation (16%)
• Where given, Haloperidol was usually above the
recommended dosage (74%)
• Physical observations were not recorded
following rapid tranquilisation
• Debriefing with the patient was not recorded
Fishbone analysis
Guidelines
lacking
Aggression
Drug
interactions
Fear
Risk from RT
medications
Delusions Not all physically
suited to restraint
Fear
Not covered in
everybody’s
mandatory
training
Local teams
sometimes lack
de-escalation/
PSTS skills
Restraint
carries risks
Resus equipment
was not 100%
correct at start
Often local
No formal record problems
of observations
Emergency Team
likewise
Injury to
staff and
patients
during RT
Guidelines perceived
as ‘out of touch’
Improvement Work
Improvement Work
• Physical observations
after rapid tranquilisation
included in the SLAM
Magnet Nursing
Competency Framework.
• Modified Early Warning Scores cards include a
prompt on the front page to record observations
post-rapid tranquillisation.
Improvement Work (contd.)
• Audit summary findings and recommendations issued in trustwide enews bulletin and e-mailed to all consultants and ward managers to
be given to their teams (March 2010, December 2011).
• Medication Incident and Error Bulletins produced by the Pharmacy
Department have highlighted serious incidents involving rapid
tranquilisation and reminders of the mandatory monitoring schedule
(e.g. April 2012).
• A poster of the rapid tranquillisation guidelines has been produced
and sent to all wards in March 2011. Inpatient practice visits audit
data in May 2012 demonstrated 95% inpatient areas had this poster
displayed.
• The SLaM rapid tranquillisation guidelines were reviewed and reratified in October 2011. Amendments to the guidelines included
advice on medication for children and older adults.
Improvement Work (last of these)
• Systems have been introduced to scan paper medication
and observation charts into the electronic record system.
5 super scanners deployed. Administrators trained.
• An alert and hyperlink have been added to the
DATIXweb incident reporting form where rapid
tranquilisation has been used. Encourages recording of
physical observations or refusals.
• A rapid-cycle audit project focused on improving physical
observations following rapid tranquillisation (due to start
in September 2012)
Jim Reason’s Swiss Cheese Model
Cheese = Barriers (good)
ACCIDENT
HAZARDS
Holes = Failures (bad)
Rapid Tranq. Cheese Model
BARRIERS
De-escalation
Safe Prescribing
PSTS restraint
Observations
ACCIDENT
HAZARDS
Rapid Tranq. Cheese Model
BARRIERS
De-escalation
HAZARDS
Safe Prescribing
PSTS restraint
Observations
CT1 Training, RT
Guidelines Poster
Include RT in PSTS Training
ACCIDENT
MEWS
Rapid Tranq. Cheese Model
BARRIERS
De-escalation
HAZARDS
Safe Prescribing
PSTS restraint
Observations
CT1 Training, RT
Guidelines Poster
Include RT in PSTS Training
ACCIDENT
MEWS
MEWS RT Cover sheet
Rapid Tranq. Cheese Model
BARRIERS
De-escalation
HAZARDS
Safe Prescribing
PSTS restraint
Observations
CT1 Training, RT
Guidelines Poster
Include RT in PSTS Training
ACCIDENT
MEWS
MEWS RT Cover sheet
Re-audit - successes
By the 2011 audit cycle:
• Documentation of rapid tranquilisation in the patient electronic notes
improved and this was sustained (48% in 2007, up to 96% in 2010, 100% in
2011)
• Documented attempts to de-escalate the patient prior to rapid tranquilisation
became more common (10% up to 66% in 2011)
• Use of Haloperidol dropped to a minimum (42% in Jan 2008 down to 3.6%
in 2011)
• Recorded debrief with the patient following rapid tranquillisation improved
(0% to 43% in 2007)
Not so good:
• Whilst recording of at least one set of observations following rapid
tranquilisation improved (0% in 2007 up to 25% in 2011), the requirement to
document physical observations at the frequency required (i.e. every 5-10
minutes for one hour and then half-hourly until the patient is ambulatory)
has not been met. This is now subject to a focused rapid-cycle audit project.
Rapid-Cycle Audit - Observations
• Cultural change through inclusion in project
• Frequent observations. Hawthorn effect
becomes a real effect
Deming, 1994
 NHS Institute for Innovation and Improvement
4 Rs of Motivation
•
Responsibilities
– Key but disciplinary in nature. Improving ownership by inclusion in
quality improvement project
•
Relationships
– Team culture is a big factor in RT habits
– Negative effect on patient relationship may accumulate
from repeated observations?
•
Rewards
– Reward to Trust in NHSLA insurance
– No such rewards for individual clinicians. Just the knowledge they have
avoided the small possibility of physical collapse
•
Reasons
– Clinicians not convinced of the value of observations
– Need to clarify that risk assessing as unsafe is ok, but to record it
– Need to convince clinicians policy writers are not ‘on another planet’
Michael Maccoby (2010)
Research Technology Management 53(4) 2010 pp. 60-61
Productive Mental Health Ward
• Good use of ground-up Quality improvement
• Clinicians are learning and taking ownership
Lessons for Patient Safety
• Best to avoid Rapid Tranquilisation.
Consider Relational Security 
• Staff safety = patient safety
• Models help you think
• The clinicians may think your policy writers are
living on another planet. Address this.
• Persevere, small improvements
get you there in the end…
• …If they don’t – change tactics!
DoH
Thanks for listening
Any questions?
Anyone achieved
rigorous post-RT
observations?