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This editorial considers the value and nature of academic psychiatry by asking what defines the specialty and psychiatrists as academics. We frame academic psychiatry as a way of thinking that benefits clinical services and discuss how to inspire the next generation of academics.
High Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either: a total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF, or a total daily dose of two or more antipsychotics which exceeds the BNF maximum calculated by percentage. HDAT is defined as ‘off-label’ prescribing and the prescribing clinician should clearly document rationale for its prescription and clear discussion with the patient regarding the risks and benefits. If the patient is deemed to lack capacity, this should be clearly documented, and appropriate legal processes followed as defined by the Mental Health Act 1983. The use of HDAT comes with greater risk of physical health complications and requires regular monitoring of electrocardiogram (ECG), body mass index (BMI) and blood biochemistry. Aims: To re-audit the number of inpatients prescribed HDAT across three acute general adult inpatient wards, and to establish whether guidelines for the prescribing and monitoring of HDAT are adhered to.
Methods
Initial audit was completed in January 2020. Education sessions were provided to rotational junior doctors in the six months following initial audit. For re-audit, medication cards for each patient on the electronic bed-state at 9pm on 27/11/2021 were checked for HDAT prescription. Data were collected from electronic notes of patients identified as being on HDAT.
Results
Initial audit in 2020 demonstrated that 3 of 49 inpatients (6%) were prescribed HDAT, with no evidence of documentation of rationale, and variable monitoring of physical health indicators. Re-audit in 2021 demonstrated that 11 of 47 inpatients (23%) were identified as being on HDAT. Of those, seven instances of HDAT were commenced during review by the multidisciplinary team or the consultant, with only two of these cases noting that the medication prescribed would result in initiating HDAT. Of the remaining cases, the prescriber was unclear. Eight had an ECG within a month prior to commencing HDAT. Only three patients had a repeat ECG within 7 days of initiation. Three patients were noted to gain at least 5 kg in weight following implementation of HDAT.
Conclusion
Education of junior doctors following initial audit had limited impact, likely due to high turnover of doctors. Implementations currently in development include: 1) Departmental teaching session for doctors of all grades, 2) Introduction of stickers on medication charts for patients prescribed HDAT to highlight monitoring recommendations, 3) Development of ward round template to include review of HDAT.
To identify the number of adult inpatients prescribed HDAT across GMMH.
To establish whether guidelines for the prescribing and monitoring of HDAT are adhered to.
To consider the initiation of HDAT, evaluating whether prescriptions of HDAT are intentionally made by consultant psychiatrists and the MDT, or by rotational junior doctors.
Background
High Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either: a total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF or A total daily dose of two or more antipsychotics which exceeds the BNF maximum as calculated by percentage.
The decision to prescribe HDAT should be made by a consultant psychiatrist and discussed with the patient and wider MDT. Clear documentation of this discussion, including the clinical indication, should be recorded within the case notes.
The use of HDAT comes with greater risk of physical health complications and requires regular monitoring of ECG, BMI and blood biochemistry. For patients detained under the Mental Health Act, consent and appropriate consultation with a SOAD should be sought for HDAT where the patient lacks capacity.
This audit investigates prescription of HDAT in the acute adult inpatient population within Greater Manchester Mental Health NHS Foundation Trust (GMMH).
Method
Six junior doctors were recruited to collect data across the 5 sites covering general adult inpatients within GMMH. Data were collected week beginning 21st January 2020. Data were collected from all 20 general adult inpatient wards within the trust. Medication cards for each patient on the electronic bed-state at 9am on the day of the audit were checked for HDAT prescription. Subsequently, data were collected from electronic notes of patients identified as being on HDAT. Data were collated and submitted to the audit lead for analysis.
Result
31 patients were identified as being on HDAT, of those, 21 instances of HDAT were commenced during the patients MDT, although in only 2 of these cases was it noted that the medication prescribed would result in initiating HDAT. Of the remaining cases, 8 were prescribed by junior doctors and 2 were unclear. 15 out of 31 patients had an ECG within a month prior to commencing HDAT, of 24 patients on HDAT for longer than 3 months, only 5 had a repeat ECG within this time.
Conclusion
Guidelines are not closely adhered to, there is clear and necessary scope for improvement.
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