scholarly journals Reducing the use of high dose antipsychotic medication in acute adult inpatient psychiatric units

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S341-S341
Author(s):  
Shay-Anne Pantall ◽  
Sarah Warwicker ◽  
Lisa Brownell
Keyword(s):  
Antipsychotic Medication ◽  
Psychiatric Inpatient ◽  
Electronic Prescribing ◽  
Antipsychotic Treatment ◽  
High Dose ◽  
Junior Doctors ◽  
List Type ◽  
Increased Risk ◽  
Adult Inpatient ◽  
Inpatient Units

AimsTo evaluate the use of antipsychotics, and high dose antipsychotic treatment (HDAT) in psychiatric inpatient unitsBackgroundThe Royal College of Psychiatrists published a consensus statement on high dose antipsychotic medication in October 1993. Such treatment carries an increased risk of adverse effects including towards ventricular tachycardia and sudden death.MethodA retrospective case note review of all male patients on acute adult inpatient units in a psychiatric hospital in South Birmingham on a date in June 2018 (n = 45) including review of electronic patient records and prescriptions. This was compared with the results of an earlier study, with identical methods, undertaken in June 2015.Result•In both 2015 and 2018, only a minority of patients (20% and 11% respectively) were informal.•In both 2015 and 2018, the majority of inpatients had a diagnosis of schizophrenia (54% and 67%)•In both 2015 and 2018, 93% inpatients were prescribed antipsychotic medication.•In 2015, 56% patients were prescribed HDAT. This reduced in 2018 to 16%.•This reduction in use of HDAT was almost entirely due to a reduction in the prescription of PRN antipsychotic medication.•In terms of regularly prescribed antipsychotic medication, in both years, the most commonly prescribed drug was flupentixol, with a range of other second generation oral and long acting medications being prescribed, usually at doses within BNF limits.Between the two years, there was a substantial change in the prescribing of PRN antipsychotics. In 2015, 59% individuals were prescribed at least one PRN antipsychotic (27% were prescribed two). In 2018, this reduced to 40% prescribed at least one, and only 2% being prescribed 2 PRN antipsychotics. In both years, oral quetiapine was a common choice (39% patients in 2015 prescribed oral quetiapine, and 34% in 2018). In 2015, 39% patients were prescribed oral or intramuscular aripiprazole, while this reduced to 7% in 2018.ConclusionThe vast majority of psychiatric inpatients were being prescribed antipsychotic medication. Prescription of high dose antipsychotic medication was common in 2015, and this was largely attributable to high levels of prescribing of PRN antipsychotics. Following an educational programme for junior doctors and ward nurses, and the introduction of electronic prescribing, we achieved a significant change in practice, particularly in the prescribing of PRN antipsychotics, which has reduced our patients’ risk of receiving high dose antipsychotic medication.

scholarly journals Hidden high-dose antipsychotic prescribing: effects of p.r.n. doses

1998 ◽  
Vol 22 (11) ◽  
pp. 675-677 ◽  
Author(s):  
John Milton ◽  
John Lawton ◽  
Mark Smith ◽  
Ann Buckley
Keyword(s):  
Antipsychotic Medication ◽  
Antipsychotic Drugs ◽  
Consensus Statement ◽  
Antipsychotic Treatment ◽  
High Dose ◽  
Junior Doctors ◽  
Drug Prescribing ◽  
Junior Staff ◽  
Actual Use ◽  
High Doses

Aims and methodThe Royal College of Psychiatrists' Consensus Statement on “The use of high-dose antipsychotic medication’ suggests only fully qualified psychiatrists (MRCPsych) should recommend the prescribing of high-dose antipsychotic treatment. We observed changes in anti-psychotic prescribing in two surveys of psychiatric in-patients conducted eight and 32 months after publication of the Consensus Statement.ResultsOverall mean chlorpromazine equivalent doses of antipsychotic drugs reduced between the surveys. When p.r.n. (as required) prescribing (usually done by junior doctors) is included, mean potential doses and numbers of patients who might receive ‘high-doses' increases substantially, although the reduction between surveys in total mean dose and proportion of patients on high-dose antipsychotic medication is preserved, and the actual use of p.r.n. medication was low (4–5% of p.r.n. prescriptions).Clinical implicationsWe recommend the development of local guidelines for junior staff concerning antipsychotic drug prescribing, regular monitoring of p.r.n. medication by consultants, and pharmacists' involvement in reviews of patients prescribed high-dose antipsychotic medication.

