Improving Physical Health Monitoring Following Rapid Tranquillisation

By Jennifer Melville, Deputy Chief Pharmacist

The ward team on Bevan Ward in City and Hackney have been working extremely hard over the past 18 months! We have been aiming to improve the physical health monitoring of patients following administration of psychotropic PRN/RT. In November 2012, a trust wide audit showed only 50% of patients who received rapid tranquilisation (RT) were monitored according to ELFT policy. Recent national work shows that we are not alone in this. The successful completion of physical health monitoring following administration of PRN/RT has been shown to be a major issue for most mental health Trusts in the UK.

The current ELFT recommended medicines for rapid tranquillisation (RT) are antipsychotics, benzodiazepines and sedating antihistamines. There is well documented evidence on the risks of these medicines when given to patients, including reduction in respiratory rate leading to respiratory collapse and prolongation of QTc leading to cardiac arrest. RT is especially of concern given some patients can be medically unwell, extremely agitated or already treated with high doses of medication. NICE recommends monitoring of all patients vital signs, including BP, pulse, respiratory rate and hydration status at regular intervals following RT, however this approach is time intensive and does not tackle the fact that given the well documented risks, the reporting of actual harm is low. Using QI methodology Bevan ward looked at the barriers to monitoring patients following RT and have worked to change the process so that patients are monitored to an appropriate level and are safe.

Bevan ward team have developed a new monitoring form that enables staff to monitor patients clinical presentation from a distance. It incorporates a RED, AMBER, GREEN method to identify signs and symptoms of pyrexia, respiratory distress, hypotension, general well-being and other adverse effects of medication. Once a patient is identified as suffering from adverse effects of RT these patients are reviewed for further follow up and physical observations including BP, pulse, respiratory rate. Given the rare nature of an adverse reaction to RT, this form enables the team to focus on patients who are more likely to need close monitoring and particularly works to highlight patients who are already medically unwell or on high doses of medication.

This work has improved the monitoring of patients to between 90 – 100% of patients who receive RT. We have shown this improvement over 16 weeks since implementing the new form.