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Are nurses too quick to use rapid tranquillisation?

  • Comments (28)

Rapid tranquillisation on mental health wards is much-debated.

On the one hand, rapid tranquillisation is sometimes needed to maintain the safety of the ward, on the other hand it carries with it extreme risks to the patient, can be addictive and arguably should be the last resort when all other methods of de-escalation have failed.

Patients are often subscribed tranquillising and antipsychotic drugs PRN so they can approach staff if they feel they need additional medication. In my experience, this can work well with patients being afforded the opportunity to take responsibility of controlling their symptoms before escalating.

However, as a staff nurse what do you do if a patient asks for medication they do not appear to need?

As you can’t tell what’s happening in someone’s mind, should you take their word for it that they know what they need?

What if they have been sitting watching TV, appearing calm for the past hour, and strolled to the nursing station to request highly-addictive benzodiazepines?

Giving medication without clinical need is not in the patient’s best interest and may in fact be feeding an addiction.

But, what if saying “no” leads to aggressive behaviour, putting patients, staff, visitors and the hospital environment at risk?

I have witnessed patients requesting lorazepam without clinical need only to be, rightly, refused this by nursing staff. In order to ensure they got the medication they wanted, I’ve seen patients then damage hospital property, threaten staff and other patients and escalate to the point that staff have no choice but to medicate in order to maintain the safety of the ward.

This positive reinforcement of disruptive behaviour only leads to the same happening again.

Benzodiazepines are all too often given without consideration to the long-term consequences. The MDT must look at ways to balance the short-term benefits of using these drugs with the long-term affect they may have on the patient and the nature of their care.

What do you think? Do we give out too many benzodiazepines without considering the consequences of long-term addiction? Are we too quick to use rapid tranquillisation to de-escalate?

  • Comments (28)

Readers' comments (28)

  • Anonymous

    presumably these are prescribed by doctors who I would hope have spoken to patients and staff about the need and effects of their medication.

    presumably it is then the doctors responsibility to offer support and guidance to patients if they don't feel they are getting their medication when they need it, or offer detox if appropriate.

    presumably (but very doubtful) management support nursing staff when patients become aggressive, demanding medication, this is not just something that happens in mental health units - patients can be aggressive and demanding on general wards. i would hope in a mental health setting you'd at least have sufficient staff with the correct training to deal more effectively with disruptive patients, we certainly don't have either on the general wards.

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  • Anonymous

    is prn diazepam or lorazepam given to a calm patient classed as 'rapid tranquilisation'?

    isn't 'rapid tranquilisation' given to patients when they are acutely disturbed?

    if a patient is addicted to benzo's shouldn't they be offered the same support as any other patient with any substance addiction?

    if a patient requests something to keep them calm, is witholding it any different to a nurse witholding analgesia to a patient who states they are in pain?

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  • Anonymous

    Acting out in order to secure a dose of medication which the patient knows is prescribed and available is a totally foreseeable event and is avoidable. Such patients may be addicted or simply indulging in manipulative behaviour.

    Nurses should avoid such confrontation as the patient will always end up "winning"

    Inappropriate behaviour should be noted and be the subject of multi-disciplinary care planning. This should result in a co-ordinated plan which should not include the PRN prescription of benzo's!

    Patients should own and co-operate with their plan of care if they are unwilling to do so then discharge is appropriate.



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  • Anonymous

    Agree with Anonymous 3.28pm.

    These situations are entirely avoidable but if benzos are prescribed prn, and the patient knows it, it can be very difficult for nurses if the patient has the intention of getting prn no matter what.

    I wonder if the answer lies in better communication with the medical team about what should be prescribed. I've seen doctors write up prn (loraz and haloperidol) IM and oral for patients before they have fully assessed the patient. Surely that assumption shows a far too relaxed attitude to powerful drugs?

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  • Anonymous

    anon 3.28 - this happens on the general wards too. patients want painkillers or benzo's, they become very argumentative if they don't get them.

    what is 'rapid tranquillisation?

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  • What about the milky white stuff?

    ;)

    Milk

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  • Anonymous

    I don't have a great deal of mental health experience at a senior level, but what are nurses supposed to do when in a vulnerable position with demanding patients demanding benzo's??!
    Often dwindling colleagues are not close by, (its laughable to think management would be on hand to help); and medical help is scant and takes ages to respond.
    Patients know when to ask for prn meds, they know the vulnerable times when staff patient ratio is at its lowest, and they know they will get it due to lack of staff to deal with any situation when they "kick off."
    The nurse patient ratio in all areas is now far too small, but can be extra risky for the nurse (and other patients ) in mental health units.

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  • Someone asked what is rapid tranquillisation(RT)?
    NICE guidelines recommend RT for the short-term management of violent or disturbed behaviour after de-escalation techniques and alternative measures have been used or are considered not clinically appropriate. Medication should be offered in tablet form first and if refused given via intramuscular injection (IM). Haloperidol and or Lorazepam are usually used.

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  • Anonymous

    Sheila O'Neill | 16-May-2013 2:55 pm

    thanks for the information.

    if a patient refuses to take the tablet does this mean you can use the injectables by force, presumably under the mental incapacity act? if this is the case who has the authority to implement this? does this also apply on a medical ward or other facility outside MH to nurses without MH training?

    In the old days, and outside the UK when things were rather different, it happened to me once on my general medical ward where we had quite a few substance abusers over the years but apart from stealing on rare occasions or taking Rohypnol from the drug cupboard they were fairly passive.

    One evening however when on duty on my own I had a very over active patient. I called the doctor who prescribed Largactil and left leaving me running all round the hospital and up and down in the lifts chasing the patient with syringe prepared on a tray. In retrospect I could hardly have used it anywhere except on the ward and in his bed or at least an armchair. I certainly would not do that now. Eventually back on the ward I managed to enlist the help of a colleague from the neighbouring ward who left her patients briefly to go down the seven floors to the basement and procure a cage bed which we tried to use as rarely as possible and hated them. However, there seemed little choice. she also summoned the junior doctor on call back to the ward and they jammed the bed across the corridor whilst I cornered the by then fairly aggressive patient on his return. we duly imprisoned him in the cage and it was left to me, with his limbs flaying, to administer the injection. however, I insisted the other two staff remained to hold him down as they were about to leave and I managed to inject him through the holes in the netting. It was always rather a case of its your patient, your problem, deal with it and in due fairness difficult for others to leave their station for longer than absolutely necesssary. fortunately he slept and without further sequelae or incident but it was not a very elegant or satisfying nursing care procedure although at the time there seemed few options alone on the ward with an aggressive patient and all the other nineteen to think about.

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  • David Dickinson

    RT is something that can only be weighed up on the spot and each situation is different.

    It is the skill of the nurse to share and recommend according to their knowledge and relationship with the patient to maximise the liklihood that in the aftermath it was the minimum required which acheived the desired outcome.

    A good consultant if it as that degree of mergency will always listen carefully to the views and opinion of a nurse.

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