Reducing the Use of Rapid Tranquilisation in Over 65s in a General Hospital

Abstract

Aims

A previous audit of use of rapid tranquillisation in older adults conducted in 2019 identified high rates of use of sedation, and poor adherence to local guidelines. Following this audit, a number of quality improvement (QI) initiatives were undertaken in order to try to improve practice, including multiple teaching sessions to a variety of staff. This re-audit was conducted to study whether initiatives had been effective in line with the Plan Do Study Act cycle of Quality Improvement.

Methods

Using the same audit tool developed in 2019, six wards (2 geriatric, 3 medical and 1 surgical) were audited. Patients over 65 given oral or intramuscular sedating medications had their drug charts and notes reviewed. Data were collected on type of sedation, route prescribed, whether it was prescribed regularly or PRN, whether an indication was documented, underlying diagnosis and what monitoring took place post sedation.

Results

297 drug charts were reviewed, and 13 patients were prescribed rapid tranquilisation (RT). The maximum daily dose was included in 63% of prescriptions similar to that of the first audit (58%). The most common route of administration was intramuscular, unlike the previous audit which was oral/intramuscular.

50% of prescriptions documented an indication, of which 25% were illegible. Whilst in the first audit the figure was 33%.

Of all the patients prescribed RT, 77% had a diagnosis of delirium, 77% had a diagnosis of dementia and about 53.8% had both. In both audits 100% of patients had a diagnosis of dementia or delirium. Most prescriptions were for lorazepam (75%). There was no evidence of observations being taken in line with post RT monitoring in the trust policy in both audits

Conclusion

Further work needs to be done to improve practice. Interventions to date have not been effective. Further plans for QI work include updating the RT policy to be more specific and useful for the acute trust, to fit in with a recently introduced electronic records system (ERS) and to include a clear section on older adults with signposting to the delirium and dementia policies. As well as adding prompts and protocols to the ERS to support safe prescribing and dispensing of RT. Teaching will be repeated and a poster has been developed and promoted on all the wards. The project group are planning to join the trust's ‘medication safety huddle’ regularly to include pharmacists in teaching and work. The audit will be repeated in three months time.