Implementation: getting started

While developing this guideline, the Guideline Development Group identified 13 recommendations in 6 areas as key priorities for implementation. With input from stakeholders, experts and health professionals, 3 areas were identified as having a big impact on practice and being challenging to implement. This section highlights some important changes to practice that may result from implementing the guideline. However, other changes to practice may be needed to fully implement the guideline.

Staff working in inpatient mental health and emergency care settings may be particularly affected by these changes.

Manual restraint

Recommendations 1.4.4 to 1.4.6 and recommendations 1.4.24 and 1.4.29.

Potential impact of implementation

This guideline recommends that taking service users to the floor during manual restraint should be avoided, but that if it is necessary, the supine (face up) position should be used in preference to the prone (face down) position. The Winterbourne View Hospital: Department of Health review and response reported that restraint was being used to abuse service users. Mind's Mental health crisis care: physical restraint in crisis found that restrictive interventions were being used for too long, often not as a last resort, and sometimes purposely to inflict pain, humiliate or punish. Mind also reported that in 2011/12 the prone position was being used, in some trusts as many as 2 to 3 times a day. This position can, and has, caused death after as little as 10 minutes, by causing a cardiac event. Consistent implementation of these recommendations will save lives, improve safety and minimise distress for all involved.

Challenges for implementation

  • Higher staffing levels will be needed in some settings to successfully implement these recommendations, particularly ensuring that a doctor trained to use emergency equipment is immediately available if manual restraint might be used.

  • Training will be needed in psychosocial interventions to avoid or minimise the use of restrictive interventions, and about why manual restraint, when used, should last no longer than 10 minutes.

Support for implementation

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Rapid tranquillisation

Recommendations 1.4.37 to 1.4.45

Potential impact of implementation

Rapid tranquillisation is defined in this guideline as the administration of sedative medication by injection, and although a number of effective agents are available for sedation, there is no evidence showing clear superiority for any one agent. Therefore individualised treatment needs to be emphasised, taking into account the service user's view, pre‑existing physical health problems, previous response to medications including adverse effects, the potential for interactions with other medications, and the total daily dose of medications prescribed and administered. Intramuscular lorazepam is recommended for service users who have not taken antipsychotic medication before because it is an effective intervention that is likely to be acceptable to the majority of service users. Prescribing the initial dose of rapid tranquillisation as a single dose will ensure that any subsequent treatment options can be individualised, taking account of both response and any emergent adverse effects of the initial treatment choice.

Challenges for implementation

  • During development of the guideline it became known that the manufacturer of intramuscular olanzapine had decided to withdraw the product from the UK market, and so the Guideline Development Group would not be able to make recommendations for its use. However, it remains a licensed product in the European Union (EU) and some organisations import the product from elsewhere in the EU.

  • Local rapid tranquillisation policies and protocols will need revision and healthcare professionals will need educating in how these differ from previous versions. It may also be necessary to emphasise the need to tailor the choice of medication for rapid tranquillisation to the individual. Where rapid tranquillisation is used, adequate numbers of skilled staff should be available to monitor the outcome of the intervention in order to make an individualised decision about subsequent choice of medication and dose frequency.

Support for implementation

  • The rationale for the recommendations is described in section 6.5.1 of the full guideline.

  • The cost difference between medication options is not large and the most cost‑effective strategy is likely to be one that tailors treatment to the individual, taking into account their preferences, current medication and medication history.

  • The use of intramuscular lorazepam for service users who have not taken antipsychotic medication before is supported because of its favourable benefit:harm profile.

  • Although it is possible to import intramuscular olanzapine into the UK as an EU‑licensed product, the Guideline Development Group was unable to comment on the use of this preparation because the manufacturer had withdrawn it from the UK market.

  • These recommendations do not preclude the use of alternative treatment options. However, their use should be tailored to the individual in line with the recommendations for rapid tranquillisation.

  • The summary of product characteristics for haloperidol recommends a baseline electrocardiogram (ECG). If an ECG is not available the prescriber should consider the risks and benefits of using this treatment and be able to justify their prescribing decision, because it may be considered an off‑label use.

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Formal external post-incident reviews

Recommendations 1.4.53 to 1.4.63

Potential impact of implementation

Formal external post‑incident reviews are an important aid in identifying the causes and effects of violence if restraint is needed to contain a situation, and the impact of this on all involved. Full recording of incidents of violence and aggression is currently variable and therefore it is difficult to get a clear picture nationally. Mind's Mental health crisis care: physical restraint in crisis reported responses from freedom of information requests made to all 54 mental health trusts in England in 2013 about the use of prone restraint. Of these, 27 trusts did not record this information.

The information gathered during a review can inform future service delivery and, on an individual level, any further work with the service user involved to make it less likely that a similar event will happen again. Use of formal external post‑incident reviews could lead to safety improvements for staff and service users, and save costs to the service long‑term if, as a result of the review, positive changes are made to avoid such situations in the future.

Challenges for implementation

  • In organisations where formal external post‑incident reviews are not carried out routinely, new policies and processes will need to be developed; staff will need to be trained to carry out the reviews and service users will need to be supported to take part in this process.

  • Additional training and guidance will be needed about when and how to approach service users to include them in the process in ways that meet their needs.

  • Getting all of the necessary staff, including a doctor, in addition to volunteers and service users to participate in the review process may have an impact on current workload and service capacity.

  • In some settings there can be many incidents in a short time. In such circumstances implementing the 72‑hour follow‑up may be more challenging.

Support for implementation

  • The framework outlined in recommendation 1.2.7 can be used to determine the factors that contributed to an incident that involved using a restrictive intervention.

  • No economic evidence was found on post-incident management strategies. Clear costs are incurred when considering the staff time needed to deliver comprehensive post‑incident reviews. These costs may be recouped by the potential for improved relationships and better understanding of events, allowing safer and more adaptive practice in the future.

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