This audit relates to all services where patients are treated for bipolar affective disorder or otherwise prescribed mood stabilisers. It relates to both in- and out-patients.
The mood-stabilising drugs valproate and carbamazepine are widely prescribed within psychiatric services and each has its own list of potentially harmful adverse effects. (Lithium monitoring is considered in audit 90, p. 211.) As a result, there are important monitoring recommendations for both drugs. These include monitoring of the possible side-effects, as well as therapeutic drug monitoring, which aims to avoid the side-effects while ensuring therapeutic levels of the drug are achieved.
Standards for audit were obtained from the guideline on bipolar disorder produced by the National Institute for Health and Clinical Excellence (NICE) (2006):
ᐅ Patients prescribed valproate should have the following baseline assessments prior to initiation of treatment:
▹ liver function tests (LFTs)
▹ full blood count (FBC)
▹ weight and height.
ᐅ Patients prescribed valproate should have LFTs and FBC rechecked 6 months after initiation of treatment.
ᐅ Patients prescribed carbamazepine should have the following baseline assessments prior to initiation of treatment:
▹ weight and height.
ᐅ Patients prescribed carbamazepine should have:
▹ LFTs, urea and electrolytes (U&Es) and FBC checked 6 months after initiation of treatment
▹ U&Es monitored every 6 months subsequent to this
▹ serum carbamazepine levels measured every 6 months.
It was expected that the standards would be met for 100% of patients.
A list of patients prescribed valproate or carbamazepine was created by examination of in-patient medication charts and out-patient records held in the pharmacy. The medical notes and online pathology results for each of these patients were then examined to determine which monitoring tests had been carried out over a previous defined period.
The percentage of patients who had undergone each test applicable to them was calculated and these percentages compared against the standards set above.
Owing to the volume of notes to be read and the amount of data to collect and analyse, it is suggested that two people undertake this audit. It is appropriate that different disciplines are involved (e.g. a doctor and a pharmacist).