Are the rapid tranquilisation nice guidelines adhered to, in patients with agitated/aggressive behavior? a QIP

AimsTo explore whether the NICE guidelines for rapid tranquilisation are adhered to in the Psychiatric intensive care unit (PICU/ Tryweryn).MethodData were collected by core trainees. Standards were taken from NICE guidelines NG10. All patients who had received rapid tranquilisation, that were in PICU from August 2019 to February 2020 were considered in this a.ResultDuring the first PDSA, we discussed with the staff in the ward regarding the protocol. Prior to actually starting the second audit, the adherence was noted to be low. However following persistence and having created a protocol jointly with the ward manager, we could see the difference. The staff were appreciated for their efforts in maintaining 100% adherence. The same was intended to be continued with some positive reinforcement from the auditing team. Over the first 2 months, 12 patients received Rapid Tranquilisation. Out of these 12, we randomly selected 4 patients to find the adherence of the NICE guidelines to be 100 per cent. The predictions regarding the adherence to protocol showed that the PDSA was successful.During the second PDSA, the adherence was 100% again. The adherence to the protocol has been followed for not just the sample that was selected, but for the entire set of patients who received the Rapid Tranquilisation. Following this QIP, we formatted the proforma which included the services to be provided/ actions to be taken, Post Rapid Tranquilisation physical health monitoring and response to medication.ConclusionThe utilisation of de-escalation techniques and behavioural support plans that was person-centred in turn brought down the rate of Rapid Tranquilisation successfully. Thus placing our PICU as having the least restraints in the UK in 2019 (Second least 3/ month). Our PICU was awarded the prestigious Nursing Times Team of the Year Award for their pioneering work.Following this QIP, we then formatted the proforma for Rapid Tranquilisation which included the services to be provided/ actions to be taken, Post Rapid Tranquilisation physical health monitoring and patients response to medication. The PICU will continue to maintain this 100% standard and we would then consider extending the Audit to both Open wards and PICU in entire North Wales.

A different perspective: using interactive virtual reality (IVR) for psychiatry training

AimsTo evaluate the potential of interactive virtual reality in teaching and training Postgraduate Psychiatry Trainees in the Keele ClusterBackgroundFace to face supervised clinical experience will always be the best way to train and learn, followed by using simulated patients in practice scenarios allowing a safe environment in which to practice and train without risk. However, the practicalities of a busy NHS often mean that the expense and time required for both of these are not possible and often PowerPoints and handouts in induction are used to prepare new starters in Psychiatry, which is clearly suboptimal. Interactive Virtual Reality (IVR) allows trainees to not only be immersed in a simulation but take control, choosing the direction of questioning for example. It also allows the training to be easily repeated and scaled to any number of students, anytime and anywhere there is an internet connection.MethodFollowing successful funding from the RCPsych General Adult Faculty we chose three common scenarios that a new started in Psychiatry would face. These included acute agitation/rapid tranquilisation, a patient wishing to leave/section 5(2) and a patient with tachycardia following clozapine initiation. Using established guidelines and literature, in conjunction with feedback from subject matter experts and practicing clinicians, scenarios were written. We then researched the best hardware and software to make this possible, ensuring that the resources required were realistic to allow accessibility to as many trainees as possible.ResultCreating IVR is challenging but an engaging medium. Achieving consensus on the training material is time consuming yet paramount to a good training session. Producing high quality videos is extremely resource intensive requiring large amounts of computing power and storage. However, the outcome is an engaging and practical alternative to face to face training.ConclusionThe possibilities for IVR for are vast. For example, trainees can practice different methods of asking questions (e.g. open vs closed) and how this affects the outcome. Training could be produced centrally and then shared, allowing best practice to be disseminated. It could improve and standardise induction, especially considering the expanding workforce. It could also improve recruitment, allowing an immersive experience of Psychiatry to those who would otherwise be unable to obtain shadowing. It also has a role in patient safety – demonstrating common scenarios that the trainee may face allowing them to practice in a safe environment.