scholarly journals High dose antipsychotic therapy (HDAT) in the Greater Manchester mental health adult psychiatric inpatient setting

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S105-S105
Author(s):  
Oli Sparasci ◽  
Emma Horrell ◽  
Gemma Buston ◽  
Oliver Edge ◽  
Tatiana Campo Celaya ◽  
...  
Keyword(s):  
Mental Health ◽  
Psychiatric Inpatient ◽  
Clinical Indication ◽  
Total Daily Dose ◽  
High Dose ◽  
Junior Doctors ◽  
Inpatient Setting ◽  
Antipsychotic Therapy ◽  
Daily Dose ◽  
Adult Inpatient

AimsTo identify the number of adult inpatients prescribed HDAT across GMMH.To establish whether guidelines for the prescribing and monitoring of HDAT are adhered to.To consider the initiation of HDAT, evaluating whether prescriptions of HDAT are intentionally made by consultant psychiatrists and the MDT, or by rotational junior doctors.BackgroundHigh Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either: a total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF or A total daily dose of two or more antipsychotics which exceeds the BNF maximum as calculated by percentage.The decision to prescribe HDAT should be made by a consultant psychiatrist and discussed with the patient and wider MDT. Clear documentation of this discussion, including the clinical indication, should be recorded within the case notes.The use of HDAT comes with greater risk of physical health complications and requires regular monitoring of ECG, BMI and blood biochemistry. For patients detained under the Mental Health Act, consent and appropriate consultation with a SOAD should be sought for HDAT where the patient lacks capacity.This audit investigates prescription of HDAT in the acute adult inpatient population within Greater Manchester Mental Health NHS Foundation Trust (GMMH).MethodSix junior doctors were recruited to collect data across the 5 sites covering general adult inpatients within GMMH. Data were collected week beginning 21st January 2020. Data were collected from all 20 general adult inpatient wards within the trust. Medication cards for each patient on the electronic bed-state at 9am on the day of the audit were checked for HDAT prescription. Subsequently, data were collected from electronic notes of patients identified as being on HDAT. Data were collated and submitted to the audit lead for analysis.Result31 patients were identified as being on HDAT, of those, 21 instances of HDAT were commenced during the patients MDT, although in only 2 of these cases was it noted that the medication prescribed would result in initiating HDAT. Of the remaining cases, 8 were prescribed by junior doctors and 2 were unclear. 15 out of 31 patients had an ECG within a month prior to commencing HDAT, of 24 patients on HDAT for longer than 3 months, only 5 had a repeat ECG within this time.ConclusionGuidelines are not closely adhered to, there is clear and necessary scope for improvement.

The effect of limited English proficiency and interpreter service use on clinical outcomes in psychiatric inpatient units

2019 ◽  
Vol 27 (5) ◽  
pp. 465-468
Author(s):  
Conor Daly ◽  
Karen Phillips ◽  
Richard Kanaan
Keyword(s):  
Length Of Stay ◽  
Clinical Outcomes ◽  
Limited English Proficiency ◽  
Service Use ◽  
English Proficiency ◽  
Psychiatric Inpatient ◽  
Psychiatric Units ◽  
Adult Inpatient ◽  
Interpreter Service ◽  
Inpatient Units

Objective: The effects of limited English and interpreter use on clinical outcomes in mental health are poorly understood. This paper describes an exploratory study examining those effects across three adult inpatient psychiatric units, predicting it would lead to increased length of stay. Methods: Forty-seven patients with limited English proficiency (LEP) were retrospectively identified and compared with 47 patients with proficient English. Length of stay, number of consultant reviews and discharge diagnosis were recorded and compared. Results: An increased length of stay for those with LEP was not statistically significant ( p=0.155). The LEP group did undergo more consultant reviews ( p=0.036), however, and attracted different discharge diagnoses, with no primary discharge diagnoses of personality disorder made ( p=0.018). Conclusions: This study provides evidence of significant effects of limited English on both service burden and outcome.

scholarly journals Audit on High Dose Antipsychotic Treatment (HDAT) Monitoring at Rampton Hospital

