Introduction

1. Safe Monitoring of Intramuscular Rapid Tranquilization - Audit Dr. Karolina Szumanska-Ryt, Dr. Ruth Collins, Dr. John Cooney St. Michael’s Unit, Mercy University Hospital, Grenville Place, Cork, Ireland Introduction Rapid tranquilisation (RT) is defined as the use of medication to calm/lightly sedate the service user, reduce the risk to self and/or others and achieve an optimal reduction in agitation and aggression. This should allow for a thorough psychiatric evaluation to take place with comprehension and response to spoken messages throughout the intervention. It is recognised that rapid tranquilisation may lead to deep sedation/anaesthesia, although this is not the overt intention. It is therefore important to ensure that vital signs are frequently monitored to avoid any possible adverse effects as a result of intramuscular RT. • Gold Standard • Based on a review of international guidelines, the following were developed as the gold standard of the audit; • All physical restraints (100%) which required intramuscular rapid tranquilization had immediate and regular monitoring • 5 - 10 minutes for the first hour • 30 minutes for the next 2 hours • Should a repeat intramuscular rapid tranquilization occur, the same monitoring standards were examined. Aim The purpose of this audit was to assess the current monitoring standards of vital signs and to identify any adverse events that may have resulted in relation to poor monitoring. • Results • A total of 92 physical restraints were examined. Of these, 62 required IM RT. 12 RT were repeated events (24%) Fig. 1. • The gold standard was not achieved as there was no evidence of safe monitoring (0%) Fig. 3. • Adverse events were seen in 19% of overall cases, of these 40% were seen in repeat RT events. • Most commonly used agents were a combination of benzodiazepine + antipsychotic (52%). • Single agent use was associated with a higher risk of repeat physical restraint and RT (32%) versus combination of agents (18%) Fig. 4. • Methods • This is a retrospective audit examining the clinical practice forms for physical restraints between November 2006 and December 2009. • Thorough examination of case notes present within ward filing system to identify the cases which required IM rapid tranquilization. • Physical restraints which did not required IM rapid tranquilization were excluded in the audit. • Inspection of commonly used tranquilizing agents and their effectiveness. • To assess if any adverse events occurred. • An adverse event was defined as; • RT resulted in direct injury to patient as a result of poor monitoring of vitals and patient. • High dose administering or unsafe combination use without monitoring of vitals. • Clinical situation prior to RT is deemed unsafe and would warrant closer monitoring of vitals. • Mean arterial pressure (MAP) < 70 based on documented vitals and no action taken. • Data was collected with standard pro forma and basic statistical calculations were used. Fig. 3. Results of safe monitoring Fig. 1. Breakdown of RT events RAPID TRANQUILIZATION RECORDING FORM: Fig. 4. Types of agents used in RT • Conclusions • Adequate monitoring of vital signs could have prevented many of the adverse events seen in this audit. Evidence also suggests that training of staff in both monitoring of patient and the use of de-escalation techniques can prevent and provide safe RT to the service user. • The use of a single agent (22 cases) was associated with a higher risk of repeat RT versus the use of 2 agents in combination (28 cases) Fig. 4. • The following were recommendations from the results of the audit; • Propose a document for vital sign monitoring (Fig. 2) along with guidance on managing common adverse events • Incorporate this document into the development of a departmental guideline for IM rapid tranquilization • Incorporate the IM RT guideline into the induction teaching program to raise awareness of key management decisions. • Training for all staff members in; • Preventative measures – recognizing risk situations • De-escalation techniques • Use of monitoring equipment • Resuscitation skills and equipment training • Re-audit to complete cycle Fig. 2.RT vital sign monitoring form