Category: Professional Posters
Purpose: Pharmacologic restraints are administered to sedate patients with aggressive behavior that could endanger themselves, staff, or other patients. An antipsychotic agent such as haloperidol is often used as a pharmacologic restraint. Haloperidol can cause extrapyramidal symptoms and/or dystonia with increasing severity at higher doses. During an annual review of adverse drug reactions (ADRs), four patients experienced an ADR after receiving multiple doses of intramuscular (IM) haloperidol. The investigator sought to implement strategies to safely optimize dosing within recommended and maximum dosing ranges to prevent ADRs associated with IM haloperidol and to potentially decrease the incidence of patients requiring multiple restraints.
Methods: This single center, retrospective cohort study within a 55-bed rural pediatric and adolescent behavioral health facility included patients admitted to the hospital for treatment of serious emotional, behavioral, or psychological difficulties. Patients aged 5 to 17 years old who received pharmacologic restraints were included. A dosing chart including recommended and maximum doses based on age and/or weight was implemented for the restraint medications historically prescribed at the facility including haloperidol, LORazepam, and diphenhydrAMINE. Prescribers were provided copies of the restraint dosing chart for reference at the beginning of the evaluation period. The investigator provided concurrent review and recommendations once a patient received two pharmacologic restraints. Haloperidol ADRs were documented through the pharmacy’s ADR monitoring program for the pre-and post-implementation periods. Primary endpoints included the incidence of patients who received two or more doses of haloperidol IM and experienced an ADR, as well as incidence of patients receiving two or more total restraints, in the one year pre- and post-implementation periods. Secondary endpoints included the percentage of patients prescribed doses of haloperidol, LORazepam, and/or diphenhydrAMINE within the recommended and maximum dosing ranges to determine if doses were being optimized and safely prescribed. Primary endpoint analyses were conducted using a Fisher’s exact test with an alpha level equal to 0.05.
Results: The incidence of patients experiencing ADRs associated with two or more doses of haloperidol IM significantly decreased post-implementation [4 of 15 patients (26.7 percent) versus 0 of 18 patients (0 percent), p equals 0.0334]. The incidence of patients receiving two or more restraints increased significantly post-implementation [16 of 56 patients (28.6 percent) versus 20 of 38 patients (52.6 percent), p equals 0.0299). In the post-implementation period, there were a total of 94 pharmacologic restraints prescribed with varying combinations of haloperidol, LORazepam, and/or diphenhydrAMINE. Haloperidol was used most frequently in 87 restraints (93 percent), followed by LORazepam in 83 restraints (88 percent), and diphenhydrAMINE in 18 restraints (19 percent). Haloperidol was prescribed within the recommended dosage range for 72 percent of the orders and was under the established maximum dose for 97 percent of the orders. Of the LORazepam orders, 93 percent were within the recommended dosage range and all orders were below the maximum recommended dose. All diphenhydrAMINE orders were within the recommended and maximum dosage ranges.
Conclusion: Implementation of strategies to provide dosing recommendations and proper monitoring of patients receiving multiple pharmacologic restraints prevented haloperidol IM-related ADRs. With improvement potential on orders being prescribed within the recommended and maximum dosing ranges for haloperidol and LORazepam, the pharmacy has expanded pharmacologic restraint options and incorporated a patient-specific dosing recommendation chart upon admission for all patients to provide prescribers with quick access to appropriate dosing during these emergent situations. The pharmacy will continue to investigate and implement further methods to decrease the incidence of patients requiring multiple restraints.