Prescribing, administration and recording of as required psychotropics

• Psychotropic drugs are frequently prescribed on an ‘as required’ basis when patients are admitted to mental health wards.
• They are intended to be available for nursing staff to administer at their discretion to patients as part of the management of acute psychiatric symptoms e.g. agitation, anxiety and distress.
• Local and national audits have identified on many occasions that these drugs are often prescribed without appropriate care, administered unnecessarily and the details surrounding their use is often inadequately documented. There is often lack of review leading to almost open ended prescriptions.

1. Ideally don't prescribe as required psychotropic drugs on admission.
2. Assess the need individually and if appropriate prescribe once only doses initially.
3. If once only doses are used then the need for a routine as required prescription should be considered.
4. When prescribing as required psychotropic drugs ensure the following details are clear on HEPMA; the individual dose, route of administration, frequency of administration, maximum dose to be given in any 24 hour period. Maximum dose in 24 hours should be added as a PRN note at the time of prescribing.
5. With the exception of clozapine, the patient’s regular antipsychotic may be an appropriate choice for as required use.
6. Do not prescribe as required antipsychotics to antipsychotic naive patients. Prescribe benzodiazepines until the clinical situation becomes clear.
7. Express the indication clearly i.e. try and avoid simply stating ‘agitation’. This should be added as a PRN note at the time of prescribing
8. Ensure there is a clear entry in the chronological account of care recording the rationale for the prescription.
9. Ensure any requirements of the Mental Health Act are met.
10. Review the prescription on a regular basis and consider discontinuation if it has not been administered within the last 4 weeks.
11. If haloperidol is to be prescribed consider potential contra-indicated interactions, the patient’s cardiac status and if practical do an ECG to exclude prolonged QTc before prescribing.
12. If prescribing any antipsychotic as required be aware to the potential of inadvertent high dose in combination with any regular antipsychotic prescription.

For in-patients, the use of all as required psychotropics should be reviewed at each MDT and an individualised as required care plan developed.

Administration

Only administer as required psychotropic drugs for the prescribed indication and then only if non-pharmacological approaches have failed or are inappropriate.

If a patient is prescribed more than one as required psychotropic drug for the same indication, avoid administering combinations if possible and always allow sufficient time for one drug to take effect e.g. 30-60 minutes before administering a second drug.

Recording

All details pertaining to each administration should be recorded in the patient’s case record i.e. the chronological account of care on the in-patient EMIS record. All use of as required psychotropic drugs should be recorded on the EMIS template. The details recorded must include;

• Date & time given
• Drug & dose given
• Reason for administration
• Details of non-pharmacological approaches attempted
• Details of response including any side effects noted
• For intramuscular doses, the details of any physical health monitoring undertaken (pulse, blood pressure, respiration, level of consciousness)

Feedback on cumulative as required psychotropic use will be discussed for each patient at each multi-disciplinary team meeting. This will facilitate appropriate review of the treatment plan.