Improving the safety of rapid tranquilisation in older people

AimsTo identify intramuscular rapid tranquilisation (IMRT) events in all >65 years inpatients in Sussex Partnership NHS Foundation Trust (SPFT) and to establish whether accompanying documentation meets SPFT guidelines. This is a re-audit, initial data were collected in 2016. Multimodal intervention has been implemented since initial data collection. In psychiatric inpatients IMRT should be administered as a last resort to calm acutely disturbed patients after verbal de-escalation and an offer of oral medication has failed. IMRT can cause physical health complications and impact therapeutic relationships. Quality improvements made since initial data collection were: an IMRT treatment algorithm for >65s, a teaching package for staff, IMRT prescription area on medicine cards and post IMRT physical monitoring forms – in line with updates to trust IMRT policy.MethodRetrospective case note audit cycle of 119 patients. Electronic and paper records were reviewed for inpatients >65 years on 1/9/2019. Records were examined for instances of IMRT– the following features were noted: diagnosis; verbal de-escalation; oral medication offered prior to IMRT; IMRT prescription location; and post-IMRT monitoring. Descriptive statistics were performed. This audit was approved by the trust audit committee.ResultThere were 34 RT events in 17 patients, reduced from 83 RT events in 20 patients in 2016. De-escalation was attempted in 62% versus 34% in 2016, oral medication offered first in 71% versus 59% in 2016. Physical monitoring was fully completed in 50% of instances in 2019, an improvement from 23% in 2016.ConclusionEducation, a new treatment algorithm, medicine card changes, and IMRT physical monitoring forms have improved adherence to trust standards. There was a 49% reduction in IMRT events in 2019 versus 2016. De-escalation is being performed more frequently, and oral sedation offered in more cases. The physical monitoring of patients has improved.

Nile Ward PICU violence reduction quality improvement project

AimsTo reduce incidents of inpatient violence and aggression at Nile Ward Psychiatric Intensive Care Unit (PICU), St Charles Hospital by at least 30% between December 2019 and December 2020. Reducing inpatient violence is a major quality improvement (QI) priority for CNWL NHS Foundation Trust.MethodAs a Psychiatric Intensive Care Unit, Nile Ward looks after male patients suffering from severe mental illness (SMI). This usually includes patients presenting with high levels of violent and aggressive behaviour. Prior to this QI project, there were high levels of patient assaults towards staff and other patients. This required a lot of medication use, including rapid tranquilisation, restraint and the use of seclusion. This QI project was started to allow the Nile MDT to explore ways to reduce serious incidents on the ward in the least restrictive manner.We implemented a number of change ideas within this project. Our change ideas included: 1. A new risk management tool : ‘Ragging', a daily risk assessment tool, was created to assess patients’ risk of violence and aggression to allow signposting of appropriate interventions to safely manage risk. 2. A brand new Staff Photo board : New photos of all permanent and bank staff displayed in the ward with no hierarchy of positions. 3. A new Patient Feedback board : Patient experience, comments and feedback displayed in common areas of the ward which are regularly updated. 4. Mutual Expectations between Staff and Patients: A set of expectations created in co-production with patients displayed in the communal areas of the ward to be followed by both staff and patients. 5. Gardening sessions : One of our newer change ideas during the COVID-19 pandemic was to provide a safe, socially distanced space for patients to be involved in growing and caring for the Nile Ward garden with our activities co-ordinator. 6. Optimisation of Physical Exercise : Focus on physical activity through garden fitness sessions and 1-1 fitness sessions in the gym. This was another change idea commenced during the COVID-19 pandemic. These sessions occur throughout the day with our fitness instructor and enable our patients to focus on their physical health & fitness. 7. Improved Ward Environment : Gym equipment were upgraded and the appearance of the ward gymnasium was enhanced using quality art created in co-production with patients.ResultThere was a 43% reduction in the number of violent incidents in the ward following QI interventions. The details of the results will be depicted in pictorial form in the poster.ConclusionOur patients are able to recover in a safe environment with a reduced level of violence and aggression resulting in patients receiving less rapid tranquilisation and restrictive interventions. We have had fewer assaults on staff which has made our staff feel safer to work in a busy PICU. Staff feel more confident in their role through the use of the new risk assessment tool . Patients and staff alike have given positive feedback to the changes implemented in this QI project, with violence being successfully reduced by 43%. We hope that our QI project can be used as an example to show how QI methodology can enable Violence Reduction within mental health services.

