NHSCT/18/1210 National Early Warning Score (NEWS)

National Early Warning Score (NEWS) Version 3_0 of 11

This is an official Northern Trust policy and should not be edited in any way

Please note that the policy library on Staffnet will contain the most up to date version of Trust policies

Reference No: NHSCT/18/1210 Title: National Early Warning Score (NEWS) Key words within

policy (max 10 words):

National early warning scores, NEWS, charts, observations, SBAR

communication tool

Policy Author(s): Padraig Dougan, Resuscitation Officer; and Suzanne Pullins, Assistant Director of Nursing Safety, Quality and User Experience

Responsible Director: Mr Seamus O’Reilly, Executive Director of Medicine

Policy Type: Trust Wide ☒ Division Specific ☐ Clinical and/or social care ☒

Policy Replacement: Yes ☒ No ☐ National Early Warning Score (NEWS) to include Obstetric Early

Warning Score (OEWS) NHSCT/14/782

Directors/Divisions

policy to be issued to:

Nursing ☒

Medicine ☒

Finance ☐

Medicine and Emergency Medicine ☒

Human Resources, Organisational Development and Corporate

Communications

☐

Community Care ☒

Surgical and Clinical Services ☒

Mental Health, Learning Disability and Community Wellbeing ☒

Women, Children and Families ☒

Strategic Development and Business Services ☐

Target Audience, ie,

specific staff groups:

Health care professionals in Acute clinical facilities

Approved by: Dr Kate Scott and Mrs Suzanne Pullins Co-chairs, Clinical and Social Care Policy and

Guidelines Committee

9 July 2018

Operational Date: 1 August 2018 Review

Date:

January 2019 (or sooner if required due to

regional implementation of NEWS2 by March 2019)

Policy Library

Categories:

(Please tick as

appropriate)

No more than 3

categories to be

selected

Clinical and Social Care - Hospital (incl Comm Hosp) ☒

Clinical and Social Care - Children’s Hospital & Community ☐

Clinical and Social Care - Community ☐

Clinical and Social Care - Mental Health and/or Learning Disability ☒

Children’s Nursing ☐ Estates ☐

Maternity & Gynae ☐ Human Resources ☐

Health & Safety ☐ Major Incident Plan ☐

Palliative Care ☐ Information Management ☐

Infection Control ☐ Allied Health Professions ☐

Family Planning ☐ Trust Wide ☒

Finance ☐

Safeguarding Children ☐

NHSCT Vision

To deliver excellent integrated services in partnership with our community.


National Early Warning Score (NEWS)

Contents

1.0 Summary of Policy …………………………………………………………….. 3

2.0 Responsibilities ………………………………………………………………… 4

3.0 Policy Statement ……………………………………………………………….. 5

4.0 Monitoring ……………………………………………………………………….. 6

5.0 Evidence Base/References …………………………………………………… 7

6.0 Personal & Public Involvement (PPI)/Consultation Process …………… 7

7.0 Equality, Human Rights & DDA ……………………………………………… 7

8.0 Alternative Formats ……………………………………………………………. 7

9.0 Sources of advice in relation to this document …………………………... 8

10.0 Policy Sign Off …………………………………………………………………... 8

11.0 Appendix 1 Protocol for Senior Nursing Assistants………………… 9-10

Appendix 2 SBAR Communication Tool .……………………………. 11


1.0 Summary of Policy / Background

1.1 In Northern Ireland, the use of Physiological Early Warning Scoring

Systems (PEWS) in the Health and Personal Social Services (HPSS)

was recommended following the Regulation and Quality Improvement

Authority (RQIA) Report “Review of the Lessons Arising from the Death

of the Late Mrs Janine Murtagh”, October 2005. The Report

recommended that PEWS is used for every patient in all acute

hospitals, as there was a need to provide clinical teams with

formalised protocols and guidance to support critically ill patients.

1.2 The NHSCT on recommendation of the HSC Safety Forum adopted

the National Early Warning Score (NEWS) in August 2013, which was

to replace PEWS observation charts for Adults.

1.3 The NHSCT on recommendation of the HSC Safety Forum adopted

the Regional Obstetric Early Warning Score Chart (OEWS) in

November 2013. The Trust’s OEWS Policy is available in the Trust

Policy Library on Staffnet. OEWS are to be completed on all pregnant

women from 12+0 weeks gestation.

1.4 The NHSCT on recommendation of the HSC Safety Forum has from

September 2015 introduced the Paediatric Early Warning Score which

covers all age groups of children up to and including the age of 16

which is addressed in the Paediatric Early Warning Score (PEWS)

and Paediatric Inpatient Observation Policy (available in the Trust

Policy Library on Staffnet).

1.5 NEWS should be used for all patients in hospital from their 16th

birthday (except for all pregnant women from 12+0 weeks gestation) to

assist in tracking their clinical condition and to ensure that the clinical

team can be appropriately alerted to any clinical deterioration so that a

timely clinical response can be triggered.

1.6 NEWS is based on a simple scoring system in which a score is

allocated to physiological measurements already undertaken when

patients present to, or are being monitored in hospital.

Six simple physiological parameters form the basis of the scoring

system.

1. Respiratory Rate

2. Oxygen Saturations

3. Temperature


4. Systolic Blood Pressure

5. Pulse rate

6. Level of Consciousness (AVPU)

A score is allocated to each as they are measured , the magnitude of

the score reflecting how extreme the parameter varies from the norm.

The score is then aggregated, and uplifted for people requiring oxygen.

It is important to emphasize that all parameters must be routinely

measured in hospitals and recorded on the NEWS Observation chart.

2.0 Responsibilities

2.1 Directors are accountable for ensuring that NEWS is implemented and

used effectively in conjunction with Clinical Response Triggers/Action

Protocols within inpatient areas across their Division.

2.1.1 Directors are responsible for ensuring that systems are in place

to provide training for staff on NEWS as appropriate.

2.1.2 Each Division must ensure that a minimum of 10 NEWS charts

are audited per adult inpatient ward per month. The expected

Standard to be achieved is 100% compliance on the identified

parameters in the use of NEWS.

2.2 Healthcare staff are individually accountable for their practice and for

the provision of appropriate care. The Registered Nurse responsible for

the patient remains responsible for the appropriate delegation of NEWS

observations to Health Care Assistants and must adhere to the NMC

guidance on the delegation of care (NMC,2015).

2.2.1 Education and Training on the use of the NEWS system must

be completed annually by all staff using the e-learning

programme found at the web-site below:

https://tfinews.ocbmedia.com/

2.2.2 Bank staff working in the Trust will access mandatory training

through the Trust, in the same way as substantive staff, and

contract agency staff are required to be trained as well but that

at an operational level it is the shift coordinators responsibility

to ensure all staff have the skill set required to care for patients.


2.2.3 Health Care Assistants (Band 3) who have been nominated

and authorized to undertake NEWS observations must prove

that they have successfully undertaken the Vital Signs-

Undertaking and Recording (CEC) course and successfully

completed their record of supervision sessions (see Appendix

1). In addition they must also complete the NEWS e-learning

programme before undertaking the recording of Clinical

observations. Note e-learning web site above.

2.2.4 Health Care Assistants must submit their certificate of

completion and record of supervised sessions to the Ward

Sister/Charge Nurse and the date completed recorded in the

Health Care Assistants’ training records.

3.0 Policy Statement

3.1 This policy sets out the standards for recording and scoring clinical

observations for adult inpatients from their 16th birthday in clinical

facilities (except within maternity) across the Northern Health and

Social Care Trust.

3.2 Only NEWS charts approved by the Trust should be used.

3.3 All healthcare professionals using NEWS must ensure compliance with

the following actions:

• All adult inpatients in the Acute setting MUST have as a minimum

one set of NEWS observations carried out in each 12 hour period.

• All 6 scored observations MUST be accurately measured and

recorded on the chart at each intervention, dated and signed

• The score for each set of observations MUST be calculated and

charted and review time stipulated on the chart.

