Safer Management of Acute Agitation in Children and Adolescents
Dr. Yulia Zyrianova implements innovative practices towards safer management of acute agitation and arousal in children and adolescents, culminating in the development of a novel Paediatric Agitation and Arousal Protocol and Medication Chart. Dr. Zyrianova, a Consultant Child and Adolescent Psychiatrist, brings a wealth of expertise to her role as Chair of the CAMHs Medication Safety Committee at PMH CAMHS Hospital Based Services.
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The implementation of innovative practices towards safer management of acute agitation and arousal in children and adolescents leading to development of novel Paediatric Agitation and Arousal Protocol and Medication Chart Dr Yulia Zyrianova Doc of Medicine, MD (Psychiatry), GDip (University Teaching), MRCPsych, Clinical Senior Lecturer (UWA), FRANZCP Consultant Child and Adolescent Psychiatrist Chair of CAMHs Medication Safety Committee PMH CAMHS Hospital Based Services
INTRODUCTION Acute severe behavioural disturbance has emerged as a significant risk to the safety of both patients and staff in the emergency department and acute psychiatric inpatient settings (BAU). CAMHS devised new paediatric agitation and arousal protocol and I postulate that it represents an improved standardized measure in management of acute agitation and arousal in children and adolescents.
Australian Commission on Safety and Quality in Health Care/ 2017 University of South Australia medication safety in mental health report to introduce a decision support tool for use in the acute care setting as a mechanism to assist staff to make more consistent decision making regarding prn medicines use A growing need for such transforming care initiative was identified.
ADVANTAGES This novel protocol incorporates: helpful decision support tool takes in to account medication reconciliation helps to reduce multiple antipsychotic use (Intra-class Polypharmacy) improves cardio-metabolic monitoring while regularly assessing levels of arousal and sedation
Pharmacologic management algorithm for a new episode of Agitation and Arousal Please refer to the Copy of the chart PATIENT AROUSAL RATING SCALE Highly aroused, violent towards self, others or property 5 4 Highly aroused, and possibly distressed or fearful 3 Moderately aroused, agitated, becoming more vocal or unreasonable or hostile 2 Mildly aroused, pacing, still willing to talk reasonably 1 Settled, minimal agitation, PRN not required 0 Asleep or unconscious
Problems with access to Lorazepam IMI CAMHS Medication Safety Committee recommendation for the use of Lorazepam IM for management of arousal, as a safer pharmacological agent with a superior pharmacokinetic profile to Midazolam or Clonazepam in this setting. We made Drug Therapeutic Committee submission for IM Lorazepam to be imported through SAS - Cat A scheme - patient behaviour could be considered life threatening in a court of law. Lorazepam s preferred use is supported by recognized international practice and has been already adopted by some states in Australia (Queensland and New South Wales), and also locally (FSH).
Transforming care initiative The process of driving this initiative was three-fold. 1. it required the development of new guidelines for the management of agitation, aggression and potentially violent behaviour in adolescents in BAU that was geared towards all level of staff s training. 2. a new Arousal Medication Chart was produced to guide the prescribing in a safe and evidence-based manner and to enforce scrutiny and accountability over PRN prescribing practice. 3. the new practices are being implemented in collaborative and reflective practitioner way with frontline staff offered opportunity to familiarise themselves in the new practice
Building therapeutic relationship with an agitated young person
IMPLEMENTATION When consultation process starts with a clear vision and strategy it must be communicated effectively to frontline staff. A new Arousal Medication Chart was produced to guide the prescribing in a safe and evidence-based manner and to enforce scrutiny and accountability over PRN prescribing practice. The alignment between People/System/Process made the desired change possible. Tapping into the knowledge of experienced staff and by consultation with specialists committees (PMH MSRG and WAPDC) created the alignment focus in this project and helped to promote the new tools to diverse range of health professionals and consumers.
Conclusion Unlocking the power of innovation requires the pro-engagement of frontline staff at every step of the continuum from vision into changes and results. The development of the chart is an example of successfully addressing specific medication safety issue and represents a significant WIN moment.