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S182-S183
Author(s):  
Astha Das ◽  
Ian Yanson
Keyword(s):  
Dose Escalation ◽  
Psychiatric Patients ◽  
Single Agent ◽  
Blood Parameters ◽  
Full Blood Count ◽  
Antipsychotic Treatment ◽  
High Dose ◽  
List Type ◽  
Consent To Treatment ◽  
One Year

Aims•High Dose Antipsychotic Treatment defined as 100% of the maximum recommended dose in British National Formulary, either as single agent or in combination.•HDAT and poly-pharmacy may be linked to heightened mortality for psychiatric patients. The Committee on Safety of Medicines, Medicines and Healthcare Products Regulatory Agency recommended ECGs, electrolyte monitoring after each dose escalation, and 6 monthly intervals.•The Royal College of Psychiatrists in 2006 suggested some justifiable cases of temporary poly-pharmacy with careful monitoring.•This audit has been done in past to improve standards, especially in High Secure Setting where prescribing HDAT is a common practice•To audit adherence to “HDAT monitoring guidelines” including regular monitoring of bloods, physical observations and ECG , done after every dose escalation plus at every 6 months.•To monitor compliance with consent to treatment documentation including reasons of being on HDAT, documentation of physical health monitoring resultsMethod•All patients prescribed high dose antipsychotic (regular and as required) were identified by treating Consultants and also going through drug cards.•One year retrospective review of haematological, ECG and physical observations were identified through Electronic notesResult•6 % of patients received HDAT within Rampton Hospital in 2018(12 males’ vs 6 females).•All patients on Regular HDAT had yearly TFT done whereas only 71% had prolactin monitoring done.•Approximately 50-60% of patients had quarterly blood monitoring including glucose, electrolytes, lipids, liver function test and full blood count.•About 40% of patients had quarterly ECG monitoring recorded.•100% patients on regular HDAT had quarterly physical observation monitoring compared to 81% patients on HDAT (including PRN).•Consent forms were completed for all patients on HDAT. 85% patients on regular HDAT has the reasons for treatment documented in the notes compared to 100% patients on HDAT (including PRN).Conclusion•Improvement in monitoring of blood parameters and cardiac function (ECG) 40-60% as compared to 2014 audit (8% to 23%).•Yearly monitoring of TFTs and Prolactin also appeared better (100% and 71%) which was (88% and 72% in 2014).•Quarterly physical observations were recorded in 77% patients on regular HDAT in 2014 which improved to 100% in 2018.•There was slight difference for those who were on PRN (77% to 81%). All prescribers informed about results and reminded of recommended guidelines•Reaudit in 2021-22 to measure change in clinical practice in prescribing HDAT.

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.

Prevalence and Precipitants of Aggression in Psychiatric Inpatient Units

2000 ◽  
Vol 34 (6) ◽  
pp. 967-974 ◽  
Author(s):  
Karen Barlow ◽  
Brin Grenyer ◽  
Olga Ilkiw-Lavalle
Keyword(s):  
Psychiatric Patients ◽  
Bipolar Affective Disorder ◽  
Psychiatric Inpatient ◽  
Management Strategies ◽  
Adjustment Disorder ◽  
Clinical Problem ◽  
Causal Factors ◽  
Increased Risk ◽  
Psychiatric Units ◽  
Inpatient Units

Objective: Aggression is a significant clinical problem in psychiatric facilities. The present study reviews data on aggression collected from psychiatric inpatient units in order to determine prevalence and causal factors. Method: Data on aggressive incidents were gathered from four adult psychiatric units in the Illawarra, Australia. Information obtained included diagnosis, causal factors and patient sociodemographic characteristics. Results: During the 18-month period, a total of 1269 psychiatric patients were admitted and 174 patients (13.7%) were recorded as being aggressive. Patients with bipolar affective disorder and schizophrenia had a 2.81 and 1.96 significantly increased risk of aggression, respectively, while depression and adjustment disorder conferred a significantly lower risk. Aggression was most likely to occur within 2 days of admission and length of stay was greater for aggressive than non-aggressive patients. The greater number of incidents occurred on day shift. Most patients who displayed aggression did so on one occasion, but a small proportion of total patients (6.0%) accounted for a large number of incidents (71.0%). High-risk patients were identified as those who were under 32 years of age, were actively psychotic, detained and known to have a history of aggression and substance misuse. The most frequent form of aggression was physical and staff were most often the victims. Conclusions: These results have important implications for predicting and thereby reducing inpatient aggression. Organisations need to ensure aggression management strategies are in place and periodically identify and assess the level of risk for workers.