• Act on the observations and scores based on the Clinical Response

Triggers/Action Protocols, which may include contacting Medical

staff or the Hospital at Night Team as appropriate.

• The Situation, Background, Assessment, Recommendation (SBAR)

communication tool should be used as per clinical response action

protocol

• Frequency of observations will be determined by current NEWS

score, patient diagnosis, current condition, previous scores or any

agreed clinical decision to change frequency made by (ST3 level

Doctor or above) which has been documented in patients’ clinical

notes


• Concern about a patient’s clinical condition should always override

the NEWS if the attending healthcare professional considers it

necessary to escalate care

• Any decision to deviate from the Trust escalation protocol must be

documented alongside the patient response and rationale

• When clinical teams (ST3 and above) decide that the routine

recording of data for NEWS is inappropriate, such decisions should

be discussed with the patient and recorded in the clinical notes

3.4 Settings outside the Acute Hospital

• All adult inpatients in the Mental Health setting will have a full set of

NEWS observations carried out on admission or following transfer

to be discussed at the earliest multidisciplinary meeting re:

continuation of NEWS observations

• All adult inpatients in the Community Hospital setting MUST have at

least one set of NEWS observations carried out in each 24 hour

period.

• When the decision is made to delegate the task of carrying out

NEWS observations the registrant must retain accountability.

4.0 Monitoring

4.1 Clinical Services Managers/General Managers/Heads of Service in

each Division will be responsible for ensuring that there is a plan to

audit the use of the NEWS systems in their area of responsibility on a

monthly basis. The plan should be approved by the Divisional

Governance Team.

4.2 Local audits of the use of NEWS will be undertaken on a monthly

basis on all ward areas.

4.3 The findings of these audits are reported to the Governance

Department and recorded on the Nursing Dashboard.

4.4 An annual NEWS audit is carried regionally in all Trusts, and the

findings reported to the Director of Nursing within the Trust and to the

Quality and Safety Forum.

4.5 Further Trust and regional audits will be carried out as agreed.


5.0 Evidence Base/References

5.1 National Early Warning Score (NEWS)

Standardising the assessment of acute-illness severity in the NHS

www.rcplondon.ac.uk/national-early-warning-score

5.2 “Review of the Lessons Arising from the Death of the Late Mrs Janine

Murtagh”, RQIA, October 2005.

https://rqia.org.uk/RQIA/files/4c/4caa7dda-4a33-4913-bea3-

c025824ae4e2.pdf

5.3 Nursing & Midwifery Council (2015) The Code Professional Standards

of Practice and Behaviour for Nurses and Midwives

5.4 Acutely ill adults in hospital recognising and responding to deterioration

NICE Clinical Guideline (CG 50)

https://www.nice.org.uk/guidance/CG50

6.0 Personal & Public Involvement (PPI)/Consultation Process

6.1 The Trust’s Resuscitation Officers, Assistant Director of Nursing and

User Experience, Medical Director and Clinical and Social Care

Governance Managers were involved in the creation of this document

following regional input from the Patient Safety Forum.

7.0 Equality, Human Rights & DDA

7.1 This policy has been drawn up and reviewed in the light of Section 75

of the Northern Ireland Act (1998) which requires the Trust to have due

regard to the need to promote equality of opportunity. It has been

screened to identify any adverse impact on the 9 equality categories.

7.2 The policy has been ‘screened out’ without mitigation or an alternative policy proposed to be adopted.

8.0 Alternative Formats

8.1 This document can be made available on request on disc, larger font,

Braille, audio-cassette and in other minority languages to meet the

needs of those who are not fluent in English.


9.0 Sources of advice in relation to this document

9.1 The Policy Author, responsible Assistant Director or Director as

detailed on the policy title page should be contacted with regard to any

queries on the content of this policy.

10.0 Policy Sign Off (Typed name/scanned signature sufficient)

Padraig Dougan

Resuscitation Officer

Lead Policy Author Date: 5 February 2018

Mr Seamus O’Reilly

Executive Director of Medicine Date: 16 February 2018


11.0 Appendix 1

Protocol for the Measurement and Recording of Physiological

Observations by nominated Health Care Assistants (Band 3)

This Appendix forms part of the NHSCT’s policy on National Early Warning Score

(NEWS) and specifically outline the delegated task undertaking the measurement,

recording and escalation of NEWS observations by nominated Health Care

Assistants (Band 3).

Each Division must ensure that the nominated and authorized Health Care

Assistants (Band 3) have received the specific training provided by CEC, supervision

and assessment regarding measurement and recording of NEWS observations.

Competence

All Health Care Assistants (Band 3) who undertake NEWS observations must prove

that they have successfully undertaken the Vital Signs – Undertaking and Recording

(CEC) course and successfully completed their record of supervision sessions and

complete the NEWS e-learning tool before undertaking and recording clinical

observations. The e-learning tool can be accessed at https://tfinews.ocbmedia.com/

When completed the certificate of completion and record of supervised sessions

must be submitted to the Ward/Department Manager and the date completed

recorded in the Health Care Assistant’s training records.

Reporting

The Registered Nurse responsible for the patient remains responsible for the

appropriate delegation of NEWS observations to Health Care Assistants and must

adhere to the NMC guidance on the delegation of care (NMC, 2015). Health Care

Assistants must follow Trust procedure regarding reporting and records of NEWS

observations.

Specific attention should be noted as follows:

• Health Care Assistants must be aware of their responsibilities in response to

any change in the patient’s condition and/or an abnormal earning warning

score. They must adhere to the processes for escalation in order to provide

safe and effective care for the patient.

• Health Care Assistants must document and inform the registered nurse who is

responsible for the patient of any NEWS 1-4.


• Health Care Assistants must document and immediately inform the

registered nurse who is responsible for the patient of any NEWS of 5 or above

or 3 in any single parameter.

Exclusions regarding the delegation of NEWS observations to Health Care

Assistants (band 3)

Health Care Assistants must not be delegated to record physiological observations

for the following patients:

• Patients on admission

• Patients requiring central neurological (CNS) observations

• Patients receiving any blood transfusions/products

• Patients who are unstable/clinically deteriorating

• Immediate post-operative patients. On-going assessment of the patient must

be carried out by the Registered Nurse. NEWS observations are only

delegated to the Health Care Assistant when the patient is assessed as stable

post operatively.

It should be noted that the Registered Nurse should not delegated the recording of

NEWS observations to a Health Care Assistant if the RN has any concerns

regarding the clinical status of the patient.

References

Nursing and Midwifery Council (2015). The Code. Professional Standards of

Practice and Behaviour for Nurses and Midwives.

Northern Health and Social Care Trust (2018). National Early Warning Score

(NEWS) available within the Policy Library on Staffnet


Appendix 2 – SBAR Communication Tool

This is an official Northern Trust policy and should not be edited in any way Please note that the policy library on Staffnet will contain the most up to date version of Trust policies Reference No: NHSCT/19/1335 Title: Rapid Tranquilisation Guidelines

Key words within policy (max 10 words):

Options for disturbed, violent behaviour in adult patients.

Policy Author(s): Dr U Huda, Divisional Medical Director Richard Bakasa, Acting Head of Acute Services (Mental Health) Dr A Collins, Consultant Psychiatrist Dr S McCann and Dr J McIlvenna, Psychiatrist of Old Age/Dementia Dr C O’Lynn, Speciality Doctor, PICU Joby Joseph, Charge Nurse Ms N Gribben, Clinical Pharmacist Dr M Bell & Dr M Jenkins, Antrim Area Hospital Emergency Department

Responsible Director: Mr Oscar Donnelly, Divisional Director of Mental Health, Learning Disability and Community Wellbeing Division

Policy Type: Trust Wide ☒ Division Specific ☐ Clinical and/or social care ☒

Policy Replacement: Yes ☒ No ☐ Replaces policy NHSCT/16/981- reviewed due to new clinical guidance and inclusion of other trust areas.

