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

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.