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This was a re-audit of off-label prescribing of quetiapine in order to identify the number of patients on off-label quetiapine in HMP Elmley, to monitor compliance by the Mental Health Inreach Team (MHIRT) psychiatrists with the Royal College of Psychiatrists guideline on off-license prescribing, to compare findings with the baseline audit and to identify areas for improvement.
All patients on quetiapine in HMP Elmley were identified and their electronic patient record was reviewed against the standards outlined in the Royal College of Psychiatrists “Use of licensed medicines for unlicensed applications in psychiatric practice (2nd edition).
There were 60 residents on off-license quetiapine prescription in HMP Elmley.
Of this number, four had their prescription initiated by a general practitioner, either while in prison or in the community. Two residents were on quetiapine first prescribed while they were on admission in hospital. 5 patients had been initiated by the MHIRT psychiatrists. 38 residents were commenced off-license quetiapine by another psychiatrist, either while they were in the community or in another prison. In 17 patients, electronic records were inadequate to determine who had prescribed the quetiapine.
The number of inmates prescribed off-label quetiapine in HMP Elmley had dropped from 82 to 60 in the 1 year since the initial audit. Of these figures, prescriptions initiated by the MHIRT psychiatrists, had dropped from 28.1% (23/82) to 8.3% (5/60).
For those prescribed quetiapine by the HMP Elmley psychiatrists, notes were audited against the RCPsych guidelines:
Licensed medication was considered first in 80.0%
Risks and benefits were considered and documented in 80.0%
The benefits and potential risks were explained to patient in 80.0%
There was documentation of informed consent in 80.0%
Quetiapine was started at a low dose and monitored in 100%
No residents required withdrawal of medication due to ineffectiveness or adverse effects.
Baseline physical health assessment was performed in 80.0%, though all had an ECG done.
Over the past year there has been an improvement in off-label antipsychotic prescribing practice within the MHIRT.
However, the number of off-label antipsychotic prescriptions still remains high throughout the prison. There should be continued effort at minimizing off-label prescribing within the MHIRT, monitored by auditing. However, work needs to be done jointly with other prescribers, such as GP colleagues, in order to avoid unnecessary prescriptions and to monitor regularly the physical and mental health of those on off-label quetiapine.
Attention deficit hyperactivity disorder (ADHD) is a highly prevalent disorder in young adult prisoners. This audit aimed to identify how many residents are prescribed medication treatment for ADHD in HMP Elmley and whether those seen by the prison psychiatrists have been managed in line with NICE guidelines. We also audited waiting times and time to follow-up appointments. This was done with the overall aim to identify potential areas for development.
We performed a spot audit of all residents in HMP Elmley who were prescribed ADHD medication on 4th November 2019, using their electronic patient records. Appointments with the psychiatrists were then subdivided into initial assessments and follow-up appointments for the purpose of analysis. Performance was measured against NICE Guideline [NG87]: Attention deficit hyperactivity disorder: diagnosis and management. We also calculated the waiting times for initial appointment and follow-up appointment.
We found that 33 of residents were on ADHD medication at the time of the audit, approximately 3% of the prison population. 64% of those had a pre-existing diagnosis and 36% had been given a new diagnosis at HMP Elmley. Of those newly diagnosed 100% had undergone a Diagnostic Interview for Adults in ADHD (DIVA) assessment for diagnosis.
Baseline physical health checks had been performed in 68% of patients prior to starting medication and a cardiovascular examination had occurred in 9%. At follow-up 100% of patients had their physical observations and weight checked and their symptoms reviewed.
91% of patients were started on methylphenidate or lisdexamfetamine as first line treatment, with the rest started on atomoxetine and the reason for this documented.
100% patients were offered general psychological support.
There was a mean 22 day wait for an initial appointment (range 0-65) and a mean 20 day wait from starting medication to a psychiatric follow-up appointment (range 8-37)
The number of residents treated for ADHD in HMP Elmley is relatively low (3%) compared to the estimated prevalence in prison population.
The key areas for improvement are in baseline cardiovascular examinations and physical health evaluations. The waiting time between initial psychiatric appointment and follow-up is another area where improvement is needed and this will form the basis of a quality improvement project.
Future steps include setting up a specific ADHD clinic with an allocated nurse practitioner to support, producing a template for ADHD assessments and follow-ups, producing a local policy on ADHD and developing specific resources for ADHD psychoeducation.
The Royal College of Psychiatrists’ Parliamentary Scholar Scheme gives higher trainees in psychiatry the opportunity to spend 1 day a week in the House of Lords working alongside a peer with an interest in health. This article describes the work of the House of Lords and Parliament using examples from the experiences of 2017–2018 scholars and outlines ways doctors can get more involved in policy and politics.
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