A retrospective audit assessing clozapine utilisation in a high secure forensic hospital
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Background/introduction: People with schizophrenia have increased mortality associated with comorbid physical conditions, socioeconomic factors and elevated suicide rates (Saha et al., 2007). Clozapine is superior to other antipsychotics for treatment resistant schizophrenia, however, utilisation is lower than ideal due to, for example, patients' fear of side effects and clinicians' general negative beliefs (Patel, 2012). Aim and objectives: The National Institute for Health and Care Excellence (NICE) clinical guideline for the prevention and management of schizophrenia (National Institute for Health and Care Excellence, 2014) states clozapine should be offered to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least two different antipsychotics. The objective of this audit was to assess compliance with this guideline, and the expected compliance standard was set at 100%. Methods/design: Patients were identified by the Trust's Applied Informatics Department based on the inclusion criteria: 1. Diagnosed with schizophrenia (F20), 2. Currently an inpatient, and 3. Admitted for >12 weeks (as stated in the British National Formulary, "Patients should receive an antipsychotic drug for 4-6 weeks before it is deemed ineffective" (British Medical Association and The Royal Pharmaceutical Society of Great Britain, 2018), two antipsychotics trialled for adequate periods as per NICE recommendations would be for a maximum of 12 weeks). Patients were assessed for clozapine eligibility based on the definition of adequate doses and durations for previous antipsychotics from a New Zealand guideline (Waitemata District Health Board, 2011) as a pragmatic approach in the absence of agreed guidelines. Exclusion criteria were: 1. Current or previous treatment with clozapine, and 2. A documented allergy or hypersensitivity to clozapine. Each eligible patient's clinical notes were reviewed for any record of being offered clozapine. Only their current admission and electronic notes were used. Audit committee comments were sought and sign off gained. Ethics approval was not required. <br/>Result(s): Ninety-eight patients were initially identified based on the inclusion criteria. Three were excluded immediately due to incorrect diagnoses and responding to current treatment, therefore ninety-five patients' data were collected and analysed. Twenty-four patients were eligible for clozapine; fifteen were offered clozapine (63%). Discussion and conclusion: Not all eligible patients were documented as being offered clozapine. Patients deserving of a clozapine trial are possibly not being offered one and the hospital may not be compliant with NICE guidance. Patients' responses to antipsychotics must be actively assessed and clozapine considered as soon as appropriate. Clinical pharmacists should perform medication reviews and make patientcentred recommendations to facilitate treatment optimisation. Trigger points could be embedded within relevant clinical systems to prospectively identify potential clozapine patients. A reaudit should be performed manually identifying eligible patients as a part of data collection due to data extracted by Applied Informatics being incorrect. The re-audit should also monitor the adherence with routine antipsychotics in real time. Re-audit should occur 12 months after audit report dissemination and any agreed actions being put into place in response to the audit report. Qualitative analyses using the results of this audit should also be considered, for example, an analysis of the specific reasons why clozapine therapy was not offered, rejected or ceased, and if these reasons were documented. These analyses can be used to inform future guidance on re-introducing clozapine.