Study protocol for a randomised controlled trial of haloperidol plus promethazine plus chlorpromazine versus haloperidol plus promethazine for rapid tranquilisation for agitated psychiatric patients in the emergency setting (TREC-Lebanon)

Background: Agitated and aggressive behaviours are common in the psychiatric setting and rapid tranquilisation is sometimes unavoidable. A survey of Lebanese practice has shown that an intramuscular haloperidol, promethazine and chlorpromazine combination is a preferred form of treatment but there are no randomised trials of this triple therapy. Methods: This is a pragmatic randomised trial. Setting - the psychiatric wards of the Psychiatric Hospital of the Cross, Jal Eddib, Lebanon. Participants - any adult patient in the hospital who displays an aggressive episode for whom rapid tranquilisation is unavoidable, who has not been randomised before, for whom there are no known contraindications. Randomisation – stratified (by ward) randomisation and concealed in closed opaque envelope by independent parties. Procedure – if the clinical situation arises requiring rapid tranquilisation, medical residents overseeing the patient will open a TREC-Lebanon envelope in which will be notification of which group of treatments should be preferred [Haloperidol + Promethazine + Chlorpromazine (HPC) or Haloperidol + Promethazine (HP)], along with forms for primary, secondary and serious adverse effects. Treatment is not given blindly. Outcome - primary outcome is calm or tranquil at 20 minutes post intervention. Secondary outcomes are calm/tranquil at 40, 60 and 120 minutes post intervention, asleep, adverse effects, use of straitjacket and leaving the ward. Follow-up will be up to two weeks post randomisation. Discussion: Findings from this study will compare the HPC versus HP combination used in Lebanon’s psychiatry emergency routine practice. Trial registration: ClinicalTrials.gov NCT03639558. Registration date, August 21, 2018.

The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis

Introduction:Non-pharmacological interventions preferably precede pharmacological interventions in acute agitation. Reviews of pharmacological interventions remain descriptive or compare only one compound with several other compounds. The goal of this study is to compute a systematic review and meta-analysis of the effect on restoring calmness after a pharmacological intervention, so a more precise recommendation is possible.Method:A search in Pubmed and Embase was done to isolate RCT’s considering pharmacological interventions in acute agitation. The outcome is reaching calmness within maximum of 2 h, assessed by the psychometric scales of PANSS-EC, CGI or ACES. Also the percentages of adverse effects was assessed.Results:Fifty-three papers were included for a systematic review and meta-analysis. Most frequent studied drug is olanzapine. Changes on PANNS-EC and ACES at 2 h showed the strongest changes for haloperidol plus promethazine, risperidon, olanzapine, droperidol and aripiprazole. However, incomplete data showed that the effect of risperidon is overestimated. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam.Conclusion:Olanzapine, haloperidol plus promethazine or droperidol are most effective and safe for use as rapid tranquilisation. Midazolam sedates most quickly. But due to increased saturation problems, midazolam is restricted to use within an emergency department of a general hospital.

Exorcising restraint: reducing the use of restrictive interventions in a secure learning disability service

Purpose The purpose of this paper is to describe the nature and impact of a restraint reduction strategy implemented within a secure learning disability service in response to the national Positive and Safe programme. Design/methodology/approach The strategy was comprised of three primary interventions – Safewards, positive behavioural support and data-informed practice – and utilised a programme management approach to ensure effective delivery. Baseline measures were collected from 12 months of data prior to implementation of the programme and the frequency of each category of restrictive intervention was then measured prospectively on a monthly basis throughout the duration of the programme. Findings Upon completion of the programme the following results were achieved: elimination of prone restraint – elimination of mechanical restraint – 42 per cent reduction in general use of restraint – 42 per cent reduction in use of seclusion – 52 per cent reduction in rapid tranquilisation. Originality/value The paper adds to the growing body of evidence that carefully designed interventions can reduce the frequency of seclusion and restraint. In this case, Safewards and PBS have combined to exert their effect. Data-led practice and senior leadership were also found to be of critical importance. Finally, the need for a stable workforce is considered.