1. Lithium Requesting at the RD&E Complied September 2010 Mandy Perry mandy.perry@nhs.net Audit of lithium requesting

2. The NICE guidelines (Ref No. CP-170-08, 2007): "Lithium Prescribing and Monitoring Guidelines" Defining Standards renal function – 6 monthly thyroid function – 6 monthly lithium levels – 3 monthly Lithium treatment is not recommended in patients with significant renal impairment, where GFR < 30 mL/min/1.73m 2

3. Audit of lithium requesting Data Collection Data selection: All biochemistry requests that include lithium in a 7 month period (01/02/10 to 31/08/10) This does not necessarily capture all patients taking lithium Specimen number NHS number Age Requesting clinician Requestor location Lithium Creatinine eGFR TSH, FT4

4. Audit of lithium requesting Questions: 1.How many lithium requests in the 7 month period? 2.How many requests are for patients taking lithium? 3.Who is requesting serum lithium? Of the patients taking lithium: 4.Has thyroid function been monitored appropriately? 5. Has renal function been monitored appropriately? 6.Are there any patients taking lithium in CKD stages 4 or 5? 7.Has serum lithium concentration been monitored appropriately?

5. Audit of lithium requesting 2. How many requests are for patients taking lithium? 1107 requests, 452 patients 1. How many lithium requests in the 7 month period?

6. Audit of lithium requesting 3.Who is requesting serum lithium?

7. Audit of lithium requesting 4. Has thyroid function been monitored appropriately?

8. Audit of lithium requesting 4. Has thyroid function been monitored appropriately?

9. Audit of lithium requesting 5. Has renal function been monitored appropriately?

10. Audit of lithium requesting 6. Are there any patients taking lithium in CKD stages 4 or 5?

11. Audit of lithium requesting 7.Has serum lithium concentration been monitored appropriately? Some patients have had more than one lithium request in the time period. Too infrequent

12. Audit of lithium requesting 7.Has serum lithium concentration been monitored appropriately? Looking at patients’ records before 01/02/10:

13. Audit of lithium requesting Questions: 1.How many lithium requests in the 7 month period? 2.How many requests are for patients taking lithium? 3.Who is requesting serum lithium? Of the patients taking lithium: 4.Has thyroid function been monitored appropriately? 5. Has renal function been monitored appropriately? 6.Are there any patients taking lithium in CKD stages 4 or 5? 7.Has serum lithium concentration been monitored appropriately? 1107 requests, 452 patients 96.4% 90% of requests are from primary care 75% of patients had thyroid function measured in the time frame. 84% of patients taking lithium had renal function measured in the time frame. 12 patients with CKD stages 4 or 5. What are the alternatives? 30% of patients had serum lithium measured once in the 7 month time frame ?How many patients taking lithium did not have lithium measured within the time frame.

14. Audit of lithium requesting What now....? What changes can we implement to ensure that lithium requesting becomes more appropriate? Sort the data by requesting clinician? National Patient Safety Alert Changes to the Quality and Outcome Framework Re-evaluate in 2012

15. Audit of lithium requesting

16. Thanks for listening

17. Audit of lithium requesting How do these results compare with other audits? National Patient Safety Agency – Patient Safety Alert 2009: “The NHS Litigation Authority dealt with two fatal and 12 severe harm incidents involving lithium therapy and the Medical Defence Union has been involved with 15 incidents directly related to lithium toxicity and monitoring. NICE standard: one lithium level measurement every three months:Not met for 70 % patients Renal function assessment every six months. Not met for 46 % patients Thyroid function assessment every six months. Not met for 51 % patients

18. Audit of lithium requesting 7.Has serum lithium concentration been monitored appropriately?