scholarly journals Off-label prescribing of quetiapine in south locality crisis teams

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S87-S87
Author(s):  
Mamta Kumari ◽  
Arun Kumar Gupta ◽  
Peter Clarke
Keyword(s):  
Side Effects ◽  
Physical Health ◽  
Health Monitoring ◽  
Treatment Options ◽  
General Medical Council ◽  
Evidence Base ◽  
Medical Council ◽  
Team Members ◽  
Off Label ◽  
Psychotropic Medicines

AimsThe audit was carried out to determine the frequency of off label prescribing of quetiapine and compliance with standards within Trust Policy (UHM PGN 02 PPT PGN 08) – Physical Health Monitoring of Patients Prescribed Antipsychotics and other Psychotropic Medicines, NICE CG178, General Medical Council Ethical Standards and Royal College of Psychiatrists – College Report CR210.The main objectives of the audit were to determine if:Patients have been appropriately informed of off-label status and consent recorded.Alternative licensed treatment first used/ruled out.Appropriate communication on transfer of care.Appropriate physical health monitoring completed.BackgroundQuetiapine is associated with various physical side effects. Patients should be fully informed of the expected risks and benefits of treatment, and the limited evidence base for off-label prescribing.There are additional issues around the transfer of prescribing to primary care.MethodThe sample consisted of 50 consecutive patients selected from the crisis team caseload in the month of December 2018.Data reviewed in this audit were taken from six months period.Records audited were obtained from RiO (electronic records) and prescription charts.Data collection was started in January 2019 and completed in March 2019The audit tool was a dichotomous scale questionnaire based on NICE guidelines.Result4 patients from the sample (8%) were prescribed off-label quetiapine.100% had physical health monitoring completed as per Trust policy.100% off-label indication been clearly documented in notes.100% Consent to treatment was documented.100% had medication reviewed in the previous 6 months.75% had licensed medication used or ruled out before considering off-label quetiapine use25% risks/benefits of treatment were documented as part of a patient discussion.25% had documented evidence that alternative treatment options were discussed.25% had documented evidence of Community consultant/GP consent/agreement was obtained before transfer of prescribing75% had a documented plan for review of quetiapine for treatment efficacy and side effects50% had a documented plan in place for ongoing physical health monitoringConclusionSuggested a wider audit may be required with greater patient numbers and which specifically filters for patients prescribed quetiapine.Audit result has been shared with Crisis team members, Medicines Optimisation Committee and South Locality Quality Standards Committee in the trust.

scholarly journals Audit of ADHD medication prescription and monitoring in intellectual disability services, Greater Glasgow & Clyde

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S66-S66
Author(s):  
Neha Bansal ◽  
Muzammil Hayat
Keyword(s):  
Intellectual Disability ◽  
Side Effects ◽  
Physical Health ◽  
Health Monitoring ◽  
Symptom Severity ◽  
Adhd Medication ◽  
Audit Tool ◽  
Medication Prescription ◽  
Ongoing Treatment ◽  
Medication Dosage

AimsStudies have shown that people with intellectual disability (ID) show a greater severity of attention deficit hyperactivity disorder (ADHD) symptoms and atypical presentation, as well as having a greater risk of developing comorbidities, such as challenging behaviour, anxiety, tic disorders and sleep problems. It is estimated that 1.5% of patients with ID will have a clinical diagnosis of ADHD.The aim of this audit was to find whether individuals with ID and ADHD, who are prescribed medication for ADHD are adequately monitored and reviewed in accordance with the ADHD medication prescription guidance by NICE and the Royal College of Psychiatrists (RCPsych).MethodThis audit looked at ADHD medication prescription for the ID population within Greater Glasgow & Clyde NHS. This is the 6th audit cycle where electronic records (EMIS) were analysed between 28/9/19 to 09/10/20. (The 5th cycle data collection period ended on 28/9/19). We collected data on all patients aged over 18 years.An audit tool was developed to find whether the following were documented; patient demographics, physical health monitoring, symptom severity, medication dosage, side effects, need for ongoing treatment and frequency of review. 100% of patients should have all components on the ADHD audit tool documented, as per NICE/ RCPsych prescription guidance.Result32 patients were identified as being diagnosed with ADHD prescribed medication. One patient was impacted by the COVID-19 pandemic which meant that the required monitoring was not fully carried out. The age ranged from 18 to 56 years. 75% had mild intellectual disability, 19% had moderate and 6% had severe, with no cases of profound intellectual disability. Blood Pressure/pulse was recorded in 84% of patients. Height/weight/ BMI was recorded in 81% of patients. 97% of patients had ADHD symptom severity, medication dosage, side effects, need for ongoing treatment and frequency of review recorded.ConclusionThere is further scope for improvement in the monitoring and documentation of physical health observations, however there was a significant improvement compared to the previous cycle of the audit. Other aspects of monitoring and documentation appear to be recorded in almost 100% of patients. This finding emphasises the challenges of physical health monitoring and compliance in psychiatry as a whole. We need to continue to encourage awareness and education around the physical health risks to our patients, not only due to their comorbidities but also as a result of the psychotropic medications we prescribe them.