Directors/Divisions policy to be issued to:

Nursing and User Experience ☐ Medicine and Pharmacy ☒

Finance and Estate Services ☐

Medicine and Emergency Medicine ☒

Human Resources, Organisational Development & Corporate Comms ☐

Community Care ☐

Surgical and Clinical Services ☒

Mental Health, Learning Disability and Community Wellbeing ☒

Women, Children and Families ☒

Strategic Development and Business Services ☐

Target Audience, ie, specific staff groups:

This policy is directed to all staff within the Mental Health Division, the acute hospital setting including Emergency Departments and CAMHS medical staff

Approved by: Dr Kate Scott & Mrs Suzanne Pullins Co-chairs, Clinical and Social Care Policy and Guidelines Committee

30 September 2019

Operational Date: 31 October 2019 Review Date: December 2021 Policy Library Categories: (Please tick as appropriate) No more than 3 categories to be selected

Clinical and Social Care - Hospital (incl Comm Hosp) ☐

Clinical and Social Care - Children’s Hospital & Community ☐

Clinical and Social Care - Community ☐

Clinical and Social Care - Mental Health and/or Learning Disability ☒

Children’s Nursing ☐

Maternity & Gynae ☐ Estates ☐

Health & Safety ☐ Human Resources ☐

Palliative Care ☐ Major Incident Plan ☐

Infection Control ☐ Information Management ☐

Family Planning ☐ Allied Health Professions ☐

Finance ☐ Trust Wide ☒

Safeguarding Children ☐

Rapid Tranquilisation Guidelines Version 3_0 Page 1 of 25

Rapid Tranquilisation Guidelines Contents Page

1 Summary 2

2 Responsibilities 2

3 Policy Statement 3

3.1 The Definition and Background of the Policy 4 3.2 Medication in Acute Psychiatric Emergencies 5

General Prescribing Principles 3.3 Maximum Doses 6

3.4 Precautions to Rapid Tranquilisation 7 3.5 Cardiovascular Disease 7

3.6 Cardiovascular Safety 8 3.7 Drug Selection 9-12

- Adults over 18 years - Older People over 65 years - People with Dementia - Children and Young people under 18 years

3.8 Monitoring after Use of Intramuscular medication 12 3.9 Drugs not recommended Rapid Tranquillisation 12 3.10 Actions after Rapid Tranquillisation 13

4 Guidelines for the Acute Hospital Emergency Departments 13

5 Monitoring of policy 14

6 Evidence Base/References 14

7 Personal & Public Involvement(PPI)/Consultation Process 15

8 Equality, Human Rights and DDA 16

9 Alternative Formats 16

10 Sources of Advice in Relation to this Document 16

11 Policy Sign Off 16

12 Appendices/Attachments 17-25

NHSCT Vision To deliver excellent integrated services in partnership with our community.


Northern Trust and Social Care Trust Rapid Tranquilisation Guidelines

1.0 Summary of Policy

This Guideline document describes the recommended pharmacological

management options that may be used to manage disturbed and violent

behaviour in adult patients cared for in the Northern Health and Social Care

Trust. The physical observations and monitoring required after the use of

injectable medication are described.

It is expected that this Guideline will be used primarily in Mental Health settings

but it will be applicable for the acute management of known or apparently

disturbed mental states in other settings. In these situations, clinicians may

wish to seek further advice on management from a psychiatrist.

However, it is important to recognise that this is NOT applicable for the primary

management of acute alcohol withdrawal.

1.1 Purpose

To ensure a consistent approach to the Rapid Tranquillisation for violent and

aggressive behaviour in order to minimise risk.

1.2 Objectives

• To effectively manage violent and aggressive behaviour whilst

maintaining patient safety and minimising risk.

2.0 Responsibilities

Senior Management

• All Trust Directors, Assistant Directors, Service Heads and Senior

Managers have responsibility for the effective implementation of this

policy. They will ensure that actions are implemented and monitored

and that information required in relation to affecting this policy is

provided promptly and completely. Compliance with these guidelines

will be monitored by relevant senior and first line managers.


Clinical Team

• Junior doctors must not prescribe rapid tranquilisation to young

people under 18 years of age without advance consultation with a

senior doctor/consultant.

• All practitioners are responsible for ensuring that they have a working

knowledge of and adhere to the guidance of this policy. All Staff should

read and sign that they have understood the policy.

• Ensure adherence to appropriate policies and procedures throughout

the decision making process.

• To ensure a full explanation is given to the patient and appropriate carer

as to why the policy interventions are necessary. In line with The Quality

Standards for The Health and Personal Social Services (NI) the Trust

must provide effective leadership and clear direction to make the most

of its people, skills, time and money as to deliver safe, sustainable and

high quality services. The ability of the organisation to reach and

maintain this requirement will be dependent on effective supervision for

all grades of staff.

• Supervision is a shared responsibility between operational manager /

supervisor and staff member.

• All staff involved in the Rapid Tranquillisation of patients with disturbed

and violent behaviour must follow this guidance.

• Clinicians should use their own clinical judgement in each case and if

they decide that a different management approach is clinically indicated

then the reasons for this should be clearly documented.

3.0 Policy Statement

• Rapid Tranquillisation should be part of an overall management plan

that includes appropriate nursing care and de-escalation techniques

and should only be considered when de-escalation approaches have

failed.

• Patients should only be treated with the medicines described in this

guideline only after it is established that the risk of not doing so is

greater than the risk of rapid tranquillisation.

• This guideline applies to the management of acutely disturbed

behaviour and not to the management of delirium.

• Staff should be trained, to a level appropriate to their role, in how to

assess and manage potential and actual violence using de-escalation


techniques, restraint and the pharmacological treatment. Staff should

also be trained to use Intermediate Life Support.

• Staff should be trained to understand and apply the Mental Health

Order of Northern Ireland 1986 and have awareness of Human Rights

Act 1998 and Common Law.

• If the patient has expressed a preference for a particular antipsychotic in

an Advance Directive consider prescribing this, if appropriate to the

clinical circumstances.

• Before an intramuscular medication is administered, the patient must be

given the opportunity to take oral medication if it is thought this would be

effective and appropriate in the clinical circumstances.

• In all cases the likely minimum effective dose of medication should be

used.

• All staff need to be aware of the legal framework that authorises the use

of these interventions.

• Staff involved in rapid tranquillisation should be aware of the licensed

indications and maximum doses of medicines (see BNF or Summary of

Product Characteristics, SPC) and should endeavour to keep within

these limits. In some cases current BNF and SPC dose may be

knowingly exceeded (e.g. Lorazepam >4mg/day), bearing in mind the

overall risks. This decision should not be taken lightly or the risks

underestimated. Record a risk-benefit decision and rationale in the case

notes. Junior doctors must consult a more senior colleague in these

cases.

3.1 The Definition and Background of the Policy

The use of psychotropic medication in acute psychiatric emergencies is with

the aim of controlling agitation, aggression or excitement. As there are no

drugs that produce an immediate antipsychotic effect, the principal aim is

immediate sedation and tranquillisation – hence, this is often known as ‘rapid

tranquillisation’. Antipsychotic (neuroleptic) drugs can be used for this purpose

and may then be continued for their antipsychotic effect, which may take two

or three weeks to develop.


The use of antipsychotics in acute psychiatric emergencies has been linked to

sudden death, the cause of which is not entirely clear. During violent struggles

an injection may be inadvertently injected intravascularly or the normally

clinically insignificant prolongation of QTc interval associated with some

antipsychotics might be potentiated by the arrhythmogenic effect of

catecholamines released during violent struggles. Monitor closely when IM

antipsychotics have to be used in patients prescribed other medicines that

might prolong QTc interval.

3.2 Medication in Acute Psychiatric Emergencies

General Prescribing Principles

The aim of rapid tranquillisation is to achieve a state of calm sufficient to

minimise the risk posed to the patient and others. Patients should be able to

respond throughout. With this in mind, it is important to individualise the dose

and type of medication for each service user. This will depend on several

factors including previous response to medication, age, physical problems

(renal, hepatic, cardiovascular or neurological disease) other prescribed

medication and possible use of drugs of abuse.

