Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: de-escalation and rapid tranquillisation

Physical health monitoring after rapid tranquillisation: clinical practice in UK mental health services

“…22 The direct contact required for physical monitoring may be impractical in such cases 17 : patients who are still aroused and disturbed may refuse to cooperate or staff may be wary of approaching them, perceiving that this might be potentially counterproductive and put both the patient and themselves at risk of harm. 6 However, our data provide only very limited evidence that monitoring is less likely to be documented in patients who remain behaviourally disturbed after RT.…”

“…The BAP/NAPICU guidelines and Maudsley Prescribing Guidelines, as well as guidance issued by the Care Quality Commission acknowledge that ‘hands-on’ physical health monitoring may not be possible in all cases post-RT. 6,23,24 But there is a lack of consensus relating to the appropriate ‘hands-off’ observations that should be undertaken in these circumstances. The BAP guideline suggests respiratory rate, level of consciousness and clinical assessment for pallor, and signs of pyrexia, dehydration, dystonia and akathisia, 6 while the Maudsley Guidelines recommend observing for pyrexia, hypoxia, hypotension, oversedation and general physical wellbeing.…”

“…6,23,24 But there is a lack of consensus relating to the appropriate ‘hands-off’ observations that should be undertaken in these circumstances. The BAP guideline suggests respiratory rate, level of consciousness and clinical assessment for pallor, and signs of pyrexia, dehydration, dystonia and akathisia, 6 while the Maudsley Guidelines recommend observing for pyrexia, hypoxia, hypotension, oversedation and general physical wellbeing. 23 But for two episodes out of every five in our sample, the minimum requirement relating to documentation of the level of consciousness and respiratory rate was not met, so it seems unlikely that more general observations relating to physical wellbeing were being undertaken routinely.…”

“…5 In addition to these pharmacological strategies, the relevant British Association for Psychopharmacology (BAP) and National Association of Psychiatric Intensive Care Units (NAPICU) joint guidelines also recommend IM promethazine, aripiprazole, droperidol or olanzapine alone, or the combination of IM haloperidol and IM lorazepam. 6…”

“…In recognition of the potential for clinically significant adverse effects associated with the use of parenteral medicines for RT, NICE recommends that blood pressure (BP), pulse, temperature, respiration, level of hydration and level of consciousness should be monitored at least every hour after RT until there are no further concerns, with more frequent monitoring in those patients who may be at an increased risk of complications for any reason. 5 The BAP/NAPICU guideline sets more stringent standards, recommending that, as a minimum, psychiatric observations, respiratory rate, oxygen saturation, systolic BP, pulse, temperature and level of consciousness should be documented every 15 min for 1 h. 6 However, little is known about the extent to which these recommendations are implemented in clinical practice. Loynes and colleagues contacted 58 mental health Trusts in England requesting copies of local audits of RT practice.…”