Procedure Reviewed By: Narinder Sangha Deputy Chief Pharmacist STANDARD OPERATING PROCEDURE

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1 Written By: Objective By: ed By: To ensure safe and consistent working practice throughout Black Country Partnership Foundation Trust (BCPFT) and to avoid unnecessary harm to patients on lithium therapy based on NPSA safety alert 'safer lithium therapy' December Scope All pharmacists and pharmacy technicians working within BCPFT. Pharmacy technicians (Band 5 or above with training) may order lithium in the absence of a pharmacist, provided the patient s Clinical Pharmacy Profile has been signed by a pharmacist and the plasma level is checked and within range. The technician must seek further advice if necessary before placing the order. Target range: Adults mmol/L Elderly mmol/L (Bipolar disorder NICE Guidelines CG 185 September 2014 (Last updated February 2016) states aim to maintain plasma lithium level between mmol/l in people being prescribed lithium for the first time. Consider maintaining plasma lithium levels at mmol/l for a trial period of at least 6 months for people who have had a relapse while taking lithium or are taking lithium and have subthreshold symptoms with functional impairment. Patient admitted on lithium therapy: 1. Pharmacy technician/pharmacist will complete a Clinical Pharmacy Profile. The brand, dose and formulation must be identified. Check the GP list, patient's own supply or speak to the patient to confirm. Endorse the Administration Card and Clinical Pharmacy Profile with the brand. Where liquid is prescribed, ensure that dose is written in millilitres. Confirm if patient has a valid lithium plasma level within the last 3 months or 7 days after latest dose change. Confirmation can be made via the acute hospitals pathology services system or by viewing results in medical notes. 2. Check that the lithium blood plasma level is within the target range for age group. 3. If not already completed by the doctor, the pharmacist or band 5 or above technician must record the lithium blood plasma level on the Administration Card in the pharmacy box, or on the front of the Administration Card. Use a Page 1 of 6

2 Written By: By: ed By: pre-printed lithium sticker if available. It also needs to be recorded on the reverse of the Clinical Pharmacy Profile and on the Lithium Level Recording Form (see form attached) in front of the ward or Home Treatment pharmacy folder. 4. If no blood result has been taken in the last 3 months, speak to nursing staff or contact the team doctor immediately to arrange a test. Record in the pharmacy box on the front of the Administration Card. Continue to order a supply but follow up request for blood test the following working day, contact team doctor again if request not actioned. If the patient has been non-compliant in the community, it is good practise to ask for a lithium level to be taken 7 days after admission. 7. Check patient has had renal function, thyroid function, calcium levels and weight/bmi checked at least within the last 6 months/before starting lithium. Record on the reverse of the Clinical Pharmacy Profile. 8. Check if patient has brought their own supply of lithium in from home. Accredited Checking Technician/pharmacist must check supply for suitability for use as per SOP For Using Patient s Own Drugs. Non checker technicians must bring supply to the attention of checker technician/pharmacist. Count number available and record on profile. 9. Write on the front of the Administration Card to check if patient has brought their own lithium record book in. If not, a new one will be required. The lithium record book needs to be kept up-to-date. Patient newly prescribed lithium: 1. Pharmacy technician/pharmacist will complete a Clinical Pharmacy Profile. 2. Priadel will be supplied if no brand specified. Endorse Administration Card and Clinical Pharmacy Profile with Priadel brand. 3. Check if patient has had baseline blood tests for thyroid function, renal function and calcium levels (at least in the last month, depending on disease states/other medication prescribed). Confirmation via the intranet link to acute hospital pathology services system or by viewing results in medical notes. Record evidence of baseline blood tests on the reverse of the Clinical Pharmacy Profile. Check patient has weight/bmi recorded. 4. If no baseline blood test taken contact team doctor and request blood test. Page 2 of 6

3 Written By: By: ed By: State request in the pharmacy box on the front of the Administration Card. DO NOT SUPPLY UNTIL BLOOD TEST RESULTS RECEIVED. 5. Endorse the front of the Administration Card to indicate that the patient will need a lithium therapy information booklet, alert card and record book. Apply a lithium pre-printed sticker if available and complete the blood result when available. Clinical Checking (Pharmacist only): 1. The pharmacist must check that lithium has been correctly prescribed and sign the clinical check box on the Clinical Pharmacy Profile. 2. Identify any possible interactions and/or contra-indications and inform/discuss with prescriber accordingly. 3. Any relevant details should also be recorded on the reverse of the Clinical Pharmacy Profile or in the patient s notes if applicable. Inpatient Supply: 1. Each patient receiving lithium will be provided with their own supply, in appropriate strengths to be stored in the trolley/cupboard. Lithium will not be kept as a stock item on the wards but will be available in the emergency cupboard. Order supply via the Clinical Pharmacy Profile in original packs. The initial supply must be clinically checked by a pharmacist. Three further supplies via clinical profile can be ordered by a pharmacy technician band 5 or above. 2. The pharmacy technician will monitor quantities of lithium available via routine caddy/trolley checking. When supply falls below 14 days of medication, he/she will request the pharmacist/pharmacy technician Band 5 or above to authorise a further supply. Routine Pharmacy Blood Test Monitoring: 1. The pharmacist/pharmacy technician (band 5 or above) must check blood result status to ensure necessary blood tests have been taken 7 days after dose, formulation or brand change, or addition of a medication which interacts with lithium then every 7 days until level stable, then 3 monthly thereafter. Monitor blood test results for all patients receiving lithium via acute hospitals pathology site before each supply request. Record the latest lithium blood plasma level on the Administration Card, on the reverse Page 3 of 6

4 Written By: By: ed By: of the Clinical Pharmacy Profile and on the ward Lithium Level Recording Form (see below). 2. Refer any blood results which fall outside of target range (even if doses have been altered accordingly) to ward pharmacist for their intervention if necessary. The pharmacist will then contact a team doctor/duty doctor if necessary to discuss. Refer to the Trust Lithium Policy for further information regarding lithium levels. 3. Check that patients stabilised on lithium therapy have had renal function, thyroid function, calcium levels and weight/bmi checked at least within the last 6 months and record on the reverse of the Clinical Pharmacy Profile. Leaves/Discharges: 1. Lithium must be prescribed on leave/discharge prescription by brand. 2. Confirm that all necessary blood tests have been taken and recorded before ordering medication from SLA Provider Pharmacy. Put the last lithium level and date onto the discharge prescription. 2. Labelled supply can be taken from ward if labelled correctly and if a supply greater than duration of leave/discharge has been risk assessed and confirmed by prescriber. This must be documented on the leave/discharge prescription. Endorse prescription 'from ward' or 'trolley/cupboard'. If a smaller quantity is required, order via SLA Provider Pharmacy. 3. Write on the leave/discharge prescription that the patient s up-to-date lithium record book needs to be given to the patient. 4. After discharge, any remaining unused lithium should be removed from the ward as soon as possible. Page 4 of 6

5 Written By: By: ed By: LITHIUM MONITORING RECORDING FORM Ward Patient s name, NHS number and date of birth Dose and brand of lithium Lithium level (mmol/l) Other blood results: Comments e.g. baseline checks/6 monthly checks Date bloods analysed/ Initials Reference range for lithium mmol/l ( mmol/L in the elderly) Page 5 of 6

6 Written By: By: ed By: and Amendment History - to be completed by Corporate Governance Version Date Description of Change 1.1 Mar 2018 ed and nothing changed 1.0 Sep 2015 New SOP for BCPFT Page 6 of 6