• Check that the patient has not had previous allergy or severe

idiosyncratic reaction to the drugs to be used.

• Check there is no recent history of Neuroleptic Malignant Syndrome or

hyperthermia.

• Simultaneous administration of IM antipsychotics and IM

benzodiazepines (Lorazepam) may be associated with excessive

sedation and cardio respiratory depression. If this combination is

deemed necessary then patients must be monitored for excessive

sedation and for postural hypotension.

• Patients taking Clozapine or Olanzapine require care when giving

benzodiazepines especially via IM route as potentially fatal orthostatic

and cardio-respiratory dysregulation have been reported. If this

combination is considered necessary it is essential to undertake

frequent monitoring of the patient.

• If the patient has expressed a preference for a particular antipsychotic in

an Advance Decision consider prescribing this if warranted by clinical

circumstances.


• Avoid unnecessary polypharmacy. This may necessitate careful choice

of drug in relation to either current treatment or expected maintenance

treatment.

• Carefully consider the number of active PRN prescriptions operative at

any one time in relation to the risk of inadvertent overdose.

• The Multidisciplinary Team in Mental Health Settings should review

PRN medication at least once a week and if PRN medication is to be

continued the rationale for its continuation should be included in the

review. If psychotropic PRN medication has not been used since the

last review, consider stopping it.

• Be mindful that parenteral doses generally have a greater bioavailability

than oral doses.

• Don’t mix medications in the same syringe.

• Patients entering LEVEL 2 on the protocol (See Appendix 1+2) must

have details of all medicines administered, rationale of use and an

assessment of effectiveness recorded in the clinical notes. All current

psychotropic PRN prescriptions on the Kardex should be reviewed in 6-

12 hours.

3.3 Maximum Doses

Staff involved in rapid tranquillisation should be aware of the licensed

indications and maximum doses of medicines (see BNF or Summary of

Product Characteristics, SPC) and should endeavour to keep within these

limits. In some cases current BNF and SPC dose may be knowingly

exceeded (e.g. Lorazepam >4mg/day), bearing in mind the overall risks.

This decision should not be taken lightly or the risks underestimated.

Record a risk-benefit decision and rationale in the case notes. Junior

doctors must consult a more senior colleague in these cases. If BNF doses

are exceeded, it is particularly important to undertake frequent and

intensive monitoring of a calmed patient. Pay particular attention to regular

check of airway and intensive monitoring of level of consciousness, pulse,

blood pressure, respiratory effort, temperature and hydration. (Appendix 4).


3.4 Precautions to Rapid Tranquilisation

• Patients never previously prescribed antipsychotic medication

Use lower doses, (Appendix 1+2)

Avoid haloperidol if possible.

• Patients with no evidence of psychotic symptoms

Consideration should be given to dependency potential or potential for

misuse of PRN medication

Use lorazepam initially however promethazine may be preferable in

Benzodiazepine - tolerant patients (see below)

• Co-morbid Substance Misuse

In patients who are benzodiazepine-tolerant consider use of IM

promethazine 25-50mg (up to a maximum of 100mg/24hours). Wait 1-2

hours after injection to assess response. Note this is an unlicensed use.

Care should be exercised if methadone prescribed due to increased

potential for QTc prolongation.

• Frail/Elderly and patients with Dementia

Use lower doses. (Appendix 2)

Only use oral route except in very extreme emergencies.

• Organic Disease

Use lower doses.

In patients with suspected or confirmed Lewy Body Dementia or

Disease; avoid the use of antipsychotics.

3.5 Cardiovascular Disease

Avoid antipsychotics (or use of IM haloperidol with IM promethazine).

Use lorazepam alone.

Consider any concomitant medication, which may prolong QTc interval.

NB: Haloperidol is contra-indicated in clinically significant cardiac

disorders. A clinical risk assessment must be carried out before

prescribing haloperidol. The Summary of Product Characteristics

(SPC) for haloperidol recommends that a baseline ECG is performed

prior to treatment for all patients and also avoiding the use of

concomitant antipsychotics. This will not always be possible in an

acutely disturbed, psychotic patient. In such a situation, the

prescribing doctor will have to balance the cardiac risks against

those arising from the patient’s behaviour.


• Compromised respiratory function

Avoid benzodiazepines.

• Alcohol Withdrawal / Risk of Seizures

Caution when using antipsychotics – lowering of seizure threshold.

• Hepatic or renal impairment

Use lower doses – risk of accumulation due to reduced clearance.

• Pregnancy

Specialist advice must be sought on the management of pregnant

women requiring emergency sedation. The risks and benefits of

treatment should be considered on a case by case basis.

3.6 Cardiovascular Safety

Antipsychotics as a group are probably associated with an increased risk

of QTc prolongation. Normal limits of QTc are less than 440 ms in men and

less than 470 ms in women. The risk of arrhythmia increases exponentially

beyond normal limits, with strong evidence that QTc greater than 500 ms is

clearly linked to an increased risk of arrhythmia. The risk is dose related

and the risk for individual drugs is probably additive when they are used in

combination.

The table below summarises the risk for QTc prolongation for common

antipsychotics.

Low Effect Moderate Effect High Effect

Aripiprazole (no effect)

Asenapine

Clozapine

Flupentixol

Fluphenazine

Lurasidone (no effect)

Olanzapine

Paliperidone

Risperidone

Sulpiride

Amisulpride

Chlorpromazine

Haloperidol

Quetiapine

Pimozide

Sertindole

Any drug or

combination of drugs

exceeding

recommended BNF

max

The SPC for haloperidol recommends a baseline ECG before commencing

treatment with haloperidol and the NICE guideline for Schizophrenia


(CG82) recommends an ECG before starting an antipsychotic if a patient is

admitted as an inpatient.

A number of medications are associated with prolonged QTc including

amiodarone, erythromycin, clarithromycin, quinine, ciclosporin,

diphendyramine, methadone and tamoxifen. Diuretics can cause

electrolyte disturbance which is also a risk factor. Consult the BNF for

further examples of drugs that prolong QTc.

3.7 Drug Selection (See Appendix 7)

Appendix 7 contains a summary of recommended drugs, their onset of

action and doses for different age groups.

Olanzapine IM injection is not available to the UK market via UK licensing

process however products are available, centrally approved for use in EU

countries with an EU license number.

A benzodiazepine may be the safest and best tolerated drug with which to

effect ‘rapid tranquillisation’ of the patient. Once the patient has been

calmed, either by de-escalation techniques or by a benzodiazepine, an

antipsychotic drug may be best for maintenance of the situation.

Remember that repeated use of a benzodiazepine may result in tolerance

to the effect and this will probably become evident by 7 to 10 days.

For Adults Over 18 years (see Appendix 1)

The flow chart in Appendix 1 outlines a stepped approach to rapid

tranquillisation for Adults over 18 years of age.

If you are unsure about initial pharmacological management then always

call a more senior doctor. If you are a junior doctor and your initial drug

treatment does not work then you should consider discussion with

someone more senior. If you are a Consultant and have tried two or three

approaches without success then it may be wise to seek a second opinion

from a colleague. If the incident is outside a mental health unit, clinicians

may wish to consult a psychiatrist for further advice.

For Older People Over 65 years (see Appendix 2)

This guideline applies to the management of acutely disturbed behaviour

and not to the management of delirium.


There is evidence that antipsychotics are associated with increased

mortality (probably by increasing the risk of cerebrovascular adverse

events) even in people without dementia. A cautious approach is

recommended.

• Oral medication should always be offered whenever possible.

• Lorazepam, starting at a low dose, is the preferred first line treatment.

• If there is confirmed history of previous antipsychotic use then oral

Haloperidol or Olanzapine may be considered.

• If a patient requires IM medication, Lorazepam should be used first

line.

