Audit of therapeutic drug monitoring of ‘clozapine plasma levels’

Aims To re audit the monitoring of Plasma Clozapine levels in Rehabilitation setting in CNTW Trust as per Trust Guidelines PGN on “Safe prescribing of Clozapine”. Objectives: To determine if 1. The reason for a clozapine plasma level request is recorded. 2. Results are recorded correctly. 3. Appropriate action is taken and recorded when results are significant. Background Clozapine plasma level monitoring is useful when assessing adherence, adjusting the dose, monitoring the effects of changes in smoking habit, investigating clozapine side effects and when toxicity is suspected. An initial audit was carried out within the Trust in 2015 and the following recommendations were made: Check and record clozapine plasma level At baseline (a level should be taken once the patient has been on the target dose for at least a week) Annually. When clinically relevant to optimise therapy. An entry must be made in the patient's progress notes recording the reason of requesting the test. On receipt of results, the paper copy must be scanned & an entry made in progress notes. The clinician should comment on the significance of the results and propose an action plan. We re-audited compliance with the guidance in Rehabilitation (inpatients and community) by reviewing patient notes for a 2 year period of 2017–2018. Method The audit work involved a review of 31 case records of patients prescribed Clozapine whose last plasma level was taken between 2017–2018. Patient's details were identified from a randomly generated list by the Trust pharmacy. Result <50% compliance was seen with baseline, annual monitoring, reason for recording and proposed action plan by clinician. >50% compliance was seen with scanned results and levels checked when clinically relevant. No significant improvement from the previous audit except improvement in compliance with documentation of levels. Conclusion Dissemination of Clozapine Key cards within teams.

Background. Clozapine plasma level monitoring is useful when assessing adherence, adjusting the dose, monitoring the effects of changes in smoking habit, investigating clozapine side effects and when toxicity is suspected.
An initial audit was carried out within the Trust in 2015 and the following recommendations were made: Check and record clozapine plasma level At baseline (a level should be taken once the patient has been on the target dose for at least a week) Annually. When clinically relevant to optimise therapy. An entry must be made in the patient's progress notes recording the reason of requesting the test. On receipt of results, the paper copy must be scanned & an entry made in progress notes. The clinician should comment on the significance of the results and propose an action plan. We re-audited compliance with the guidance in Rehabilitation (inpatients and community) by reviewing patient notes for a 2 year period of 2017-2018.
Method. The audit work involved a review of 31 case records of patients prescribed Clozapine whose last plasma level was taken between 2017-2018. Patient's details were identified from a randomly generated list by the Trust pharmacy. Result. <50% compliance was seen with baseline, annual monitoring, reason for recording and proposed action plan by clinician.
>50% compliance was seen with scanned results and levels checked when clinically relevant.
No significant improvement from the previous audit except improvement in compliance with documentation of levels.
Conclusion. Dissemination of Clozapine Key cards within teams. Aims. To assess level of compliance with national and local guidance with regards to the recording of service users smoking status and offering of interventions. Background. Across the general population, prevalence of smoking is decreasing but in those with severe mental illness, the prevalence hasn't significantly changed. LYPFT are working towards becoming a smoke-free trust. The Trust Guidance expects that Trusts should ask 100% of service users if they smoke (which should be recorded on their physical health CQUIN) and of those that do, should be offered nicotine replacement therapy and cessation advice. Public Health England is working towards all hospital trusts across the UK being Smoke-free. Method. All service users on each of the 4 adult inpatient wards at the Becklin Centre, Leeds, were included in the audit. A total of 78 service users were included in the audit.

Assessing the delivery of smoking cessation interventions in adult inpatients
We reviewed the digital records for every service user, specifically looking at the physical health CQUIN. We recorded if smoking status had been documented and what interventions (if any) had been recorded as given. Possible interventions included offering brief advice and offering Nicotine replacement therapy. We then reviewed medication charts to see if any nicotine replacement therapy had been prescribed.
Result. The audit found that approximately half of all service users in our audit smoked cigarettes and that the vast majority of these had their smoking status documented in their digital medical records.
Three quarters of those that smoked were offered brief cessation advice and half of them were offered Nicotine Replacement Therapy. Only a third of service users that smoked had NRT prescribed on their medication chart. This represented 65% of those recorded as being offered NRT. Conclusion. There are numerous possible reasons for the above outcomes. These include a lack of knowledge and confidence in delivering smoking cessation interventions, conversations having taken place but not recorded and confusion regarding the appropriate staff member to deliver the intervention. In addition, whilst only medical professionals typically prescribe NRT, the physical health CQUIN is recorded by nurses. Therefore, this may reflect a lack of communication between staff groups.
Our trust will become smoke free in the near future. To facilitate this, we hope to reduce the discrepancy between the number of service users who smoke and the number prescribed NRT.
Trends in referrals to liaison psychiatry teams from UK emergency departments for patients over 65