Alternative Injection Sites Reducing Prone Restraint in Tier

Alternative Injection Sites: Reducing Prone Restraint in Tier 4 CAMH’s Embedding a new culture within nursing through education

Background/Context (Wider Trust) l Reportedly high use of ‘Prone Restraint’ l Strong correlations between Prone use and administration of rapid tranquilisation (70%) l Nurses were stating that there were no alternative options in these situations to give injections l A review identified multiple issues with giving injections in the Dorsogluteal muscle l Licensing issues identified as barriers to alternatives l Nurses reported high levels of anxiety in changing there approach

Background/Context (Within CAMH’s) l Acknowledging the trauma associated with Gluteal IM injection site for abuse victims l Normalised for children to receive vaccines within deltoid therefore continue with this practice l Reported high use of Prone Restraint prior to implementation l When administering during restraint, little changes required to holds in Supine position. Limiting the duration of the physical intervention as a whole.

Practice development (Trust Wide) l Identified alternative sites l Developed ‘confidence’ l Providing a range of options to manage clinical situations – promoting service user involvement (PBS plans). l Building relationships between wards and PAT Team/Positive and Safe Lead to call on for support l Workshop development : l 60 minutes l Clinical simulation aids l Attendance/ further support

Rapid Tranquillisation (RT) policy (Including prescribing, post administration monitoring and remedial measures, Revised Sep. 2016) l Use a site for IM administration which maintains patient dignity and reduces risk l Lorazepam, Haloperidol and Promethazine may be administered into the deltoid, gluteal or lateral thigh muscle l Aripiprazole may be administered into the deltoid or gluteal muscle

Alternative Site - Deltoid l Easily accessible l Patients are generally a lot more comfortable l Little change required to holds in Supine Position l Good blood flow l 1 ml maximum volume l Frequently used in CAMH’s l Not suitable for repeated use/Risk assessment in ED or Low Body Weight patients

Alternative Site - Ventrogluteal site l Reduce risks , due to no major blood vessels or nerves in the area l Less fat and great muscle mass, increases potential effectiveness of the intervention l Good blood flow l Suitable for volumes between 1 -4 ml l Challenging to administer l Low confidence in staff

Demonstration

Changes to Practice l 55% reduction in Prone restraint across Tier 4 CAMHS l Focus group reported improvements in patient experience following the changes l Increases in service users making advanced directives about approaches to be taken in administering RT l Staff report increased effectiveness following administration, which may assist to reduce the length of restraint l Training of Preceptorship nurses has resulted in changes to culture and practice l Currently 20% of RT administration is through Deltoid and Ventrogluteal sites

Next Steps/ Trust Wide Implementation l Revised policies for Behaviour Support and Administration of Rapid Tranquilisation l Improved process for reporting RT administration l ELearning injection awareness training now available Trust wide l Continued access to skills workshops across the Trust l Confident nurses who are role modelling the alternatives and professionally challenging calls when Gluteal Muscle is suggested l Review and further development of Ventrogluteal site training for nurses l Continued monitoring and evolution of the approach l Hot Spot monitoring of Prone Restraint incidents by Positive and Safe Team

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