• IM Haloperidol may be used if there is confirmed history of previous

antipsychotic use.

• If previous use of antipsychotics can’t be confirmed and Lorazepam

fails to control the situation, low dose of oral Olanzapine may be

considered. In such cases it may be appropriate to consult a doctor

experienced in the management of older people.

For People with Dementia (see Appendix 2)

• People with Alzheimer's disease, vascular dementia or mixed

dementias with mild-to-moderate non-cognitive symptoms should not

be prescribed antipsychotic drugs because of the possible increased

risk of cerebrovascular adverse events and death.

• People with Dementia with Lewy Bodies (DLB) with mild-to-moderate

non-cognitive symptoms, should not be prescribed antipsychotic drugs,

because those with DLB are at particular risk of severe adverse

reactions.

• Non-pharmacological options should be considered as first line

management. If this is ineffective, then Lorazepam may be

considered. Risperidone is licensed for short-term use for persistent

aggression in people with moderate to severe Alzheimer’s dementia.

The starting dose is 0.25mg twice daily increased to 0.5mg twice daily.

If ongoing use of Risperidone is considered necessary then the advice

of a doctor experienced in the management of dementia should be

sought.

• The use of Olanzapine is unlicensed but may be justified in some

cases as per Maudsley Guidelines (12th edition). Consider a dose of

2.5- 5mg PO/IM. (Max 5mg/24hrs)


• In very exceptional circumstances, when oral treatment is impossible,

low dose haloperidol IM may be used. In these cases, consider

consulting a doctor with experience in managing disturbed behaviour

in people with dementia.

For Children and Young people under 18 years (see Appendix 3)

• The NICE Guideline on Violence and Aggression NG10 states that

restrictive interventions (which includes Rapid Tranquilisation) should

only be used if all attempts to defuse the situation have failed and the

child or young person becomes aggressive or violent. Staff must be

familiar with and use the de-escalation techniques outlined in the

NICE guideline to avoid having a restrictive intervention.

• A multidisciplinary approach is required and junior doctors e.g.F1s

must seek advice from a senior doctor or consultant before carrying

out rapid tranquilisation

• The general prescribing principles for adults outlined in Point 3.2-3.7

apply when prescribing for children and young people.

• Medication can be given against a child’s will with parental consent

i.e. permission from a person with Parental Responsibility under The

Children’s Act NI and or common law. If repeated medication is

required, the Mental Health Order NI (1986) should be considered.

Children and young people should be informed that a medication is

going to be given and always given the opportunity to accept oral

medication.

• The flow chart in Appendix 3 outlines a stepped approach to rapid

tranquilisation for Children and Young People aged between 6 and

18 years of age. In the following circumstances contact someone

more senior with experience in psychiatry: (a) if you are a junior

doctor and your initial drug treatment does not work, (b) if you are a

Consultant and have tried two or three approaches without success

then it may be wise to seek a second opinion from a colleague or

consult with a psychiatrist who works within the Child and Adolescent

Mental Health Service (CAMHS) within office hours

• The CAMHS Consultant on call hours are as follows:

Monday –Friday 9am - 9pm

Saturday and Bank Holidays 10am - 2pm


Sunday 9am - 5pm.

Outside these times, there is no CAMHS consultant on call and any

queries would need to go through the on–call arrangements for Mental

Health Liaison Service. This team offers an assessment service for our

young people outside the CAMHS Crisis working hours

3.8 Monitoring after Use of Intramuscular medication

• Appendix 4 outlines the monitoring required after the use of

intramuscular medication.

• If patients refuse monitoring of vital signs or of they remain too

behaviourally disturbed to be approached, this must be documented in

the patients notes at each time monitoring would have been due. The

patient should be observed for sign/symptoms of pyrexia, hypotension,

over sedation and general physical well-being and documented

accordingly.

3.9 Drugs NOT recommended for rapid tranquillisation

The following drugs are NOT recommended for rapid tranquillisation:

• Oral and IM Chlorpromazine – IM Chlorpromazine is painful and can

cause severe hypotension. Chlorpromazine must never be given

intravenously

• IM Diazepam – absorption is erratic

• IM depot antipsychotics

• Zuclopenthixol acetate is not recommended for routine use in rapid

tranquillisation due to its slow onset of action. It may however be

recommended by a senior doctor or consultant when:

� The patient is disturbed/violent over an extended time period

� Past history of good/timely response

� Past history of repeated parenteral administration required

� Cited in an advance decision.


3.10 Actions after Rapid Tranquillisation

• When Rapid Tranquillisation has been implemented, the Duty Doctor

must be called to attend the ward to ensure the treatment has been

effective and that undue adverse effects are no longer likely to occur.

• The Duty Doctor must assess the patient’s mental state and record

same.

• After IM Rapid Tranquilisation administered , or where clinically

necessary with oral medications, a Registered Nurse must observe the

patient for 1 hour and record NEWS (National Early Warning Score) at

10 minute intervals if possible. If patient is secluded or unwilling to have

NEWS recorded the Registered Nurse must observe the patient directly

at their side or through the viewing window and assess the patients

level of consciousness continually and record at 10 minute intervals

positive interaction with the patient, such as:

- The patient talking to the nurse

- The patient sitting or standing and being alert.

• These interactions must be recorded on the Seclusion Care Plan or

Nursing Notes.

• Any concern regarding the patient’s physical wellbeing such as reduced

respiration or change in level of consciousness a group of staff who are

MAPA trained must enter the room and check the patient’s physiological

observations and summon medical assistance as per policy.

• A report of use of IM Rapid Tranquillisation should be made on a

Trust Incident Form/Datix web for review within Mental Health for

learning purposes.

• The ward manager will discuss the service user’s experience after the

use of restrictive interventions and record their views in the relevant

patient notes. A referral to advocacy services will be offered in all cases.

4.0 Rapid Tranquilisation Guidelines for Emergency Departments

As per The Royal College of Emergency Medicine (RCEM) guidelines 05/16 –

Management of Excited Delirium/Acute Behavioural Disturbance

Acute Behavioural Disturbance (ABD) is a medical emergency in the

Emergency Department (ED). As per College Guidelines, in the ED setting


sedation should be with intravenous benzodiazepines, ketamine or

antipsychotics. Individuals displaying ABD may need much higher doses of

sedative agents than typically required or recommended.

Pharmacological management should be part of an overall management plan

that includes appropriate nursing care and de-escalation techniques

• Buccal olanzapine (zyprexia velotabs) 10mgs can be used where a

patient is compliant and parenteral route avoided.

• Where there is actual or clear risk of violence or aggression. De-

escalation including oral PRN (olanzapine 10mg buccal melt) not

possible or appropriate due to Risk of harm to self or others.

• In The Emergency Department Setting:

- 1 – Lorazepam IM (4mg) / IV (2-4mg)

- 2 - Ketamine IM (2-4mg/kg) / IV (1-2mg/kg)

- 3 – Haloperidol IM (10-20mg) / IV (5-10mg)

- (doses as suggested by RCEM for Rapid Tranquilisation)

Full patient monitoring in line with the RCEM guidance on safe procedural

sedation, including ETCO2 monitoring, must be used in all cases in which

sedation is administered if possible.

5.0 Monitoring

This policy will be reviewed in 3 years or less if changes to Regional Guidance,

post SAI or if a review is required.

6.0 Evidence Base/References

NHSCT National Early Warning Score (NEWS) Policy

NHSCT Resuscitation Policy includes Do Not Attempt Cardiopulmonary

Resuscitation Policy (DNACPR)

Royal College of Psychiatrists Consensus Statement on High Dose

Antipsychotic Medication CR190, 2014

BNF for Children 74th edition. bnf.org


Maudsley Prescribing Guidelines 12th Edition, Taylor, D, Paton C, Kapur S,

Informa Healthcare London 2010

Violence and Aggression: Short term management in Mental Health, Health

and Community Settings. National Institute for Health and Clinical Excellence

NG10, May 2015.

