Alternative Injection Sites: Reducing Prone Restraint in Tier 4 CAMH’s

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

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

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

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

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

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

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

8. Demonstration

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

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

11. Any Questions ?