Minimising risk in high dose antipsychotic therapy (King, 2018)
King A.
Journal of Psychopharmacology 2018;32(Supplement 12): 6.
Background/introduction: High Dose Antipsychotic Therapy (HDAT) lacks evidence of benefit but evidence of harm is compelling (Royal College of Psychiatrists, 2014; Taylor et al., 2015). POMH-UK audits the use of antipsychotics in the country. In 2012 the national average rate of prescribing of HDAT was 21% whilst the trust average was higher than this at 27% (Prescribing Observatory for Mental Health, 2012). An October 2017 medicines management audit showed the local directorate had a rate of prescribing of HDAT of 40% which was substantially higher that the reported trust average rate of 14%. In the same medicines management audit it was shown that the rate of HDAT monitoring in the directorate per the trust policy had dipped to 24%. The combination of high prevalence in prescribing of HDAT and inadequate physical health monitoring represented an area of potential risk and it was decided to start a Quality Improvement (QI) project to mitigate this. Aim and objectives: The aim was to minimise risk in high dose antipsychotic therapy by ensuring prescriptions are appropriate and that adequate monitoring takes place. The specific objectives were: * Increase rate of HDAT monitoring from 24% to 100% in 6 months, * Ensure all antipsychotic prescriptions are reviewed weekly, and * To reduce the number of inappropriate HDAT prescriptions. Method/design: 1. A QI team was assembled. The team is formed of pharmacists, ward managers, doctors, nurses and consultant psychiatrist. The team was sponsored by the clinical director and a QI coach was assigned. 2. An initial brainstorming meeting was held to formulate aims and change ideas. 3. The QI team then met regularly to discuss implementation of these change ideas; * Weekly Audit of HDAT by pharmacy * Weekly MDT reviews * Junior Doctor training session and pharmacist session at Academic Meeting * Sharing of audit results weekly * HDAT calculator shared with nursing staff * Dose reckoner posters placed in clinical rooms * Ward patient boards updated with HDAT status 4. Parameters measured included; * Rate of HDAT monitoring (outcome measure) * Prevalence of HDAT prescribing (outcome measure) * Number of weekly reviews by MDT (process measure) * Number of weekly reminders sent out by the pharmacy team (process measure) Results: The rate of monitoring of HDAT patients increased by 53% (from 24% to 77%) in the duration of the project. All wards saw an improvement in rates of monitoring. The overall mean increased from 45.8% to 61.65%. In addition, the rate of prescribing of HDAT was reduced by over 20% (from 40% to 19%). There was a mean reduction in prevalence of prescribing of HDAT from 30.5% to 23.17% during the project. Discussion and conclusion: HDAT monitoring has improved. This and the overall reduction of HDAT prescribing represents a reduction in risk to patients. The current rate of HDAT monitoring is less than the aim of 100%. The next phase will concentrate on 2 inpatient wards where rates of monitoring were just 17% and 33% respectively. It has been noted that one of the wards, a PICU, has a rapid turnover of patients, and so often data is collected on or close to the admission date, before the monitoring is completed. This may need to be taken into consideration to give a true reflection of practice on this ward. Further data collection should continue before it can be concluded that the improvements are embedded into practice.