The Royal College of Emergency Medicine Best practice Guideline: Guidelines

for the Management of Excited Delirium/Acute Behavioural Disturbance (ABD),

May 2016

SPc Haloperidol tablets and Injection, Electronic Medicines Compendium,

www.medicines.org.uk accessed 30/10/2015

SPc Aripiprazole Tablets and Injection, Electronic Medicines Compendium,


SPc Olanzapine tablets and Injection, Electronic Medicines Compendium,


SPc Risperidone tablets, Electronic Medicines Compendium,


SPc Lorazepam Tablets and Injection Electronic Medicines Compendium,


7.0 Personal and Public Involvement (PPI)/Consultation Process

Dr A Collins Consultant Psychiatrist

Dr Catherine O’Lynn Speciality Doctor

Dr J McIlvenna Old Age Psychiatrist

Dr S McCann Old Age Psychiatrist

Mr Richard Bakasa Acting Head of Service & Acute Mental Health Services

Joby Joseph Charge Nurse

Ms N Gribben Clinical Pharmacist

Divisional Governance Team subgroup

Medical Staff Committee

Dr Mark A Bell & Dr M Jenkins Antrim Hospital Emergency Department

Dr F McCartan Child & Adolescent Mental Health Services

Dr Uzma Huda Divisional Medical Director, Mental Health Services

Dr Dave Watkins Consultant Paediatrician and Divisional Medical Director,

Women, Children and Families Division


8.0 Equality, Human Rights and DDA

This policy has been drawn up and reviewed in the light of Section 75 of the

Northern Ireland Act (1998) which requires the Trust to have due regard to the

need to promote equality of opportunity. It has been screened to identify any

adverse impact on the 9 equality categories.

The policy has been ‘screened out’ without mitigation or an alternative policy

proposed to be adopted

9.0 Alternative formats

This document can be made available on request on disc, larger font, Braille,

audio-cassette and in other minority languages to meet the needs of those

who are not fluent in English.

10.0 Sources of Advice in relation to this document

The Policy Author, responsible Assistant Director or Director as detailed on the

policy title page should be contacted with regard to any queries on the content

of this policy.

11.0 Policy Sign off.

Dr Uzma Huda ___________________________

Date: 2 September 2019

Lead Policy Author

Oscar Donnelly ____________________________ Date: 2 September 2019 Director


12.0 Appendices/Attachments

(1) Pharmacological management of violent and aggressive behaviour (for adults over 18 years) (2) Pharmacological management of violent and aggressive behaviour For over 65 years + dementia patients

(3) Pharmacological management of violent and aggressive behaviour For Children and Young people aged under 18 years (4) Rapid Tranquillisation - Monitoring Guidelines (5) Guidelines for the use of Flumazenil (6) The Neuroleptic Malignant Syndrome (NMS) (7) Dose Information (8) Medication Notes


Appendix 1

Pharmacological management of violent and aggressive behaviour (FOR ADULTS over 18 years)

See Appendix 2 for management of over 65years and Dementia patients (will require ¼ to ½ of the standard adult doses)

Note: Medications listed are separate options except where explicitly stated to be used in combination Olanzapine IM injection is not available to the UK market via UK licensing process however products are available, centrally approved for use in EU countries with an EU licence number

Pharmacological management should be part of an overall management plan that includes appropriate nursing care and de-escalation techniques.

If de-escalation techniques are unsuccessful or inappropriate, consider pharmacological management.

LEVEL 1

Disturbed but accepting oral medication

LEVEL 2

Disturbed but refusing oral medication or risk of harm to self or others

• Ongoing verbal de-escalation.

• Consider moving to LEVEL 2 if oral therapy is refused or is not indicated by previous clinical response or is not a proportionate response.

Appropriate oral medicines and doses are listed below. Consider combination of lorazepam with an antipsychotic if indicated by clinical circumstances. NOTES

• Oral Lorazepam alone may be preferable where there is uncertainty about previous history: o Including history of cardio-vascular disease o Uncertainty regarding current medication o Possibility of current illicit drug/alcohol intoxication

• Oral antipsychotics or promethazine may be preferable in patients with

o Current regular benzodiazepine use o A history of respiratory depression

• Review all medication administered within the last 24hrs – be aware of BNF maximum doses.

• Ensure Crash Bag is available within 3 minutes. Consider IM treatment with lorazepam, aripiprazole, or olanzapine as single agents

OR Lorazepam in combination with an antipsychotic OR Haloperidol in combination with promethazine NNOTES

NOTES

• Dilute Lorazepam 1:1 with saline or water for injection prior to administration.

• Flumazenil must be available if IM Lorazepam is used.

• Haloperidol 5mg IM ≈ 8mg PO

• If IM Haloperidol is used, monitor for emergence of EPSEs, especially dystonia and give Procyclidine 5mg orally or IM according to severity of symptoms.

• For Aripiprazole and Olanzapine, leave at least 2hrs between injections. Max of three injections in 24hrs

• Do not give IM Lorazepam within one hour of prev IM Olanzapine

Lorazepam 1 – 2mg (Max 4mg/24hrs) Haloperidol 5 – 10mg (Max 20mg /24hrs) Note: Best with promethazine 25mg Olanzapine orodisp 10mg (Max 20mg/24hrs)

If unsuccessful or inappropriate If unsuccessful or inappropriate

LEVEL 3 Situation rapidly deteriorating or failure to respond to LEVEL 2 Interventions

• Review current treatment to date.

• Seek advice from a more senior doctor, or a Consultant before proceeding.

Options to consider at this stage include:

• Repeat IM injections as per LEVEL 2.

• Promethazine 50mg IM, useful in benzodiazepine intolerant patients. Onset of action is slow. Allow 1-2 hours to assess response before repeating to maximum of 100mg in 24 hrs.

• Zuclopenthixol acetate (See Guideline notes 7.10)

Review the situation after 45 minutes. If response is inadequate consider repeating oral therapy or moving to LEVEL 2.

Review the situation after 45 minutes. If there is continued concern seek advice from a more senior doctor before proceeding further

Lorazepam 1-2mg IM (Max 4mg/24hrs) Aripiprazole 5.25-9.75mg IM (Max 30mg/24hrs)

Haloperidol 5-10mg IM (Max 20mg/24hrs) + Promethazine 50mg IM. (ECG recommended pre dose)

Olanzapine 5-10mg IM (Max 20mg/24hrs)


Appendix 2

Pharmacological management of violent and aggressive behaviour FOR OVER 65 YEARS + DEMENTIA PATIENTS

(will require ¼ to ½ of the standard adult doses) Note: Medications listed are separate options except where explicitly stated to be used in combination Olanzapine IM injection is not available to the UK market via UK licensing process however products are available, centrally approved for use in EU countries with an EU licence number


• If de-escalation techniques are unsuccessful or inappropriate, consider pharmacological management.

• Ensure all risks and benefits are considered before prescribing antipsychotic drugs especially in older adults with dementia; if needed use doses in lower dose range for Dementia

• Avoid antipsychotics in patients who have Lewy Body Dementia or Parkinsons

LEVEL 1

Disturbed but accepting oral medication

LEVEL 2

Disturbed but refusing oral medication or risk of harm to self or others

• Ongoing verbal de-escalation.


Appropriate oral medicines and doses are listed below. Consider combination of lorazepam with an antipsychotic if indicated by clinical circumstances. NOTES

• Oral Risperidone licensed for treatment of aggression in Alzheimer’s dementia


• Oral antipsychotics may be preferable in patient with o Current regular benzodiazepine use o A history of respiratory depression

• Olanzapine licensed for agitation and disturbed behaviour in schizophrenia and mania ONLY


• Ensure Crash Bag is available within 3 minutes. Consider IM treatment with lorazepam, haloperidol or olanzapine as single agents

OR Lorazepam in combination with an antipsychotic

NOTES



• Haloperidol 2.5mg IM ≈ 4mg PO

• If IM Haloperidol is used, monitor for emergence of EPSEs, especially dystonia and give Procyclidine 5mg orally or IM according to severity of symptoms.