Working Effectively as Part of a Team

2018 ◽  
Author(s):  
David Metcalfe ◽  
Harveer Dev
Keyword(s):  
Patient Safety ◽  
Good Reason ◽  
General Medical Council ◽  
Healthcare Team ◽  
Medical Council ◽  
Public Concern ◽  
Team Members ◽  
Policies And Procedures ◽  
Professional Body ◽  
Significant Step

Teamworking is an inevitable part of working within a complex multidisciplinary environment. Thankfully, most interactions with other members of the healthcare team will be positive and constructive. Unfortunately, such happy circumstances do not make for particularly interesting SJT scenarios. The following section is therefore full of colleagues that are angry, rude, dishonest, unprofessional, and even intoxicated. In Raising and Acting on Concerns About Patient Safety (2012), the General Medical Council (GMC) states that ‘all doctors have a duty to raise concerns where they believe that patient safety or care is being compromised by the practice of colleagues or the systems, policies and procedures in the organizations in which they work’. The GMC proposes taking the following steps in sequence when you develop serious concerns about a colleague: ● Raise the concern with ‘your manager or an appropriate officer of the organisation . . . such as the consultant in charge of the team, the clinical or medical director’. Alternatively, a foundation doctor may raise their concern with an appropriate person responsible for training such as their Foundation Programme Director. ● Raise the concern with a regulator (such as the GMC), professional body (such as the British Medical Association), or charity (such as Public Concern at Work). This step should be taken if you have exhausted options for raising the concern internally and there is an ‘immediate serious risk to patients, and a regulator or other external body has responsibility to act or intervene’. ● Raise the concern publicly. This step should be taken when you have exhausted options for raising the concern internally and have ‘good reason to believe that patients are still at risk of harm’. Your usual duty is to avoid breaching patient confidentiality. This is a highly unusual and significant step to take and is unlikely to be appropriate without first having taken advice from an appropriate organization such as the GMC, BMA, or Public Concern at Work. The questions within this section highlight your ability and willingness to work with team members. You will need to work collaboratively and respectfully within a multi- disciplinary team, as well as provide advice and support to colleagues.

Establishing a physical health monitoring service for patients on depot antipsychotic medication

2016 ◽  
Vol 33 (S1) ◽  
pp. S564-S564
Author(s):  
M. Gill ◽  
M. McCauley
Keyword(s):  
Side Effects ◽  
Physical Health ◽  
Antipsychotic Medication ◽  
Health Monitoring ◽  
Side Effect ◽  
Blood Test ◽  
Best Practice ◽  
Self Report ◽  
Physical Parameters ◽  
Depot Antipsychotic

