Jonathan Knott, Royal Melbourne Hospital: Therapeutic Sedation in the Emergency Department

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Assoc Prof Jonathan Knott, Head of Emergency Research, Royal Melbourne Hospital; Clinical Sub-Dean for Emergency Medicine, University of Melbourne delivered this presentation at the 2013 Safe and Secure Hospital Conference. The comprehensive program addressed the following issues:

Early intervention via early reporting of disruptive, aggressive, and bullying behaviour to minimise work place violence
An innovative training model to help clinicians, security and policy makers respond to the problems of challenging behaviours
Therapeutic sedation in the Emergency Department: Best practice in managing the highly agitated patient
A systems approach to the prevention of Occupational Violence and Aggression (OVA)
Contract management security: The change from in-house security to contract security
Role of the Risk Based Approach throughout the design process
Preventing and managing clinical aggression in the paediatric and youth health setting
The roles, functions and training provided by the Mental Health Intervention Team (MHIT), New South Wales Police Force
Interactions between Police, Health staff, Ambulance and Hospital Security and future directions
A Legal Perspective: Prevention and management of violence in hospitals
Code Grey responses - Are they legal?

For more information about the annual event, please visit the conference website: http://www.healthcareconferences.com.au/safehospitals

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Jonathan Knott, Royal Melbourne Hospital: Therapeutic Sedation in the Emergency Department

