Safe use of Lithium therapy

Transcription

1 Safe use of Lithium therapy Clinical Audit bpac nz better medicin e

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3 Clinical Audit Safe use of Lithium therapy Claiming MOPS credits The RNZCGP has endorsed this audit as a Continuous Quality Improvement (CQI) Activity for the allocation of MOPS credits. General practitioners taking part in this audit can claim credits in accordance with the current Maintenance of Professional Standards (MOPS) programme. This status will remain in place until January To claim MOPS points you can indicate completion of the audit on the annual claim sheet or alternatively you can claim them through MOPS online on the RNZCGP web site. Retain the following documents as evidence of participation in the audit: A summary of the data collected (Appendix one). A Practice Review Activity summary sheet (Appendix two). If this is an organisation activity a certificate of participation. Prepared by Dr Trevor Walker Best Practice Advocacy Centre Level 8, 10 George Street P.O. Box 6032 Dunedin Phone Fax

4 Audit on the safe and effective use of Lithium Background Lithium is an effective mood stabiliser but there are many possible adverse effects. Some, such as mild gastrointestinal upset, mild polyuria and fine hand tremors are usually not dangerous and often settle once the dose is stabilised or with a moderate reduction in the dose. There are also several more significant metabolic adverse effects such as thyroid disorders, diabetes insipidus and hyperparathyroidism. Potentially fatal toxicity can occur. Toxicity most often occurs when serum lithium concentrations are above the therapeutic range. However the optimum range varies between individuals and laboratory published ranges are only guides. Mild symptoms of toxicity can occur below the upper limit of the published range. Many factors can effect serum lithium concentrations, these include: Sampling time Adherence to the recommended regimen Renal function Interacting drugs (for example NSAIDs, ACE inhibitors and diuretics) Fluid depletion Crash diets Ill health Avoiding the potential adverse effects of lithium therapy requires careful monitoring of patients on lithium. This audit is designed to: Stimulate reflection on your systems for monitoring lithium therapy, Provide a benchmark of your monitoring of lithium therapy, and Identify opportunities for CQI in your monitoring of lithium therapy. 1

5 Key Recommendations Bpac nz key recommendations for routine pathophysiological monitoring for people on lithium therapy are indicated in the table below. More frequent monitoring may be required for people over the age of 65, on interacting drugs or with or at high risk of renal, thyroid or cardiac disease. Other monitoring requirements are equally important. Further guidance is provided in the reference. References Lithium in primary care. (2006). Best practice Journal, 3, Bpac nz New Zealand. Routine monitoring for people on lithium Parameter Baseline Monthly 3 monthly 6 monthly Less frequently Serum lithium Thyroid function Once after initiation Electrolytes Renal function Calcium and magnesium Two yearly Weight Monthly for 6 months for women Pregnancy test of childbearing age ECG for people over 45 or at increased risk Yearly for people over 45 or at increased risk 2

6 Audit of monitoring for people on lithium therapy Indicators Three monthly measurements of serum lithium levels. Three monthly assessments of renal function. Three monthly measurements of serum electrolytes. Six monthly measurements of Thyroid Stimulating Hormone (TSH). Six monthly measurement of weight. Two yearly measurements of serum calcium. Criteria People taking Lithium have a serum lithium result recorded in their notes in the previous four months. People taking Lithium have a renal function result recorded in their notes in the previous four months. People taking Lithium have serum electrolyte results recorded in their notes in the previous four months. People taking Lithium have a TSH result recorded in their notes in the previous seven months. People taking Lithium have a weight recorded in their notes in the previous seven months. People taking Lithium have a serum calcium result recorded in their notes in the previous 25 months. Standard All people who are on lithium therapy meet the above criteria. 3

7 Data Eligible patients Eligible patients are those who are currently on lithium therapy. Identifying Patients Identify patients taking lithium from clinical prescribing records. For patients using Medtech 32 an electronic way of doing this is described at appendix xx. Sample size and type The clinical notes of all people in the practice taking lithium should be reviewed. What data should be collected? See recording sheet at Appendix one. 4

