A reduction in patient safety incidents with lithium has helped prevent litigation claims and hospital admissions in Norfolk. Nicola Cree spoke to Tim Anderson, lead clinical pharmacist at Norfolk and Waveney Mental Health Foundation Trust
In the five years to December 2009, the National Patient Safety Agency recorded 560 patient safety incidents relating to the use of lithium.
One of the key themes the NPSA identified was monitoring. In the same period, NHS Norfolk reported no adverse safety events related to lithium.
The area has pioneered a lithium therapeutic drug monitoring database for over seven years. It was a winner of a 2003 Pharmaceutical Care Award (PJ, 3 July 2004, p14).
Comparison with reporting in other areas suggests that Norfolk should have expected to see at least 35 adverse event reports in that time, says Tim Anderson, lead clinical pharmacist, Hellesdon Hospital, Norfolk and Waveney Mental Health Foundation Trust. The decrease in incidents has helped the trust prevent litigations claims and hospital admissions, he adds.
The database, which currently monitors around 1,300 patients, is based at Hellesdon Pharmacy and sends patients reminders to have their bloods lithium levels monitored (see Panel).
The current database
Maintains a register of people in Norfolk taking lithium
Maintains a record of patients’ blood levels for lithium
Communicates with GPs and patients direct
Sends blood test reminders to all patients every three months; sends up to three reminders, with the third alerting the GP direct
Helps ensure adequate information, education and access to specialist advice for patients
Is integral with a full shared-care agreement
Before the launch of the database, 32 per cent of patients had their blood levels monitored only once in a year. In total, less than 30 per cent of patients had adequate monitoring, and 24 per cent of tests were outside the acceptable range.
Now, 95 per cent of patients have blood monitoring twice yearly, compared with 68 per cent of patients who had two or more tests recorded in a UK-wide survey of monitoring (BMC Psychiatry 2010;10:80).
“Having someone look after a toxic drug in a group of patients who can be disorganised from a practical point of view is a good thing,” Mr Anderson quotes one area GP as saying. The prescribing lead at NHS Norfolk cites the service as money well spent, he adds.
The database has upscaled local monitoring to near National Institute for Health and Clinical Excellence standards, Mr Anderson says, because GPs in the area, when they see the blood form requesting lithium levels, also tick thyroid function, urea and electrolytes and serum creatinine levels.
Patients do not find it imposing he says, and few choose not to join the scheme.
The service has helped identify patients suffering from complications of lithium treatment, with one carer using the service to help identify signs of lithium toxicity in a patient who had recently suffered from diarrhoea and had become dehydrated, Mr Anderson says. The database meant the carer could seek help quickly and the patient could be admitted to hospital promptly for treatment.
The success of the database has meant that the trust was able to sign off on the NPSA guidance before the December 2010 deadline, however, it has decided to develop the database further in order to continue to improve patient safety.
The new database will have better recording and reporting facilities. Improved ways of contacting patients, such as email and text messaging, will be focus of the new system. It will also look to collect data on interactions, such as when taking non-steroidal anti-inflammatory drugs. The upgrade will also mean that additional blood tests, such as thyroid function are requested.
Currently, results are reported in lists and the aim is that they will be reported in new visual formats. The old system is quite administratively heavy, but the new system will have less paper involved and will be more automated in terms of data collection, he says. The database the current system works on is also near capacity so the update is being implemented to increase capacity.
Mr Anderson hopes that the upgrade will allow others to use the system, including district general hospitals and community pharmacies, and he hopes to have in place a single user access system. Currently the service is funded by the primary care trust, and Mr Anderson says he is not yet sure where the funding will come from once PCTs disappear.
“We’d hope locally that the service would continue to be supported … we feel that with the results we’ve had with regard to lithium incident reporting and the potential for litigation around lithium toxicities, it’s actually not a huge amount of money to ensure safety for quite an important group of people on chronic medication,” he says.
The cost of the licence and the staffing of the service, probably is around the same as treating 12 patients for a year with quetiapine, Mr Anderson says. “If you can save 10 or 12 people from switching due to toxicity or lack of effect due to poor blood monitoring, you pay for the service.” The trust has some indications that it reduces prescribing of atypical antipsychotics.
The service is also looking to integrate with GPs systems, including electronic information transfer, and will also be looking to set individual patient ranges for certain patients.
Mr Anderson advises that, although the NPSA guidance states that there should be guidelines in place nationally, Norfolk found that guidelines did not always work and they were not followed.
“[NHS Norfolk] basically shows that the database works over and above the guidelines,” he says.