• For olanzapine, leave at least 2hrs between injections. Max of three injections in 24hrs

• Do not give IM Lorazepam within one hour of prev IM Olanzapine.

Lorazepam 0.5-1mg PO (Max 2mg/24hrs) Haloperidol 0.5-2.5mg (Max 5mg/24hrs)

Olanzapine orodisp 2.5mg-5mg PO (Max 5mg/24hrs) Risperidone 250mcg to 500mcg PO in Dementia only(Max 2mg/24hrs)



• Review current treatment to date.

• Seek advice from a more senior doctor, or a Consultant before proceeding.

Options to consider at this stage include:

• Repeat IM injections as per LEVEL 2.

• Promethazine 25mg IM with caution, useful in benzodiazepine intolerant patients. Onset of action is slow. Allow 1-2 hours to assess response before repeating to maximum of 50mg in 24 hrs


Review the situation after 45 minutes. If there is continued concern seek advice from a more senior doctor before proceeding further

Lorazepam 0.5 -1mg IM (Max 2mg/24hrs)

Haloperidol 0.5mg – 2.5mg IM (Max 5mg//24hrs) ECG recommended pre-dose

Olanzapine 2.5 to 5mg IM (Max 5mg/24hrs)


Appendix 3 Pharmacological management of violent and aggressive behaviour

(For CHILDREN and YOUNG PEOPLE aged UNDER 18 YEARS)

Note: Medications listed are separate options except where explicitly stated to be used in combination Olanzapine IM injection is not available to the UK market via UK licensing process however products are available, centrally approved for use in EU countries with an EU licence number


If de-escalation techniques are unsuccessful or inappropriate, consider pharmacological management. Decision to use RT should be led by senior psychiatrist (Consultant, SpR, Staff Grade) in discussion with nurse in charge. If diagnosis of PSYCHOSIS suspected but uncertain, avoid antipsychotic medication until medical assessment complete if possible. Junior doctors must not prescribe rapid tranquilisation to under 18 year olds without consulting a senior doctor/consultant in advance.

LEVEL 1

Disturbed but accepting oral medication as part of de-escalation strategy

LEVEL 2 Actual or clear risk of violence or aggression. De-

escalation including oral PRN not possible or appropriate; risk of harm to self or others

• On-going verbal de-escalation.

• Consider combination of oral lorazepam+antipsychotic if clinically indicated


Appropriate oral medicines and doses are listed below.

NOTES


• Oral antipsychotics may be preferable in patients with o Current regular benzodiazepine use o A history of respiratory depression


• Consult a CAMHS doctor before proceeding with IM medication in a child

• Consult a CAMHS doctor before using IM medication in a young person unless IM medication is already included in the young person’s care plan

• Check if an individual care plan recommends an approach not covered in guideline


• Ensure Resus equipment and emergency bag is available within 3 minutes.

NOTES



Children 6-12 years Lorazepam 0.5-1mg IM (Max 4mg/24hrs)

Children 6-12 years Lorazepam 0.5-1mg (Max 4mg/24hrs)

Review the situation after 45min. If there is continued concern, seek advice from a more senior colleague before proceeding further.



• A senior doctor must review current treatment to date, consider appropriateness of current placement and check sufficient time has been allowed for a response. They should review treatment + response every 24 hours and consider the following points.

• If there has been a partial response to lorazepam consider repeating the dose. If insufficient response to lorazepam, carry out a full review and seek a 2

nd opinion if needed.

Other options to consider at this stage include:

• Repeat IM injections as per Level 2 to maximum daily doses • For ≥13years: Haloperidol 1 -5mg IM (Max 10mg/24hrs) OR Haloperidol IM combined with Lorazepam IM OR Olanzapine 2.5 -

10mg po/IM (Max 20mg/24hrs by all routes). ***Do NOT combine with IM Lorazepam + use with caution if IM Lorazepam has been given within 1 hour***

Young people 13-18years Lorazepam 0.5-2mg (Max 4mg/24hrs) OR Haloperidol 1-5mg (Max 10mg/24hrs) OR Risperidone <50kg 0.5mg, >50kg 1mg (Max 3mg/24hrs)

Young People 13-18years Lorazepam 0.5- 2mg IM (Max 4mg/24hrs)


Rapid Tranquillisation - Monitoring Guidelines Appendix 4

Rapid tranquillisation - Monitoring

After any parenteral drug administration for RT, or where clinically necessary with oral medication, patients require to be monitored as below. (Where the patient’s mental state or behaviour makes this impossible this must be documented. Observe for, and record, any signs of over sedation, pyrexia, hypotension or general malaise.) Use the Trust NEWS chart: Level of consciousness Temperature Pulse Blood pressure Respiratory Rate Monitoring should be every 10 minutes for one hour, then half-hourly until the patient is ambulatory. The Early Warning Score should be calculated from the NEWS each time and further action taken if indicated by this. If necessary, a doctor should be called and transfer to an acute medical facility may sometimes be required. Remember that protection of the airway is paramount and it is important to maintain good hydration. If the patient is asleep or unconscious, the use of pulse oximetry to continuously measure oxygen saturation is recommended. Pay particular attention to level of consciousness and blood pressure when IM antipsychotics and IM benzodiazepines are used in combination. An ECG is recommended when parenteral antipsychotics are given, especially when higher doses are used. Staff should be sufficiently well trained to interpret ECG traces (including calculation of QT/QTc interval). If an ECG shows any cause for concern then a physician must be asked for advice on patient management. NOTE: An ECG is essential if IM antipsychotics are used in adolescents.

Management of problems occurring during Rapid Tranquillisation

Problem Remedial Measures

Acute Dystonia (including oculogyric crises)

Give procyclidine 5 - 10mg Orally or IM

Reduced respiratory rate <10/minute or oxygen saturation <92%

Give oxygen; ensure patient is not lying face down. Give flumazenil if benzodiazepine induced. If induced by any other agent the patient will require mechanical ventilation.

Irregular or slow pulse <50 beats/min

Refer to specialist medical care immediately.

Fall in blood pressure > 30mmHg drop in systolic BP on standing or diastolic BP <50mmHg

Lie patient flat, raise legs if possible. Monitor closely and seek further medical advice if necessary.

Increased temperature Withhold antipsychotics –risk of NMS or perhaps arrhythmias. Monitor closely, cool the patient, and check muscle creatinine kinase. Refer to specialist medical care if continued or other signs of NMS present e.g. sweating, hypertension or fluctuating BP, tachycardia, incontinence (retention or obstruction), muscular rigidity (may be confined to head and neck), confusion, agitation or loss of consciousness. See Appendix D for further information on NMS.

FOR GUIDELINES ON THE USE OF IV FLUMAZENIL SEE APPENDIX 5

TRANSFER PATIENT TO EMERGENCY DEPARTMENT


Appendix 5

Guidelines for the use of Flumazenil INDICATIONS FOR USE If, after the administration of Lorazepam the

respiratory rate falls below 10 resps per min

CONTRA- INDICATIONS Patients with epilepsy who have been receiving long term benzodiazepines. Life threatening condition controlled by benzodiazepines e.g. raised intracranial pressure , status epilepticus.

DOSE AND ROUTE OF ADMINISTRATION Initial 200 mcgs intravenously over 15 seconds. If required level of consciousness not achieved then, Subsequent dose of 100mcgs over 10 seconds, at 60 second intervals

TIME BEFORE DOSE CAN BE REPEATED 60 SECONDS

MAXIMUM DOSE 1 mg in 24 hours (one initial dose and eight subsequent doses).

SIDE EFFECTS Patients may become agitated, anxious or fearful on awakening and may experience nausea, vomiting or flushing.

MANAGEMENT OF SIDE EFFECTS Usually subside

MONITORING WHAT? HOW OFTEN?

Respiratory rate Continuously until respiratory rate returns to baseline level. N.B If respiratory rate does not return to normal or patient is not alert after initial doses given then assume sedation due to other causes.