8 Taking Action The first step in taking action is to identify the criteria where gaps exist between expected and actual performance and decide on priorities for change. Once priority areas for change have been decided on, an action plan should be developed to implement any changes. The plan should assign responsibility for various tasks to specific members of the practice team and should include a timeline. It is important to include the whole practice team in the decision-making and planning process. It may be useful to consider the following points when developing a plan for action : (RNZCGP 2002) 1. Problem solving process What is the problem or underlying problem(s)? Change it to an aim. What are the solutions or options? What are the barriers? How can you overcome them? 2. Overcoming barriers Identifying barriers can provide a basis for change. What is achievable find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting. Identify the barriers. Develop a priority list. Choose one or two achievable goals. 3. Effective interventions No single strategy or intervention is more effective than another and sometimes a variety of methods are needed to bring about lasting change. Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour. 5

9 Review Monitoring change and progress It is important to review the action plan against the timeline at regular intervals with the practice team. It may be helpful to discuss the following questions: Is the process working? Are the goals for improvement being achieved? Are the goals still appropriate? Do you need to develop new tools to achieve the goals that have been set? Following the completion of the first cycle it is recommended practices complete the first part of the clinical audit summary sheet (a copy of which is attached as Appendix two). Undertaking a second cycle In addition to regular reviews of progress with the practice team a second audit cycle should be completed in order to quantify progress on closing the gaps in performance. It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended practices complete the remainder of the clinical audit summary sheet. General Practitioners claiming credits towards MOPS will be required to complete the summary sheet (Appendix Two). Those undertaking this audit but not claiming credits towards MOPS are strongly recommended to complete the summary sheet as it will provide them with a succinct review of the audit process. 6

10 Appendix One: Data recording sheet Safe use of lithium therapy Patient number Totals Percentages Serum lithium in previous four months Renal function in previous four months Serum electrolytes in previous four months TSH in previous seven months Weight in previous seven months Serum calcium in previous 15 months 7

11 Appendix Two: RNZCGP Summary Sheet RNZCGP Summary Sheet Safe use of lithium therapy Doctor s name: The activity was designed by, please tick appropriate box: RNZCGP Organisation e.g. IPA (name of organisation) bpac Individual (self) Topic: Audit of safe use of lithium therapy Describe why you chose this topic (relevance, needs assessment): First cycle (15 credits) Data: Information collected Date of data collection: Please attach: A summary of data collected or If this is an organisation activity, attach a certificate of participation. Check: Describe any areas targeted for improvement as a result of the data collected Action: Describe how these improvements will be implemented. Monitor: Describe how well the process is working. Will you undertake another cycle? 8

12 Second cycle (15 credits) Data: Information collected Date of data collection: Please attach: A summary of data collected or If this is an organisation activity, attach a certificate of participation. Check: Describe any areas targeted for improvement as a result of the data collected Action: Describe how these improvements will be implemented. Monitor: Describe how well the process is working. Will you undertake another cycle? Additional comments: 9

13 Appendix Three: Identifying patients on lithium therapy Ten minute audit from Best Practice Journal, Issue 3 Identifying your patients on Lithium If you are using MedTech you simply complete the query builder form as shown on the opposite page. Select items from the box on the left and transfer them to the appropriate box on the right of the screen. Once patients are identified we suggest you flag their notes for discussion at their next visit. Medtech - 32 Query Builder Designer View Query Name: Data Sheet View Query Store Table Prescriptions Fields Date of Prescription Drug - Brand Name Drug - Code Drug - Generic Group Code Drug - Generic Group Description Drug - Generic Name Drug - H B L Price Drug - Interaction Class Code Drug - Interaction Class Description Drug - Medicode Drug - Mfgr Drug - Pharmac Code Drug - Pharmac Code2nd Drug - Pharmac Code3rd Drug - Pharmac Code4th Where Column Condition Prescriptions - Date of Prescription Between Tue 17 Jan 2006 and Wed 17 Jan 2007 Prescriptions - Drug - Generic Group Code Equal to Lithium carbonate C Build query in order as specified above (for advanced users only!) Select Select Patient - Name Surname Patient - Name First Name Run Query Patient - Dob Patient - Nhi No Prescriptions - Drug - Generic Group Description View SQL Output data in order specified above Close Help 10

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