Electronic Letters to:
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eLetters: Electronic letters published:
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High Dose Antipsychotic Prescribing
- Neeraj Bajaj (11 June 2008)
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High-dose and Combination Antipsychotic Prescribing in a High Security Hospital.
- Noir Thomas, Edward Silva, Inti Qurashi, Arun Chidambaram (2 July 2008)
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High rates of redundant PRN prescriptions
- Naaheed Mukadam (30 July 2008)
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Neeraj Bajaj, ST3 The State Hospital, Carstairs
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nbajaj{at}doctors.org.uk Neeraj Bajaj
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Paton et al have identified PRN prescribing of antipsychotic drugs for the management of behavioural disturbance as being mainly responsible for High dose antipsychotic prescribing and have given three possible explanations for the failure of the quality improvement programme to change practice. They have identified Junior Doctors as being responsible for most of the PRN prescriptions. I will like to draw their attention to another possible explanation for the failure of their quality improvement programme. With the implementation of European Working Time Directive, NHS trusts across UK have been busy making junior doctor rotas compliant and majority of mental health trusts have made on-calls for junior doctors non -residential, which means junior doctors are not on site during on-call hours and are allowed to be on-call from their residence. Nursing staff are under pressure to minimise calls to junior doctors out of hours to maintain compliant rotas. This has led to a culture of PRN prescribing of antipsychotic drugs as a matter of routine at the time of admission rather than patient need. This problem is set to get worse from August 2009 when working hours for junior doctors will be reduced from 56 to 48 hours per week. Secondly, it is not clear whether this Audit included patients on Forensic and Rehabilitation wards, a group of patients identified in a study by Lelliott et al, 2002 to be 1.3 times more likely to be on high dose antipsychotics than those for a person on an acute ward. This audit thus missed an important opportunity to assess the relationship between high dose antipsychotic prescribing and ward type. REFERENCES Lelliott P, Paton C, Harrington M, Konsolaki M, Sensky T, Okocha C. The influence of patient variables on polypharmacy and combined high dose of antipsychotic drugs prescribed for in-patients. Psychiatr Bull 2002; 26: 411 -14 |
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Noir Thomas, Specialist Registrar in Forensic Psychiatry Mersey Care NHS Trust. Ashworth Hospital, Edward Silva, Inti Qurashi, Arun Chidambaram
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noir.thomas{at}merseycare.nhs.uk Noir Thomas, et al.
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We write in response to the study by Caton et al, which mirrors a process of intervention and service improvements adopted as standard practice at Ashworth Hospital. High dose prescribing (defined as above 100% BNF maximum including individual or combination antipsychotic therapy) was, until recently, a common management strategy, largely attributed to the nature of high secure patients; often presenting with treatment refractory illness associated with significant violence. A baseline audit in 2005 identified 50 patients (24%) of a total 212 prescribed high dose antipsychotic medication. Recognition that almost 1 in 4 patients were prescribed high dose regimes particulalrly in view of limited evidence of efficacy (NICE, 2002), led to changes in service governance and clinical practice. High dose cases were identified according to RMO who were invited to present their rationale for prescribing along with evidence of monitoring of relevant physical health investigations, as part of a monthly audit meeting. This served also as an opportunity to obtain regular peer review in the management of the most difficult clinical cases and identify 'prescribing outliers'. This was coupled with educational intervention in the form of related journal presentations and a review of the current evidence base at academic meetings. Audit cycles have been repeated annually since 2005. Cumulative data (to include 2008) demonstrate a sustained decrease in the use of high dose regimes. Comparison of audit findings between 2005 and 2008 highlight the improvements made. In 2008, only 10% of cases (n=20) continued to exceed BNF limits, in comparison with 25% (n=50) in 2005. Of these 20 individuals, 2 are prescribed monotherapy, the remaining 18 receiving high dose combination antipsychotic medication. The majority of the latter are receiving Clozapine augmentation with another atypical, a generally accepted treatment. Our findings are similar in nature to that of Caton et al, with high dose regimes predominantly represented by polypharmacy (90% of the sample in 2005), frequently on a pro re nata basis. Recognition of this has resulted in a change in prescribing practice with this being regularly reviewed, prescribed in the short-term and discontinued if unnecessary. Our figures also compare favourably against other forensic services as demonstarted by a national external audit (POMH, 2007). Furthermore, a reduction in high dose prescribing has not precipitated an escalation in adverse incidents, as might be expected, but corresponds with the lowest number of patients in seclusion at Ashworth Hospital in recent years. Our experience at Ashworth Hospital suggests that the prescribing of high dose antipsychotics can be succesfully addressed by simple changes in clinical governance. References: 1 Schizophrenia: Core interventions in the treatment and management of Schizophrenia in Primary and Secondary care. NICE. Clinical Guidleines. Dec 2002 2 Prescribing of high dose antipsychotics for pateints on forensic wards. POMH-UK. Topic 3. Baseline audit. Royal College of Psychiatrists, 2007. |
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Naaheed Mukadam, SpR St. Margarets Hospital, Epping
Send letter to journal:
naaheed{at}gmail.com Naaheed Mukadam
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The POMH audits highlight the standards clinicians should be striving to meet in prescribing practice. The POMH audits on high dose and combination antipsychotic prescriptions in forensic units (2007) and general adult services (2008) brought to light the frequency of high dose and combination antipsychotic prescriptions and found that most of these prescriptions were due to PRN prescribing. Clinical experience suggested that most PRN prescriptions were not actually used and were often prescribed by junior doctors on call as a safeguard, so I conducted a service evaluation of forensic and adult wards in the trust where I worked to establish how often PRN medication was actually given. The same audit standards used by the POMH were used to decide if antipsychotic prescriptions were high-dose or combination. I found lower rates of high-dose prescribing for single antipsychotics than the POMH: no patients were prescribed high-dose single antipsychotics in the forensic units and only 5% of patients in the adult wards were prescribed a single antipsychotic at doses higher than BNF recommended limits. The rates of combination prescriptions were similar to those found in the POMH audit, with 48% of patients in both kinds of units being prescribed more than one antipsychotic. Seventy-six percent of combination prescriptions combined FGA’s with SGA’s and approximately 98% of these combinations were due to PRN prescriptions. This data would suggest that a significant percentage of our patients are at risk of adverse outcomes as a result of high-dose/combination antipsychotic prescribing but on further examination of the prescriptions, it was found that over 90% of the PRN prescriptions had not been used in the previous week. This finding is important as it highlights the discretion used by nursing staff in administering PRN medication despite a high percentage of patients being prescribed it. It also highlights the redundancy of PRN prescriptions and calls for regular clinician review of the need for these prescriptions. It was disappointing, therefore, to find that despite “reminder stickers” on prescriptions charts being the intervention with 100% take-up in the 2008 POMH audit, that this had no effect on prescribing practice. Unfortunately, the POMH audit only details how many services requested the various interventions and does not inform us as to who, if anyone, within the trust received this information. Although Paton et al have stated that PRN medication is usually prescribed by junior doctors, their interventions have not been targeted at this group and it would seem that the request for the interventions was at the service/managerial level. What is needed is grassroots education of junior doctors as the main prescribers of PRN medication. If they had guidance on calculating total antipsychotic doses and had to carry out screening such as blood tests and ECG’s for all patients prescribed potentially high-dose antipsychotics, it is likely the rates of unnecessary PRN antipsychotic prescriptions would dramatically reduce. Perhaps it is this kind of intervention that POMH should be implementing in future audits. |
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