IntroductionPatients with major mental illness are recognised to be at risk of premature death for a multitude of reasons. Those with schizophrenia and bipolar disorder are at highest risk.ObjectivesInternational best practice recommends monitoring of blood tests, physical parameters such as weight, BMI, waist circumference and blood pressure, and side effects of patients prescribed antipsychotic medication. A clinic was established to target these interventions.AimsThis initiative aimed to improve the physical health monitoring of patients prescribed depot antipsychotic medication in a catchment area of approximately 36,000 in Ireland.MethodsA twice-yearly, multidisciplinary monitoring clinic was established. A protocol was drawn up, following a literature review and inspection of current international guidelines, and a proforma assisted as an aide-mémoire. A self-report questionnaire, the Glasgow Antipsychotic Side Effect Scale, was used to enquire about side effects.ResultsEvaluation took place in descriptive form with audit used to examine outcomes. Full blood test monitoring improved from 9% of patients to 61% in one year, with 78% of patients having had at least one blood test recorded. Prior to the clinic's establishment, only one patient had had any physical parameters recorded, but this improved to 96% recorded after the clinics were run. Side effect documentation also improved.ConclusionsThe clinic was well-received and led to improved teamwork. Future recommendations include organising the clinic so as to include simultaneous blood testing. A similar project is being planned to target all patients attending who are prescribed antipsychotic medication.Disclosure of interestThe authors have not supplied their declaration of competing interest.

scholarly journals High dose antipsychotic treatment monitoring audit

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S348-S348
Author(s):  
Jake Scott ◽  
Jose Belda
Keyword(s):  
Side Effects ◽  
Physical Health ◽  
Health Monitoring ◽  
Clinical Benefit ◽  
Health Assessment ◽  
Antipsychotic Treatment ◽  
High Dose ◽  
Health Checks ◽  
Increased Risk ◽  
Multi Disciplinary Team

AimsTo quantify how many patients were prescribed high dose antipsychotic treatment (HDAT) and establish whether guidance for monitoring HDAT was being followed in an Assertive Outreach Team.BackgroundSevere mental health disorders are associated with significant premature mortality, predominantly due to physical health conditions. Antipsychotic medications are associated with side effects, including metabolic syndrome and QT prolongation, which increase the risk of serious physical illness. HDAT is defined as when the total dose of antipsychotics prescribed exceeds 100% of the maximum BNF dose, if each dose is expressed a percentage of its maximum dose. There is limited evidence of clinical benefit with HDAT but an increased risk of side effects. Patients prescribed HDAT should therefore be monitored for side effects and clinical benefit. Sussex Partnership NHS Foundation Trust developed a form specifically for this purpose, to be completed in addition to a physical health assessment.MethodAll patients on caseload were audited using the electronic notes. Current inpatients were excluded, as inpatient HDAT monitoring forms are attached to paper drug charts and therefore were not available for review.ResultA total of 61 patients were audited. Nine were excluded due to being inpatients. 16 were on community treatment orders and 26 were prescribed a long-acting antipsychotic injection. 10 were prescribed clozapine. The median number of medications prescribed was one. Four patients were prescribed HDAT ranging from 117-150% of the maximum BNF dose. Of these four, one had a HDAT form but this was out of date. 39 of 52 (75%) patients audited had had a physical health assessment in the past 12 months. Two of the 13 missing a physical health assessment were on HDAT.ConclusionPhysical health monitoring should be carried out for all patients on antipsychotics, but is particularly important for patients on HDAT. This audit identified a problem in both general physical health checks and HDAT monitoring. On discussion with the multi-disciplinary team a number of barriers to appropriate physical health monitoring were identified. There was a lack of awareness within the multi-disciplinary team that patients were receiving HDAT and regarding the implications for side effects. A reliable system to highlight the need for physical health checks was also missing and the team did not have sufficient equipment to perform the necessary checks. Identifying these barriers should enable improvements in physical health and HDAT monitoring which can be re-audited.

scholarly journals Gabapentin abuse: A case presentation on how to manage this growing concern

2018 ◽  
Vol 8 (11) ◽  
pp. 43 ◽  
Author(s):  
Jason A. Gregg ◽  
Ronald L. Tyson ◽  
Anthony W. Alvarez
Keyword(s):  
Side Effects ◽  
Treatment Options ◽  
Dose Titration ◽  
Close Monitoring ◽  
Additional Indication ◽  
Adjunct Treatment ◽  
Off Label ◽  
Cognitive Difficulties ◽  
The Us ◽  
History Of