  1. 1. Therapeutic sedation in the Emergency Department Jonathan Knott Melbourne Health University of Melbourne
  2. 2. Introduction • • • • • • Alternative environments Better environments Managing issues De-escalation Show of Force Restraint
  3. 3. Background Restraint is employed in 0.3 to 1.5% of Australasian ED presentations Cannon et al ANZ J Psych 01 Knott et al ACEM scientific meeting 02
  4. 4. ED Restraint in 5 Melbourne EDs Code Grey called on 8% of MH presentations Mechanical restraint required for 4% • Median time • Maximum time 3 hours 39 hours Therapeutic sedation required for 11% • • • • Diazepam Midazolam Droperidol Olanzapine 42% 36% 25% 11%
  5. 5. 0200 Emergency – Friday night 45 yo, BIB police after a domestic dispute with his girlfriend. He is clearly intoxicated and stated “I may as well just go and jump off the Westgate Bridge”. On arrival police say he has been cooperative. He is upset and agitated but agrees to stay in ED and be assessed. There is no evidence of self-harm. His blood alcohol comes back at 0.35 and he falls asleep
  6. 6. 0400 Patient (Jack) is now awake and agitated. He appears too intoxicated to walk but is keen to leave stating “you are doing nothing for me I am going to just go home”. When asked what will he do at home he states “kill myself”.
  7. 7. 0530 Jack gets off the trolley and when a nurse attempts to stop him leaving he pushes her to the ground and staggers down the corridor in his gown. Security are called and arrive 5 minutes later. Jack is yelling abuse at the security staff and refusing to engage with the clinical staff
  8. 8. Contributing Factors to Code Greys Psychiatric illness Alcohol intoxication Drug intoxication Unfilled request Medical condition Other 52 % 30 % 16 % 13 % 10 % 10 %
  9. 9. Code Grey • Team composition – Disciplines – Leadership • Training • Governance
  10. 10. Daniel Daniel, 23, 110kg brought in by parents at 2300 as he is too agitated at home, hasn’t slept for three days. May be using drugs. Elevated in ED but accepts oral medication and sleeps. Parents stay with him
  11. 11. Daniel Next morning he is getting increasingly upset and has pulled out his IV. He is refusing oral medication. Psychiatry think he will be admitted but have not finalised their assessment. The ED consultant wants to give IV sedation so calls a Code Grey to assist
  12. 12. Daniel Security arrive and are negotiating with Daniel with the doctor’s assistance Daniel reaches into his bag, security grab his arm and all move in to contain him. He is suddenly, very agitated
  13. 13. Daniel At this point the mother is screaming at security to let her son go and grabs one of the officers from behind around the neck. He is pulled off balance and the team splits
  14. 14. Survey of restraint practice – ACEM 2010 Case vignette with three hypothetical clinical scenarios 1. Cause of agitation unknown: “A 33-year-old male, of average build, is brought into ED by the police. The hospital internal security alert (“code grey”) is called. He is severely agitated, aggressive and is shackled to a trolley after threatening staff and kicking doors. No medical or medication history is available. You do not know if he is affected by drugs/alcohol or has mental illness. You decide to administer chemical restraint.
  15. 15. Choice of initial chemical restraint Route of administration Values (%) Drug Intravenous Intramuscular Oral 476 (60.8) 26 (3.3) 5 (0.6) 32 (4.1) 10 (1.3) 10 (1.3) 4 (0.5) 3 (0.4) 132 (16.9) 18 (2.3) 23 (2.9) N/A 8 (1.0) 2 (0.3) 2 (0.3) N/A N/A N/A 8 (1.0)b 1 (0.1) N/A 1 (0.1) N/A N/A Chlorpromazine N/A 1 (0.1) N/A Ketamine N/A 1 (0.1) N/A Suxamethonium N/A 1 (0.1) N/A Midazolam Haloperidol Olanzapine Diazepam Droperidol Lorazepam Clonazepam Propofol
  16. 16. Reason for choice of initial chemical restraint 692 (88.3%) Rapid onset Relative safety 630 (80.5%) Sedation guidelines 92 (11.8%) Dosage forms 80 (10.3%) Duration of action 4 (0.5%) Familiarity of use 2 (0.3%)
  17. 17. Results: Combination therapy: 500, 63.9% Initial pharmacological agent Midazolam Haloperidol Midazolam Diazepam Droperidol Others 92 (18.4) 5 (1.0) 80 (16.0) 5 (1.0)a 0 202 (40.4) Olanzapine 3 (0.6) 0 3 (0.6) 0 2 (0.4)c 2 (0.4) 9 (1.8)b Haloperidol 22 (4.4) Olanzapine 18 (3.6) 0 Diazepam Droperidol Lorazepam Clonazepam Propofol Chlorpromazine Ketamine 0 11(2.2) 0 0 0 1 (0.2) 0 26 (5.2) 0 6 (1.2) 3 (0.6) 1 (0.2) 0 0 2 (0.4) 1 (0.2) 1 (0.2) 3 (0.6) 0 0 1 (0.2) 1 (0.2) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL 52 (10.4) 238 (47.6) 100 (20.0) 12 (2.4) 82 (16.4) 16 (3.2)
  18. 18. Reason for choice of combination
  19. 19. Droperidol v Olanzapine as adjuncts to Midazolam • Randomised, double-blind, placebo-controlled, double-dummy, clinical trial • Drugs most commonly used in Victoria • St. Vincent’s, Royal Melbourne, Austin EDs • August 2009-March 2011
  20. 20. Results Control n=115 Droperidol n=112 Olanzapine n=109 10 (4-25) 6 (3-10) 5 (3-10) <0.001 27.0 35.7 35.8 0.27 @ 10 min 48.7 66.1 67.9 0.01 @ 30 min 78.3 92.0 89.9 0.01 @ 60 min 87.0 94.6 95.4 0.03 Time to adequate sedation min, median (IQR) Proportion (%) sedated @ 5 min p
  21. 21. Results 0.50 0.75 1.00 Kaplan-Meir failure curve 0.00 0.25 control droperidol olanzapine 0 20 40 60 80 Time to sedation (min) Placebo Droperidol Olanzapine 100 120
  22. 22. Results Control n=115 Droperidol n=112 Olanzapine n=109 p 15.7 10.7 8.3 0.21 Oxygen desaturation (%) 7.8 8.0 4.6 Airway obstruction (%) 4.4 2.7 2.8 Hypotension (%) 5.2 3.6 2.8 Arrhythmia (%) 0.9 0.0 0.9 Profound decreased GCS (%) 0.9 0.0 0.0 Adverse event Proportion of patients (%)
  23. 23. Take Home Message Both drug combinations are superior to midazolam alone • • • • More rapid sedation More likely to be sedated at any time Less ‘sedation failure’ Less ‘rescue’ medication Comparable:  ED length of stay  Place of discharge  Safety profiles
  24. 24. Reducing Restrictive Interventions • Victorian project • Reduce restraint and seclusion in mental health settings and EDs • Eliminate interventions? • What do patients think?
  25. 25. Patient Preferences • • • • Structured interview Code Grey and restraint in the previous 24 hours Knowledge and necessity of restraint VAS for 5 emotional axis • • • • • Anger Happiness Anxiety Gratitude Fear • Injury • Preference for future restraint
  26. 26. Results Aware of restraint 31 • Mental illness • Intoxication • Not associated with sedation (70%) (77%) (61%) Reason for restraint 18 (41%) Restraint necessary 11 (31%) • Mental illness • Intoxicated Reported Injury (22%) (50%) 11 (25%)
  27. 27. Results 0 5 10 Anger 37 7 33 Happiness 12 33 33 Gratitude 19 35 23 Anxiety 30 19 26 Fear 28 19 26
  28. 28. Results Patients with mental illness – Less happy – Less grateful – No difference in anger, anxiety or fear scores Choice of chemical restraint made no difference to impact of restraint
  29. 29. Future restraint Restraint For others For myself Sedation Physical Manual None Unsure 46% 25% 18% 9% 23% 52% 23% 23% 14% 16% Divergence = 32%
  30. 30. Conclusion Highly agitated patients are a major issue for EDs Restraint of the unknown patient remains an ethical minefield The role of senior experienced leadership is unknown Patient expectations may not be selfevident
  31. 31. References • • • • Intravenous droperidol or olanzapine as adjuncts to midazolam for the acutely agitated patient: a multi-centre, randomised, double-blind, placebo-controlled clinical trial. Chan E, Taylor DMcD, Knott JC, Kong D, Castle DJ, Phillips G. Annals Emerg Med 2013; 61(1):72-81 Variation in the management of hypothetical cases of acute agitation in Australasian emergency departments. Chan EW, Taylor DMcD, Knott JC, Kong DW. Emerg Med Aust 2010; 22: 524-32 Mental health presentations to the Emergency Department JC Knott, A Pleban, D McD Taylor, D J Castle. ANZ J Psych 2007; 41 (9): 759-67 Randomised double-blind clinical trial of intravenous droperidol versus midazolam for sedation of the acutely agitated patient in the Emergency department. JC Knott, DMcD Taylor, DJ Castle. Annals Emerg Med 2006: 47 (1); 61-7
  32. 32. Results QTc interval (<60 minutes after adequate sedation) 450 400 350 Corrected QT interval 500 Control group Droperidol group Olanzapine group

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