Re-Audit of Blood Monitoring of Lithium in Outpatients of Working Age Under Dudley Mental Health Services

Abstract

Aims

Lithium remains the first line mood stabilising therapy recommended by NICE for Bipolar Disorder and an important treatment option for augmentation of the treatment of Depression. Lithium has a strict monitoring requirement due to long term impact on Renal, Thyroid function and risk of toxicity due to a narrow therapeutic range. This Re-Audit aimed to assess improvement in Lithium Blood monitoring in working age adults in Dudley following an initial 2021 audit.

Methods

We used the standards set by NICE CG185- Bipolar Disorder Assessment and Management. We agreed a standard of 3 monthly monitoring of lithium levels due to the number of indications for 3 monthly monitoring to ensure safest practice. We also agreed to standards for 6 monthly monitoring of Urea and Electrolytes (U&Es) and Thyroid Function Tests (TFTs). An additional standard was agreed that at every outpatient review Lithium blood results should be reviewed and documented. A sample of 40 patients was gathered from the 8 outpatient sector teams. We used Rio notes system for demographic, diagnosis and clinical information and blood results systems EMIS and ICE for blood results over a period of November 2021- November 2022.

Results

There was a noted minor improvement to compliance with 3 monthly monitoring, overall increasing from 10% to 17.5%, but this result is still poor. The number of patients who had 4 or more Lithium blood tests over the 12 month period was more of a positive increase, to 32.5% from 17.5% in the previous audit cycle. There was also an improvement in the mean number of lithium blood tests per patient from 2.67 to 3.3. For U&Es 90% of patients were monitored 6 monthly while for TFTs 85% of patients were monitored 6 monthly. There was a slight reduction in documentation of blood results at clinic review, reducing to 62.5% from 67.5% in the initial audit.

Conclusion

While the progress is positive, the results are still far below where the trust would like to be. We considered whether frequency of outpatient review, poor awareness of 3 monthly monitoring standards and a lack of formal system to remind or ensure patients are monitored appropriately. It was agreed that measures to ensure compliance such as a lithium blood monitoring clinic may be useful to improve compliance with monitoring.