Gabapentin was first approved by the US Food and Drug Administration in 1993 as an adjunct treatment of epilepsy. In 2004, an additional indication of pain associated with post-herpetic neuralgia was added. Misuse of gabapentinoids dates back to 2010 while surging recently to the tenth most commonly prescribed medication in 2016. Abuse can be as high as 65% for even those who legally obtained the medication through a prescription. It is used off-label up to 95% of the time despite limited evidence of its efficacy particularly with multiple pain types. The surge in misuse can be attributed not only to off-label use but also an assumption of no abuse potential coupled with clinicians seeking alternative treatment options to the opioids. More common side-effects include sedation, dizziness, and cognitive difficulties. However, even normal dosing can produce side-effects similar to other addictive substances including: euphoria, talkativeness, and increased energy (opioids); sedation (opioids, benzodiazepines); and dissociation (hallucinogens). In fact, a few states including Kentucky, Ohio, and West Virginia will or have already added gabapentin to the controlled substance rosters even though no federal designation is in place. Identified risks for gabapentin misuse in the literature are limited with the exception of a history of or current substance abuse, particularly opioids. Unfortunately, gabapentin is often co-prescribed with opioids lending to a heightened risk of opioid-related mortality. Clinicians must understand that gabapentin is not effective for a variety of pain conditions nor is a routine substitute for opioids. In addition, close monitoring practices often associated with opioids and benzodiazepines (i.e., regular monitoring for aberrant drug taking behaviors, limits on supply, guarded dose titration) should be applied to that of gabapentin.

scholarly journals An audit into the monitoring of off-label antipsychotics in primary care

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S213-S213
Author(s):  
Damir Rafi ◽  
Javier Ferreiro-Pisos ◽  
John Millwood Hargrave ◽  
Cristina Losada Pérez
Keyword(s):  
Primary Care ◽  
Side Effects ◽  
Physical Health ◽  
Second Generation ◽  
Health Screening ◽  
Adjunctive Treatment ◽  
Off Label ◽  
Second Generation Antipsychotics ◽  
Audit Standard ◽  
Physical Health Screening

AimsTo ascertain whether patients prescribed second generation antipsychotics for off-label indications are being monitored and screened adequately for physical health side-effects.BackgroundThe prevalence of off-label antipsychotic use has increased significantly over recent decades. Common off-licence uses include dementia, post-traumatic stress disorder, adjunctive treatment for unipolar depression and personality disorders. Recent studies have demonstrated that up to 65% of antipsychotic prescriptions are now off-label. Since the metabolic side-effects of second-generation antipsychotics are well-established, guidelines have emphasised the need for active, routine physical health screening of all individuals taking these drugs. However, there have been few studies or reviews which have specifically investigated screening rates of individuals receiving antipsychotic medications for off-licence indications.MethodAn audit of patients taking second-generation antipsychotics for off-label indications, under the caseload of Neighbourhoods 1, 3 and 4 of Lewisham Assessment & Liaison team, was conducted. After isolating individual patients fulfilling inclusion criteria, patient investigation documents were requested from relevant GP practices. 40 patients were isolated in total, and data were successfully collected in 60% (n = 24). Data were collected via a proforma. This consisted of patient information, indications for antipsychotic use, and each variable to be monitored. The audit standard used was the recommendations of the 12th Maudsley guidelines. Data were then entered into SPSS and analysed.ResultThe most common reasons for off-label antipsychotic prescribing were Emotionally Unstable Personality disorder (42%, n = 10) and depression (29%, n = 7). Findings demonstrated that 54% (n = 13) of patients audited had ‘basic’ blood screening (FBC, U&E, LFTs), however glucose (38%, n = 9), Prolactin (13%, n = 3), and Creatine Kinase (0%, n = 0), and monitoring was less frequent. 0% (n = 0) were completely monitored as per audit standard.ConclusionPrimary care monitoring of off-label antipsychotics is unsatisfactory, with no patients having a complete set of investigations. Reasons for this are unclear at this stage, however based on initial discussion with GP surgeries, may be due to lack of education regarding screening investigations, patients lost between primary and secondary care services, and a lack of clarity regarding responsibility and designated roles. This audit will be expanded to also include patients from Neighbourhood 2 of the Lewisham Assessment & Liaison team. A more detailed investigation will be conducted into the barriers to physical health screening, such that a targeted intervention can be implanted.

