The use of additional sedative psychotropic medication to calm agitated or aggressive patients is known as rapid tranquillisation (RT). Several studies of RT practice have been conducted in psychiatric intensive care units (PICUs) and acute psychiatric settings.

We carried out a cross-sectional survey of the use of parental sedation in an English secure hospital using data from medication charts and case notes.

We studied the medication charts of 316 patients and found 203 incidents (all involving intramuscular route) of parenteral sedation involving just 35 patients. The vast majority (30; 85.7%) of those administered parenteral sedation were female and most (23; 65.7%) had emotionally unstable personality disorder. The most common indication was self-harm (44; 21.7%). In 24 (11.8%) instances the patient had requested an injection. A single drug was administered in 159 (78.3%) cases. The most commonly administered drug was lorazepam (152 cases) followed by haloperidol (69) and olanzapine (21). Case note documentation was frequently inadequate and in very few cases was there evidence of physical monitoring.

The use of parenteral sedation was rather different from that previously described in PICUs. Hospital policy and NICE guidance were not always being followed. Measures to rectify these deficits are being taken.

Rapid tranquillisation (RT) is a high risk clinical intervention in terms of potential physical health complications. There has been no published work in the UK to survey nationally whether standards for post RT physical monitoring (as set out in organisation's RT documents) are being adequately audited.

To review current auditing of RT practice in England, with particular emphasis on examination of post RT physical monitoring.

A scrutiny of evidence provided by English NHS mental health trusts to illustrate auditing of adult RT documents.

Fifty-eight mental health trusts in England were contacted. Less than one-third could provide evidence of an audit of post RT physical health monitoring. These audits were variable with respect to what aspect of physical health monitoring they focused on. When results of all audits were combined, it revealed a concerning finding that basic physical observations and investigations were not performed consistently following RT.

The current paucity of trust audits of post RT physical monitoring and the poor practice observed in those audits could reflect a lack of clarity in both trust and national guidelines, as well as poor clinical practice. Given the risks to a patient's physical health associated with RT it is essential to ensure high quality care in this area.

This paper presents the psychometric properties, including factor structure, internal reliability and relative validity of a 16-item questionnaire measuring patients’ relative activation with milieu activities while hospitalised in an acute psychiatric inpatient unit.

24 hours after admission, and before discharge, psychiatric inpatients (N = 132) completed a set of validated self-reports and the pilot questionnaire, the Checklist of Unit Behaviors (CUB). The CUB outlines items that reflect the extent to which the patient avoided or engaged with the treatment milieu within the previous 24 hours. Factor analysis, bivariate correlations and repeated-measures t-tests were used to analyse the data.

Factor analysis identified two factors for the CUB: (1) Behavioural Approach; and (2) Behavioural Avoidance. Psychometric properties were satisfactory (Approach, Cronbach's α = 0.93; Avoidance, Cronbach's α = 0.79). Over the course of treatment, CUB-Approach increased (p < 0.001) and CUB-Avoidance decreased (p < 0.001). The construct validity of the CUB was supported through correlations with measures of positive and negative affect.

The CUB demonstrates strong psychometric properties, quantifying patients’ behavioural activation in the treatment milieu. Daily use of the CUB provides clinically useful information that has the potential to improve patient care and treatment planning.

Despite not being underpinned by a strong evidence base, rapid tranquillisation is frequently the intervention of choice for dealing with violent and aggressive behaviour in psychiatric hospitals. This is the second of a two-part review of recommendations set out in UK trusts' adult rapid tranquillisation documents. In this article we focus on the drugs recommended, their routes of administration and clinical parameters influencing their use.

A review of adult rapid tranquillisation documents currently in use in NHS or HSC trusts providing adult mental health services in the UK.

A total of 45 rapid tranquillisation documents met the inclusion criteria and were examined. Sixteen drugs were recommended, via four separate routes of administration. Beyond the use of oral and IM lorazepam, haloperidol and olanzapine there was no consensus as to which drugs should be used for rapid tranquillisation in adults. Eleven clinical decision-making parameters were identified that influenced the selection of drugs for IM administration. However, the wide variation and sometimes absence of advice surrounding these parameters was concerning.

The results of this review demonstrate that there is a need to rationalise rapid tranquillisation and develop consensus guidelines that allow for evidence based decision-making tools.

Delirium is a severe and complex neuropsychiatric disorder and because of its diverse aetiology is often poorly managed. The refeeding syndrome is a well known cause of delirium, characterized by metabolic disturbances elicited during reintroduction of nutrition after a period of starvation. Although a common complication, it is often not recognized by clinicians.

A 53-year-old man presented at the emergency department with psychomotor agitation, irritability and disorientation in time. Apart from previous alcohol abuse he had no documented medical history. Examination led to detection of an intracranial haemorrhage, which could explain cognitive dysfunction. After admission, his level of consciousness gradually improved and he resumed eating and drinking. However, a deterioration of his mental status occurred after three days.

Blood analysis revealed a severe hypophosphataemia indicating refeeding syndrome. After a new dietary regimen and aggressive supplementation of electrolytes his mental state improved rapidly. Following correction of phosphate plasma concentration, no further episodes of severe confusion or disorientation were observed.

This case report illustrates that clinicians in both psychiatric and general intensive care must be aware of the numerous causes of delirium that can be present concurrently. Refeeding syndrome may be overlooked initially when more alarming causes of a delirium are noticed.