scholarly journals Improving analgesia prescription for trauma inpatients

2018 ◽  
Vol 7 (4) ◽  
pp. e000397
Author(s):  
Sophie Stanger ◽  
Mark Dahill ◽  
Charlotte Hillary ◽  
Robert Whitham ◽  
Andrew Tasker
Keyword(s):  
Information Technology ◽  
Electronic Prescribing ◽  
Patient Comfort ◽  
Junior Doctors ◽  
Trauma Patients ◽  
Time Saving ◽  
Improvement Project ◽  
Increased Risk ◽  
Effective Pain Relief ◽  
One Year

Patients value effective pain relief. Complications of inadequate pain control include increased risk of infection, decreased patient comfort and progression to chronic pain, all of which have significant socioeconomic consequence. Accessibility to analgesia is vital to effective administration. This improvement project aimed to improve the consistency and adequacy of analgesia prescribing for trauma inpatients over a 12-month period. Four PDSA (‘plan, do, study, act’) cycles resulted in sustained and significant improvements in analgesia prescription. The interventions included senior encouragement, teaching sessions, targeted inductions and implementation of a novel e-prescribing protocol. Prospective data and real-time discussion from stakeholder medical and management teams enabled iterative change to practice. Drug charts were reviewed for all trauma inpatients (n=276) over a 10-month period, recording all analgesia prescribed within 24 hours of admission. Each prescription was scored (maximum of 10 points) according to parameters agreed by the acute pain specialty leaders. An improving trend was observed in the analgesia score over the study period. Each intervention was associated with improved practice. Based on observed improvements, a novel electronic prescribing protocol was developed in conjunction with the information technology department, resulting in maximum scores for prescribing which were sustained over the final 3 months of the study. This was subsequently adopted as standard practice within the department. One year following completion of the project, a further 3 weeks of data were collected to assess long-term sustainability—scores remained 10 out of 10. Addressing the prescribing habits of junior doctors improved accessibility to analgesia for trauma patients. The electronic prescribing tool made prescribing straightforward and faster, and was the most successful intervention. Doctor satisfaction using this time-saving tool was high. Identifying a stakeholder within the information technology department proved pivotal to transferring the project aims into clinical practice.

scholarly journals High-dose antipsychotic treatment in clinical practice

1999 ◽  
Vol 23 (11) ◽  
pp. 661-664 ◽  
Author(s):  
Philip J. Tyson ◽  
Ann M. Mortimer ◽  
Jason A Wheeler
Keyword(s):  
Clinical Practice ◽  
Antipsychotic Medication ◽  
Royal College ◽  
Treatment Compliance ◽  
Antipsychotic Treatment ◽  
Clinical Implications ◽  
High Dose ◽  
Dose Treatment ◽  
High Dose Treatment ◽  
High Doses

Aims and methodA trust-wide audit of antipsychotic prescription was conducted in order to investigate the prevalence of high-dose treatment in a population with schizophrenia and assess compliance with Royal College of Psychiatrists' guidelines on the use of high doses. Details of antipsychotic medication were recorded and in cases of high-dose treatment compliance with the College's guidelines was assessed.ResultsSixteen out of 361 patients (4%) were receiving high-dose medication. At re-audit this figure fell to four patients (1%). High-dose treatment comprised of a combined depot and oral medication in most cases. There was poor compliance with the College's guidelines.Clinical implicationsThe study stresses the importance of monitoring patients on high-dose antipsychotics, particularly when taken in combination.

Do we follow prescribing and administering guidelines?