scholarly journals An audit into the physical health monitoring of patients who are prescribed antipsychotics in HMP Birmingham

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S326-S326
Author(s):  
Olivia Horton ◽  
Rajesh Moholkar
Keyword(s):  
Life Expectancy ◽  
Physical Health ◽  
Health Monitoring ◽  
Medical Systems ◽  
Team Members ◽  
Health Checks ◽  
Computer Reminders ◽  
And Training ◽  
Health Diagnosis

AimsTo assess the compliance of physical health monitoring with NICE and Maudsley prescribing guidelines for those patients prescribed antipsychotics in HMP Birmingham. To assess secondary objectives including who prescribed the antipsychotics (GP vs psychiatrist), the indication and diagnosis they are prescribed for (licensed or otherwise) and which antipsychotics were usually prescribed.BackgroundPatients with psychosis or schizophrenia have a reduced life expectancy of 15-20 years when compared to the general population. The physical health effects of the medication prescribed for these conditions play a large role in this. Physical health monitoring and appropriate intervention is vital to reduce the discrepancy in life expectancy and improve the quality of life of these patients.MethodNotes of 105 patients in total at HMP Birmingham were reviewed to assess whether the primary outcomes of weight, waist circumference, physical observations, blood tests, medical systems review and education/lifestyle advice were done at the correct times. Secondary objectives of which antipsychotics were prescribed, the profession of the prescriber and the indication for the medications (or diagnosis) were also audited.ResultAntipsychotics were initiated by both GP's and psychiatrists. Appropriately, there were no prescriptions for clozapine. Olanzapine and quetiapine were the most common antipsychotics prescribed. Not all medications were prescribed for licensed indications and some lacked documentation of both a mental health diagnosis and indications in terms of symptoms. Average BMI of patients was overweight, with BMI ranging as high as 45. The pre-prescription, 12 weekly and annual physical health checks had poor compliance. Those that were completed in line with NICE and Maudsley guidelines were done so by coincidence at the time of diabetic reviews.ConclusionThe physical health monitoring of patients on antipsychotics in HMP Birmingham is not currently compliant with clinical guidelines. There needs to be improved systems in place for the monitoring of physical health both before prescriptions are initiated and after at the NICE recommended intervals. Amongst other actions, improved computer reminders and training of existing and new team members will be done. The monitoring requirements will be re-audited in 6 months following immediate implementation of the recommendations outlined below.

Health screening audit – south Barnet PCMH pilot

2017 ◽  
Vol 41 (S1) ◽  
pp. S700-S700
Author(s):  
H. Rahmanian
Keyword(s):  
Mental Health ◽  
Physical Health ◽  
Health Monitoring ◽  
Mental Health Problems ◽  
Health Problems ◽  
Consultant Psychiatrist ◽  
Team Members ◽  
Team Meetings ◽  
Physical Health Problems ◽  
Competing Interest

Physical health monitoring is an integral part of caring for patients with mental health problems. It is proven that serious physical health problems are more common among patients with severe mental health illness (SMI), this monitoring can be challenging and there is a need for improvement.AimsThe aim of this project was to improve the physical health monitoring for patients with mental health illness. The patients group was under the care of south Barnet primary care mental health pilot (SB PCMH Pilot). SB PCMH pilot is a multidisciplinary team that includes: consultant psychiatrist mental health nurse and psychologist.ResultsBetween November to December 2014, 60 patients were discharged from SB PCMHT and the electronic case notes of 38 of them who had an assessment/intervention by the service were reviewed. Results showed that 82% of the records verified that discussion and screening of physical health, smoking, drugs and alcohol had been completed. The data was discussed in team meetings with all team members. After thorough team discussions and brainstorming; the team agreed that an improvement in the process of monitoring was needed to work towards ensuring these matters are discussed with 100% patients and that this is accurately recorded. It was agreed to re-audit in 3 months.Re-auditA re-audit completed between January to April 2015 confirmed an improvement as 98% of patients seen for an assessment by SB PCMH pilot have had their annual health checks and appropriate health screenings discussed and recorded routinely.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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