ALWAYS READ IN CONJUNCTION WITH CURRENT BNF DOSING GUIDANCE


Appendix 6

The Neuroleptic Malignant Syndrome (NMS)

• Incidence: estimated at <1% of all patients

• Mortality: (untreated) 20%

• Onset may be acute or insidious

• Course may fluctuate

• May occur out of hospital

SIGNS AND SYMPTOMS RISK FACTORS TREATMENTS RESTARTING ANTIPSYCHOTICS

• Fever/Hyperthermia/Sweating

• Hypertension/Tacycardia/ autonomic instability (fluctuating BP)

• Muscular rigidity (may be confined to head and neck)

• Confusion/agitation/varying degrees of unconsciousness

• Incontinence/retention/obstruction

• Raised White Blood Cell Count (WBC)

• Raised Creatinine phosphokinase (CK)

• Organic brain disease, dementia, Parkinsons, Alcoholism

• Hyperthyroidism

• High Potency typical drugs, recent or rapid dose increases or dose reductions, abrupt withdrawal of anticholinergics, antipsychotic polypharmacy

• Dehydration

On ward

• Withdraw the precipitating drugs immediately - antipsychotics, antidepressants, lithium

• Correct dehydration and hyperpyrexia- rehydrate, use ice-packs.

• Control agitation with short acting benzodiazepines. IM Lorazepam has been used. In the Emergency Department

• Dopamine antagonists: bromocriptine/dantrolene

• Artificial ventilation

• Antipsychotic treatment will be required in most instances and re-challenge is associated with acceptable risk

• Stop antipsychotics for at least 5 days, preferably longer to allow symptoms of NMS to completely resolve.

• Begin with small doses and increase very slowly with close monitoring of temp, pulse and BP + physical status

• Consider using an antipsychotic structurally unrelated to that previously associated with NMS, or a drug with low dopamine affinity (quetiapine or clozapine). Aripiprazole may also be considered but it has a long half- life and has been associated with NMS.

• Avoid depots (of any kind) and high potency conventional antipsychotics


Dose Information Appendix 7

Medication Time to Peak Plasma concentration

Child (6-12 years) Adolescents (13 – 17)

Adults (18 – 65) Older People (65+) People with Dementia

Lorazepam tablets and IM injection

50 – 90 minutes (Sedation within 30-45 minutes)

By Mouth or by IM injection 0.5 - 1mg Maximum 4mg/24hrs

By Mouth OR by IM injection 0.5mg - 2mg Maximum 4mg/24hrs

By Mouth Or by IM injection 1mg - 2mg Maximum 4mg/24 hours

By Mouth Or by IM injection 0.5mg - 1mg Maximum 2mg/24 hours

By Mouth Or by IM injection 0.5mg - 1mg Maximum 2mg/24 hours

Aripiprazole IM injection 1 –3 hours

Not Applicable

Not Applicable

By IM injection 9.75mg (1.3ml) – Consider lower dose (5.25mg) on basis of clinical status Effective range 5.25 –15mg Max dose 30mg/24hrs by any route

Effectiveness in over 65’s not established. Consider lower doses on basis of clinical status. Starting dose 5.25mg, usual maintenance 5.25- 9.75mg. Max 15mg daily(oral +IM) as per Maudsley

Not Recommended

Risperidone tablets /oral solution

1 -2 hours <50kg 0.5mg once daily >50kg 1mg once daily

<50kg 0.5mg once daily >50kg 1mg once daily

Not applicable Not applicable In Alzheimer’s 250mcg to 500mcg once or twice daily

Olanzapine tablets/ Orodispersible tablets

5 – 8 hours

Not Applicable Not Applicable

By mouth 10mg Maximum 20mg/24 hours

As a second line option By mouth 2.5 - 5mg Maximum 10mg/24hrs.

By mouth(unlicensed) but may be justified in some cases. 2.5 - 5mg Maximum 5mg//24hours

Olanzapine IM injection

15-45 minutes (peak levels up to 5 times that of oral doses)

Not Applicable

2.5- 10mg IM repeated after 2 hours if needed. Maximum combined oral/IM dose is 20mg daily NOT to be exceeded. Max of 3 injections/24hrs for 3 days

5- 10mg IM repeated after 2 hours if needed. Maximum combined oral/IM dose is 20mg daily NOT to be exceeded. Max of 3 injections/24hrs for 3 days.

2.5mg -5mg IM repeated after 2 hours if needed. Max combined oral/IM dose is 10mg daily NOT to be exceeded. Max of 3 injections/24hrs for 3 days

2.5mg IM repeated after 2 hours if needed. (Unlicensed) Maximum combined oral/IM dose is 5mg daily NOT to be exceeded. Max of 2 injections/24hrs for 3 days

Haloperidol Oral solution and tablets

2 – 6 hours (Sedation usually within 30-45 minutes)

Not Applicable

By Mouth in psychosis 1mg - 5mg Maximum 10mg/24hrs

By Mouth 5mg - 10mg Maximum 20mg/24 hours

Only use first line if there is confirmed Hx of previous exposure to typical antipsychotics. Start with lower doses than younger adults: 0.5mg- 2.5mg. Usual Max 5mg/24hrs.

Consider licensed oral risperidone as an alternative as stated above OR use Haloperidol 0.5mg (Max 2mg/24hrs)

Haloperidol injection

15 – 60 minutes (Sedation in 30 – 45 minutes

Not Applicable

If no recent ECG, consider risk/benefits as use may be unlicensed . By IM injection 1mg – 5mg Maximum 10mg/24hrs

If no recent ECG, consider risk/benefits as use may be unlicensed . By IM injection 5mg – 7.5mg Maximum 20mg/24 hours

Only use first line if there is confirmed Hx of previous exposure to typical antipsychotics. Start with lower doses 0.5mg- 2.5mg (Max 5mg/24hrs)

Use only in very exceptional circumstances. Consider consulting a doctor with experience in dementia; 0.5mg (Max 2mg/24hrs)

Promethazine oral and IM injection

Oral peaks 2-3hours IM peaks 1-2 hours

Not Applicable

Not applicable By Mouth or by IM injection 25mg-50mg. Max 100mg/24 hrs

Consider appropriateness if confusion is a concern By mouth or by IM injection 25mg. Max 50mg/24hrs

Not recommended however may consider in those with compromised respiratory function or sensitive/tolerant to Benzos. By mouth or by IM injection 12.5mg-25mg. Max 50mg/ 24hrs


Appendix 8

Medication notes:

• Remember, 0.5mg Lorazepam is equivalent to 5mg Diazepam

• The repeated use of a benzodiazepine may result in tolerance to the effect and this will probably become evident

by 7 to 10 days.

• Haloperidol 5mg IM is equivalent to approximately 8mg orally

• IM Benzodiazepines (Lorazepam) should not be given until at least one hour after IM olanzapine (severe

bradycardia and a couple of deaths associated with giving these two medications together)

• If the patient has received parenteral benzodiazepine, IM olanzapine administration should only be considered

after careful evaluation of clinical status, and the patient should be closely monitored for excessive sedation and

cardiorespiratory depression.

• Olanzapine injection is not licensed for use beyond 3 days

• There is probably an increased risk of cerebro-vascular events in older patients with all antipsychotics

• Risperidone is the only licensed antipsychotic drug for the treatment of aggression in Alzheimer’s dementia.

• Haloperidol is licensed for treatment of agitation and restlessness in the elderly. SPC recommends a pre-

treatment ECG.

• Olanzapine is licensed for treatment of agitation and disturbed behaviour in schizophrenia or mania.

• Orodispersible tablets no advantage in speed of onset but are harder to spit out or conceal

• Avoid antipsychotics if: known cardiac problems, abnormal ECG parameters, on concomitant meds which may

prolong QTc, diagnosis of Lewy Body Dementia or Parkinson’s disease.

NHSCT/18/1210 National Early Warning Score (NEWS)

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