2011 ◽  
Vol 26 (S2) ◽  
pp. 593-593
Author(s):  
F. Popescu
Keyword(s):  
Mental Health ◽  
Clinical Governance ◽  
Electronic Prescribing ◽  
Junior Doctors ◽  
List Type ◽  
Type Number ◽  
Dose Unit ◽  
Audit Cycle ◽  
Health Trust ◽  
Correct Code

This audit was done in July 2010 in an Geriatric Psychiatric Unit. Data collected from 45 drug cards with a total of 368 prescriptions, both psychotopic and non-psychotropic, regular and PRN prescriptions.The aim was to analyse ?% of prescriptions on drug cards are meeting Birmingham and Solihull Mental Health Trust guidelines in both medics prescribing and nurses administering.Prescribing guidelines:Ø drug: generic name, capitals, dose amount, dose unit, frequency, route of administrationØ patient: full name, address, date of birth (D.O.B.), patient id (P.I.D.), allergy status, team, wardØ prescribing doctor: signature, printed name, date of prescriptionØ In general: legibility and black inkAdministering guidelines:• At administration of the drug, the practitioner must, sign with initials in the appropriate column of the official prescription sheet or introduce the correct code.The results:2 tables can′t attachSIGNATURE AT ADMINISTRATION by the nurses•Signed 95%•Signed + code 18.5%•Administered by the nurses but not signed by dr. 0.5%Recommendations:1.Medics and nurses teaching2.Introduction of the prescribing guidelines in the junior doctors trust induction handbook3.Notes with prescribing /administering guidelines4.Special print name box on the drug card5.Introducing electronic prescribing to avoid missing allergies6.Re-audit December 2010The first four recommendations have been already implemented.The audit has been registered with the Clinical Governance Department. By the time of the presentation of the poster with your permission in March, the audit cycle will be closed.

scholarly journals An audit of high-dose and combination antipsychotic prescribing across the general adult inpatient wards in Mersey Care NHS Foundation Trust

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S82-S83
Author(s):  
Declan Hyland ◽  
Beth Hemmings ◽  
Yasmine Elagamy
Keyword(s):  
Combination Therapy ◽  
Serum Cholesterol ◽  
Antipsychotic Medication ◽  
Hba1c Level ◽  
Serum Prolactin ◽  
High Dose ◽  
Antipsychotic Therapy ◽  
Electronic Prescription ◽  
Effect Site ◽  
Adult Inpatient

AimsTo review the number of prescriptions of regular high-dose antipsychotics and combination antipsychotic therapy across the eight general adult inpatient wards in Mersey Care NHS Foundation Trust and examine whether these prescriptions followed Trust recommendations for high-dose antipsychotic therapy (HDAT).BackgroundThe two main rationales behind prescribing HDAT are pharmacokinetics differ in individuals and so insufficient amounts of antipsychotic may reach the effect site at maximum dose in some patients and variations in the effect site between patients may mean higher doses are required to achieve therapeutic effect.MethodThe electronic prescription records for all patients on the eight general adult inpatient wards were scrutinised. 121 patients were prescribed antipsychotic medication. Any patients on a combination of regular antipsychotic medication or on HDAT were identified. Any patient on combination therapy or HDAT was studied to determine if Clozapine had been considered. The electronic notes of HDAT patients were analysed to ascertain whether tests recommended by Trust guidelines – BMI, blood pressure (B.P), pulse rate, ECG, FBC, U and Es, LFTs, serum prolactin, serum cholesterol and HbA1c level had been performed prior to initiation and following any dose increase.Result21 of 121 patients prescribed antipsychotic medication were on combination therapy. 11 were subject to HDAT. 8 of the 11 HDAT patients were on combination therapy. Clozapine was considered before initiating HDAT in 9 of the HDAT patients. Clozapine was considered in 13 of the 21 patients on combination antipsychotic therapy, but only two were initiated on Clozapine (combined with Olanzapine or Risperidone).100% of HDAT patients had an ECG prior to initiation of HDAT; only 36% had one after dose increases above BNF maximum. 100% of HDAT patients had their BMI measured before initiation. 91% had baseline B.P and heart rate checked. Of the recommended blood tests, 100% of HDAT patients had baseline FBC, U and Es, LFTs and serum cholesterol. Fewer patients had a baseline HbA1c level (91%) or serum prolactin (46%) measured.ConclusionPrevalence of HDAT across the general adult inpatient wards in the Trust was 9%, much lower than the 28% reported in the HDAT audit completed by the Prescribing Observatory for Mental Health in 2012. Patients within Mersey Care are more likely to be prescribed combination therapy than HDAT. Not every HDAT patient has been considered for Clozapine. There is a need to ensure Trust monitoring guidelines for HDAT patients are being strictly adhered to.

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