Prehospital pathway offering oral dissociative procedural sedation for patients with learning disabilities

Barriers to accessing healthcare, delays in diagnosis and suboptimal treatment have resulted in inequitable healthcare for people with learning disabilities. For people with learning disabilities, healthcare interactions are often unfamiliar and complex, and reasonable adjustments need to be made. Allowing more time for assessments, collaborating with caregivers and reducing personal triggers can help to overcome these challenges. However, despite this, there are some patients who require sedation to allow them to access certain investigations or interventions in a safe and tolerable manner.The Physician Response Unit (PRU) in North East London has developed a learning disability pathway offering prehospital oral dissociative sedation. The choice of combination oral ketamine and oral midazolam was informed by existing literature and expert clinician opinion. Traditional approaches involving intravenous or intramuscular routes can result in physical restraint and psychological distress. Alternatively, high strength parenteral preparations of ketamine and midazolam can be added to a small volume of drink and given to the patient by their carers under the supervision of the PRU team.In the first year of the pathway, 36 patients were referred and 9 patients went on to require prehospital oral dissociative sedations. There were no moderate, severe or sentinel events and only two minor adverse events. All the patients seen on the pathway were able to tolerate investigations or interventions that previously had been impossible to provide.