Drug monitoring in secondary care

This case study will help if you:

  • work in secondary care
  • prescribe medications that require monitoring to ensure that safe, therapeutic levels are achieved
  • wish to demonstrate skills in quality improvement.

The National Institute for Health and Care Excellence (NICE) worked with us to develop this case study.

Key points to consider

  • The supporting information you bring to your appraisal should cover the whole of your practice. Including any NHS and independent sector work you do.
  • Your appraiser, employer or professional membership body can offer advice on what information to bring and how to present it. The NICE website also has guidance relevant to different areas and types of practice that might help you.

Many medications prescribed in primary and secondary care require monitoring. This is to make sure that drug levels are high enough to provide therapeutic effect and low enough to prevent toxicity. Monitoring for signs of toxicity frequently includes clinical review (e.g. for tendinopathy or cognitive effects) and blood tests (e.g. for renal or hepatic dysfunction and/or drug levels). For each medication, guidance on the required monitoring can be found in the relevant clinical guideline.

The following case study is about lithium prescribing in secondary care. It shows the principles and approaches which are available to protect patient safety when prescribing and monitoring drugs with a narrow therapeutic window.

The example is informed by guidance from NICE. NICE guidance is developed in and for England. The Scottish Intercollegiate Guidelines Network (SIGN) has guidelines on Mood Disorders in Pregnancy. These highlight the risks of lithium during pregnancy and include at annex 3 guidance on monitoring in pregnancy. Those working outside of England are advised to check for any national and regional guidelines which may vary from NICE guidelines.

Scenario – Dr L

Dr L is a psychiatrist working in an NHS hospital. Some of her patients are adults with bipolar disorder who have been prescribed lithium. She is considering how to meet the requirements for appropriately demonstrating quality improvement.

How the doctor met our requirements

Dr L reviewed the NICE guidance on management of lithium therapy and the NICE guidance on bipolar disorder. She noted that once a patient has stable lithium levels, they need their lithium levels to be checked every three months. Their weight or body mass index (BMI), urea and electrolytes (U&Es), calcium and thyroid function tests (TFTs) should also be checked every six -months. The guidance on bipolar disorder recommends that at every appointment, patients are monitored for symptoms or signs of neurotoxicity such as paraesthesia, ataxia, tremor and cognitive impairment. These symptoms can occur even when lithium levels are within the therapeutic range. The guidance on lithium therapy also advises that patients taking lithium carry a lithium card. They should be informed about the adverse effects of lithium and the risk of toxicity if they become dehydrated.

Dr L supervised a junior doctor to undertake a quality improvement project. It involved a  an audit of all patients prescribed lithium therapy at the date of starting the audit. It explored whether each of these patients had had:

  • lithium levels checked within the last three months,
  • U&Es, calcium and TFTs within the last six months, and
  • a documented review for neurotoxicity, weight or BMI checks and discussion or check of understanding about possible adverse effects of lithium within the last six months.

The audit demonstrated that not all patients prescribed lithium had had the required monitoring. In particular, the audit highlighted that documentation of whether patients held a lithium card and whether they had received information about the potential adverse effects of lithium was frequently missing from their record.

Those patients who had not had the required monitoring were contacted to attend an early clinical review. Their GPs were contacted to tell them of the recall, and to provide the GP practice with guidance on monitoring patients prescribed lithium and contact details for further specialist advice.

The audit was presented and discussed at the department’s clinical governance meeting.

It was agreed that the recommendations for blood tests and other monitoring needed to be reinforced. It was discussed at a departmental meeting and an email reminder was sent to all psychiatrists in the department. Dr L also contacted the trust’s electronic prescribing team to explore whether a three-monthly reminder could be set up. This would be to tell the responsible clinician that lithium monitoring was due.

It was also agreed that there should be a focus at every clinical review, on checking patients’ understanding of the symptoms of lithium toxicity. Patients should also be asked whether they had a lithium card and a National Patient Safety Agency (NPSA) booklet about lithium therapy. NPSA booklets for patients were then made available in all clinic rooms.

The junior doctor who had undertaken the audit worked with the inductions team to include training about lithium in junior doctors’ induction. Dr L also invited a colleague to co-run a departmental lunchtime training session on shared decision making. This was following GMC advice and had a focus on prescribed medicines.

Dr L supervised a junior doctor to repeat the audit of lithium monitoring three months later. He also added this audit to the list of audits to be completed at least annually in the department.

At her appraisal, Dr L:

  • Described the NICE guidelines on lithium monitoring and bipolar disorder.
  • Explained how she had supported a junior doctor to undertake a full audit
  • Explained how she  added an audit of lithium monitoring to the list of audit projects to be completed by junior doctors.
  • Discussed how she had reduced the risk of harm by arranging for all patients a clinic review as soon as possible. 
  • Explained how she alerted other colleagues via a clinical governance presentation.
  • Described how she had taken steps to promote good practice going forward, including seeking regular electronic reminders, scheduling a repeat audit and annual repeat audits thereafter.
  • Described how she would educate staff, including junior doctors, and make a patient information resource available.