Use of a Novel Standardized Administration Protocol Reduces Agitation Pro Re Nata (PRN) Medication Requirements: The Birmingham Agitation Management (BAM) Initiative

BACKGROUND

Agitation management is a principal challenge on inpatient psychiatric units. Overreliance on common prescribing strategies of pro re nata (PRN) medication administration is problematic, given the tendencies to have overlapping or unclear indications.

OBJECTIVE

Piloted project to determine whether a standardized protocol for agitation intervention may reduce PRN medication administration.

METHODS

The Birmingham Agitation Management (BAM) interdisciplinary team uniquely connected the Brøset Violence Checklist (BVC) for assessment of agitation severity to a standardized PRN medication order set. Nurses on the piloted unit were trained on how to score the BVC and administer medications. Patients were assessed by the BVC every 4 hours and, based on their score, would receive no medication, low-dose benzodiazepine, high-dose benzodiazepine, or high-dose benzodiazepine plus antipsychotic. The primary end point compared the number of PRNs administered after novel protocol implementation with a retrospective cohort. Secondary measures included analysis of medication-related effects, seclusion, and physical restraint rates.

RESULTS

377 patients were included in the final analyses (184 pre-BAM, 193 BAM intervention group). No significant differences were seen in patient characteristics between groups. The total number of PRNs administered decreased by 42.5%, with both the mean and median number of administrations decreasing significantly (95% confidence interval [CI] = [1.68-5.75]; P < 0.001). A trend was noted between the number of PRNs administered and seclusion rates, but did not reach statistical significance (95% CI = [-7.28 to 60.31]; P = 0.124).

CONCLUSIONS

In seemingly the first initiative of its kind, we found that a standardized agitation management protocol can help decrease the total number of PRN administrations for agitation without worsening of restraint rates and may possibly reduce the risk of adverse effects. These results require validation in specific, larger populations.

Adherence to national recommendations on antibiotic policies and impact on prescribing in an NHS region

Focal points

Cerebral blood flow velocity during tilt table test for pediatric syncope

BACKGROUND

Brain hypoperfusion during neurocardiogenic syncope develops as a consequence of hypotension and bradycardia. Transcranial Doppler indicates that an increase in cerebral vascular resistance occurs before or during the loss of consciousness.

OBJECTIVE

Cerebral blood flow velocity was studied during tilt table testing in pediatric patients with neurocardiogenic syncope. We assessed whether a critical reduction in flow velocity (>40%) was predictive of the presyncopal manifestations during the test.

METHODS

A 2-MHz transcranial Doppler measured blood flow velocity in the right middle cerebral artery in 27 pediatric patients (ages, 8 to 18 years) during a three-stage 80 degrees tilt table test protocol. A positive test required development of syncope or presyncope with at least 30% decrease in systolic blood pressure and/or heart rate relative to preceding values. Patients were divided into: group I (isoproterenol-induced positive tests), group II (positive without isoproterenol), and group III (negative tests).

RESULTS

Within the first 3 minutes of the upright position mean cerebral blood flow velocity in groups I, II, and III decreased by 18%, 29%, and 17%, respectively, as the systolic and diastolic blood pressures showed only minimal changes. A decreased mean blood flow velocity of 48% and 45% and an increase in resistance index of 42% and 26% from supine values in the absence of hypotension, were detected in groups I and II at 46 seconds (range, 30-120 seconds) and 50 seconds (range, 0-300 seconds) before any clinical symptom (presyncope latency). Mean blood flow velocity during presyncope decreased by 58% and 59%, whereas resistance index was double. A significant correlation (rho = -0.62) was found between presyncope latency and the decreased mean cerebral blood flow velocity. Similar blood flow velocity changes were not detected in group III.

CONCLUSION

A sustained reduction >40% in mean cerebral blood flow velocity in the absence of hypotension always resulted in presyncopal or syncopal manifestations. It seems that once this critical threshold is identified during the tilt table testing, supine position may be resumed several seconds before the clinical manifestations of syncope.

When They Drink Too Much Nursing Interventions for Patients with DISORDERED WATER BALANCE

Disordered water balance affects as many as 60% of severely psychiatrically disabled persons. Most patients do not progress to the point of a medical emergency, but are in a state of mild chronic intoxication, making them unavailable for treatment and requiring nursing care to treat the effects of the chronic intoxicated state. Interventions depend on the severity of the disordered water balance and vary from teaching fluid intake control to controlling all patient access to fluids. Nursing management of water intoxication is a trial and error approach. Through a thorough assessment and close observation of the patient, the nurse can determine which interventions would be most appropriate for the patient.

Issues in the nursing management of patients with water intoxication

The syndrome of water intoxication, experienced by a small percentage of hospitalized chronically mentally ill patients, is a two-stage process, usually beginning with polydipsia. In some patients the physiological ability to excrete excess free water is lost, and polydipsia progresses to hypervolemia and hyponatremia. The hyponatremia responds to fluid restriction. Nevertheless, nursing intervention associated with limiting a patient's fluids is complex, including psychodynamic, social, and behavioral factors. Because of the complexity of nursing care, and because of the unanswered questions about etiology and treatment of water intoxication, the area is fertile for nursing research.