The Impact of Introducing a Lithium Care Pathway

- To establish if patients prescribed Lithium is monitored according to NICE Guidelines
- To establish if potential adverse effects and toxic effects of Lithium are discussed with patients
- To establish if any side effects, or lack of, are recorded
- To establish if patients other medications are recorded and potential interactions noted
- To establish if there has been an improvement in practice as a result of implementation of previous audit recommendations

South Eastern HSC Trust is an integrated organisation, incorporating acute hospital services, community health and social services and serves a population of approximately 440,000, of whom approximately 55,000 are aged over 65 years. Lithium (Li) has a narrow therapeutic index so can become toxic, causing harm or death, particularly in the elderly population with co-morbid illness and interacting medications.

National Patient Safety Agency (NPSA) suggests lithium therapy is an error-prone process and monitoring of Lithium levels is a particular issue so guidelines have been issued. An initial Li audit covering a one year period was undertaken in 2011 and then, following implementation of a Li care pathway and specific Li clinics in September 2012, a further Li audit covering a one year period was repeated. Prior to this audit, patients on Li were seen in a general Old Age psychiatry clinic and no care pathway was followed. The initial audit highlighted that there were unclear boundaries of responsibility for Li monitoring between primary and secondary care; lack of a database of patients prescribed Li; lack of a Li monitoring nurse post in secondary care; lack of access to blood results at clinics; laboratory reference range was too high for elderly patients (0.4-1.0mmol/l); lack of documentation of risks and side effects; lack of communication between health professionals and patients and some lack of knowledge about management of Li.

Funding was received for computer access in each clinic room from Mental Health Services, for Mental Health Outpatient Clinic and for a nurse Li monitoring post. Funding was provided for an initial start-up Li clinic by Mental Health Services for Older People, so that all patients could be commenced on Li care pathway at the same time. Following this, a Li clinic was booked in a usual outpatient clinic session (no additional cost). Meetings were held with Trust management, other staff and stakeholders including laboratory staff and regionally at HSCB with GPs. A Li database was developed, the Li reference range was changed to 0.4-0.8mmol/l for patients over 65 years and a regional Li care pathway and communication form was agreed, including a LES for GPs. Education sessions were provided for staff locally and regionally.

Progress was monitored by re-audit, following implementation of the action plan of the initial audit. The main result was an improvement in patient safety, with 33% GP monitored patients and 19% hospital monitored patients having a toxic (>1.0mmol/l) Li level in initial audit and 8% and 0%, respectively, having toxic Li levels in re-audit. This correlated with an improvement in patients having all their blood monitoring meeting NICE guidelines for GP monitored (17% to 54%) and hospital monitored (56% to 86%) patients. There was also a significant improvement in documentation of discussion of side effects (36% to 100%); kidney risk (0% to 95%); thyroid risk (0% to 95%) and toxicity risk (16% to 100%) with patients. There was also improved documentation of patients having been given educational material about Li (0% to 95) and a Li record book (0% to 95%); having indication for Li recorded (72% to 100%); having other medication recorded (72% to 100%) and possible interactions noted (11% to 90%). Please see enclosed poster and powerpoint presentation for further detail.

Engage key stakeholders early in the process and highlight patient safety issues as the reason for the need for change. One of the single most important changes was the change in the laboratory reference range, as it highlights that a result over 0.8mmol/l is abnormal for patients over 65 years, so engagement of laboratory services management was crucial.