Safe and effective use of ACE inhibitors
In this Audit 
Audit focus
This audit focuses on baseline monitoring of patients before starting treatment with an ACE inhibitor.
For the purposes of this audit, baseline is defined as three months before starting treatment. Baseline monitoring for angiotensin II
receptor blockers is not covered in this audit although the general principles are the same as for ACE inhibitors.
Background
ACE inhibitors are commonly used and are indicated for a range of conditions including heart failure, hypertension,
post myocardial infarction and diabetic nephropathy.
The pharmacological actions of ACE inhibitors include reduced glomerular filtration, raised serum potassium and reduced
blood pressure. In most patients these effects are an indicator of a beneficial effect and are not associated with adverse
events. However, ACE inhibitors can cause clinically significant hyperkalaemia, renal impairment or hypotension in patients
with pre-existing risk factors such as volume depletion, concurrent diuretics, renal impairment, heart failure, diabetes
and concurrent use of medicines with the potential to interact (e.g. NSAIDs). Baseline monitoring helps identify patients
at risk of adverse effects before starting an ACE inhibitor. ACE inhibitors are most likely to cause hypotension after
the first dose or after a dose increase.
Ongoing monitoring is also recommended during treatment to check for clinically significant changes in serum potassium
and renal function from baseline but is not covered in this audit.
Cautions prior to use of ACE inhibitors
ACE inhibitors should be used with caution in a range of situations due to the increased risk of adverse effects or
interactions with a patient’s existing medicines. Precautions include the following:
- Renal impairment and contraindicated in patients with bilateral renal artery stenosis
- Hyponatraemia, hypovolaemia and dehydration
- Concomitant high dose diuretics due to the risk of hypotension
- Peripheral vascular disease and renovascular disease
- Hyperkalaemia
- Hypotension
- Severe heart failure
- Concomitant use of NSAIDs due to the risk of renal impairment, potassium sparing agents due to
the risk of hyperkalaemia.
There is also potential for other medicine interactions including lithium.
Justification for baseline monitoring
Hospital admissions due to renal impairment, hyperkalaemia and hypotension are common in patients taking ACE inhibitors.
Baseline monitoring of renal function, electrolytes and blood pressure would be expected to prevent some of these events
although there is a lack of supporting evidence from clinical studies.1 Most national and international practice guidelines
recommend baseline monitoring of patients but compliance is variable, ranging from about 20 – 80 %.2, 3
Baseline values of electrolytes, creatinine and blood pressure also set a benchmark for ongoing monitoring of treatment
effectiveness and safety.
Recommendations
For patients taking an ACE inhibitor there should be documented evidence of measurement of creatinine, electrolytes
and blood pressure within the three months prior to starting treatment.*
* Three months is an arbitrary period suggested to capture most clinical situations. For example, for most patients
it will be appropriate to measure blood pressure immediately before starting treatment whereas a less recent electrolyte
or creatinine measurement may be appropriate, unless the patient is clinically unstable or at increased risk of an adverse
effect.
Plan
Summary
This audit focuses on the measurement of serum creatinine (to estimate glomerular filtration), electrolytes and blood
pressure prior to starting a patient on an ACE inhibitor.
Recommended audit standards
For the purposes of this audit, 80% of patients taking an ACE inhibitor should have documented values of serum creatinine
and electrolytes and 100% for blood pressure within the three months prior to starting treatment.
Data
Eligible people
Any patient that has received a prescription for an ACE inhibitor in the last 12 months is eligible for this audit.
Identifying patients
You will need to have a system in place that allows you to identify eligible patients who have been prescribed an ACE
inhibitor and audit their clinical notes. Many practices will be able to identify patients by running a “query” through
their PMS system.
Sample size
The number of eligible patients will vary according to your practice demographic. If you identify a large number of
patients, take a random sample of 30 patients whose notes you will audit.
Criteria for a positive result
A positive audit result is for 80% of patients to have documented baseline serum creatinine (eGFR) and electrolytes,
and 100% of patients have a documented baseline blood pressure.
Identifying opportunities for Audit of Medical Practice
The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.
Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.
Taking action
It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).
Problem solving process
- What is the problem or underlying problem(s)?
- Change it to an aim
- What are the solutions or options?
- What are the barriers?
- How can you overcome them?
Overcoming barriers to promote change
- Identifying barriers can provide a basis for change
- What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them
in the practice setting
- Identify the barriers
- Develop a priority list
- Choose one or two achievable goals
Effective interventions
- No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed
to bring about lasting change
- Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance
and behaviour
Review
Monitoring change and progress
It is important to review the action plan develop previously against the timeline at regular intervals. It may be helpful
to review the following questions:
- Is the process working?
- Are the goals for improvement being achieved?
- Are the goals still appropriate?
- Do you need to develop new tools to achieve the goals you have set?
Following the completion of the first cycle, it is recommended that the doctor completes the first part of the
Audit
of Medical Practice summary sheet (Appendix 1).
Undertaking a second cycle
In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order
to quantify progress on closing the gaps in performance.
It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle
should begin at the data collection stage. Following the completion of the second cycle it is recommended that practices
complete the remainder of the Audit of Medical Practice summary sheet.
Claiming credits for Te Whanake CPD programme requirements
Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).
Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the
RNZCGP website).
N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.