Audit: lithium monitoring for psychiatric inpatients and community patients during the initiation phase

Aims Measure compliance with standards requiring baseline work up before Lithium therapy is commenced and subsequent Lithium level monitoring during the initiation phase Method All inpatients and outpatients who were started on Lithium between 2018 and 2019 within the Leicestershire Partnership NHS trust. Case notes were of patients 128 were retrieved from the electronic system and an audit proforma was completed to ascertain adherence to auditing standards as per BNF and trust guidelines. Parameters monitored were full blood count (FBC), renal functions test including serum electrolytes, thyroid function test, and BMI before commencing Lithium, and serum Lithium periodically after. ECG was needed for those patients with cardiovascular illness. Data were systematically compiled and analyzed descriptively using Microsoft Excel Result A total of 128 patients were included in the study. 111 (86.71%) had FBC, 118 (92.19%) had renal function test and electrolytes, 114 (89.06%) had thyroid function test while 99 (77.34%) had their BMI/weight recorded before initiating Lithium. 26 out of 36 patients with cardiovascular disorder had their ECG recorded. After Lithium was commenced, 108 (84.37%) had serum Lithium tested a week later, while only 89 (69.53%) had lithium monitored weekly. Trust guidelines recommend weekly monitoring for up to 4 weeks after a stable dose was reached. This was monitored in only 16 out of 128 patients. Conclusion Most of the patients had blood test done before being commenced on Lithium. However it was observed that serum Lithium was not adequately monitored at regular intervals after dose escalations. These finding indicate that there has to be greater awareness of the trust and BNF guidelines with regards to Lithium monitoring.

Hyponatraemia monitoring in those prescribed antidepressants -an audit from an inpatient older adult ward Aims. To assess follow-up of sodium levels for in-patients prescribed antidepressants in practice compare to the standard of 3 monthly sodium levels for all patients who are prescribed antidepressants and at risk of hyponatraemia Method. A list of the 20 most recently discharged patients from Meridian Ward, an older-adult functional inpatient ward, was prepared by the team administrator on 6th May 2020.
We audited the entire duration of our patient's stay on Meridian Ward (we did not include periods of their admission when they were on other wards) using the electronic notes system, Carenotes.
We also checked the electronic biochemistry results system, ICE, for sodium results, and the discharge summary for mentions of fluid restriction, medications and handover to GP of sodiumchecking. We also checked scanned drug charts to see if they were on antidepressants and other implicated drugs.
For people with episodes of hyponatraemia, in order to retrieve further info we looked at discharge summary and searched the activity notes for the following terms "Hyponat" "sodium" "fluid restrict" "Low na" We regarded the following conditions as risk factors for hyponatraemia: cardiac malignancy respiratory hypothyroid renal hepatic stroke We regarded following medications as risk factors: opioids diuretics carbamazepine theophylline antipsychotics NSAIDs PPIs ACE-I ARBs amiodarone domperidone sulphonylureas Result. 14 of the 20 patients were taking antidepressants. Of those: 13 were eligible for regular sodium monitoring due to risk factors 11 of these had 3-monthly sodium levels during admission For only 2 of these did we make a plan for the GP to continue to monitor the sodium level in community 3 had an episode of hyponatraemia implicated antidepressants: sertraline plus mirtazapine mirtazapine (very serious episode which caused seizure) sertraline for 2 of them an appropriate plan was made 1 without a plan -a mild hyponatraemia with nothing documented in the notes Conclusion. During their admission to Meridian Ward, 85% of patients taking antidepressants who had risk factors for hyponatraemia had three-monthly sodium levels in line with the trust guidance. However, only two patients (15%) had a plan for further sodium levels in the discharge summary sent to the GP. This highlights a need for improved awareness of risk factors for hyponatraemia and, in particular, improved communication with general practitioners who are going to take over prescribing of antidepressant medications.
Recommendations 3 monthly Na levels for all patients with risk factors i.e. on any antidepressant prescribed PLUS any one of: There were no ethical issues as the data were retrospective and anonymised.
Sample size was 13, comprising 7 males and 6 females. All service users were less than 18 years of age. Result. 7 out of the 13 patients who were prescribed antipsychotics had a Severe/Profound LD.
Among the 5 patients who had been prescribed antipsychotic medication, 4 were on Risperidone and 2 were on Aripiprazole. The reasons for starting antipsychotic medication were clearly documented for all 5, the most common reasons being overt aggressive behaviour and general agitation/anxiety.
Only 1 patient had antipsychotic medication initiated in the previous 12 months. NICE guidelines had been generally followed for the management of this case, with good documented evidence.
For the other 4 patients, in whom antipsychotic medication was initiated more than 12 months ago, there was a lack of documentation of the subsequent assessment of side effects, extrapyramidal side effects, body weight, blood pressure, glycaemic control and lipid profile. 1 of these patients did not have a documented review of antipsychotic medication in the previous 6 months. For the other 3 patients, their medication reviews did not consider whether to reduce the dose or stop antipsychotic medication.
1 patient had been transferred to primary care, with a clear transfer of prescribing responsibility and documented evidence that written guidance was provided to primary care which addressed all the necessary management details. Conclusion. Although there was clear documentation of reasons for initiating antipsychotics, there appeared to be a lack of awareness of NICE guidelines for antipsychotic medication reviews, side effect and metabolic markers assessment, and their documentation. This is an area for potential change in practice to conform better to national guidelines and improve patient care. Aims. To ascertain the compliance of the Mental Health Service of Older People (MHSOP) memory clinics in obtaining ECGs, based on the agreed criteria. Background. Cholinesterase inhibitors are a main pharmacological treatment for Alzheimer's dementia (AD). These drugs may worsen pre-existing cardiac conditions or cause significant cardiac side effects. A baseline ECG can be beneficial before starting patients on these medications. Previously in Leicestershire, all memory clinic patients were receiving routine ECGs. However, new standards were set based on the NICE guidelines and criteria outlined in other regions, to reduce the use of this time consuming and expensive investigation for patients who may not require it. Method. A total of 120 patients attending memory clinics in Leicestershire over a 6 month period (April to September 2019), were randomly selected and their electronic records retrospectively reviewed. The data collection tool was designed to encompass the key aspects of the criteria for obtaining an ECG for those attending the memory clinic. The information was analysed using Microsoft Excel. Result. Of the 120 patients, 23 (19.2%) were diagnosed with AD, 10 (8.33%) with mixed and 19 (15.8%) with vascular dementia. 68 (56.7%) had a diagnosis of "other" which included mild cognitive impairment or diagnosis still under investigation. 0 patients were diagnosed with Lewy Body Dementia or Parkinson's dementia. Of the total number of patients, only 10 had an ECG done, 2 with a diagnosis of AD, 1 with mixed dementia, 1 with vascular dementia and 6 "other". The 10 ECGs done were all requested by nursing staff.

Baseline ECGs done in memory clinics in Leicestershire
Although 27 (22.5%) patients were identified to have a diagnosis of AD or mixed dementia, plus at least one of the criteria for an ECG, only 6 (22.2%) were discussed with the Multi-Disciplinary Team (MDT) following which only 3 of the 27 patients (11.1%) had an ECG Conclusion. Despite having clear criteria for requesting an ECG for those attending the memory clinic, compliance over the 6 month period was low. The following recommendations may be useful in improving compliance: Displaying the ECG algorithm in the memory service clinic rooms.
Raise awareness amongst memory service clinicians of the criteria for requesting ECGs.
"Are they medically fit?" -clinical audit on the physical assessment of mental health patients in A&E