Older people are particularly vulnerable to the adverse effects
associated with antipsychotics, which are often prescribed
off-label and sometimes for inappropriate indications, e.g. for
insomnia. Non-pharmacological treatments should be used
first-line and continued if an antipsychotic is initiated. These
medicines should only be prescribed if they are likely to be
beneficial for the condition being treated and the patient
closely monitored for the development of intolerable or
serious adverse effects. Treatment should be initiated as a
trial at the lowest dose likely to provide therapeutic benefit.
In most cases, indefinite treatment is not appropriate and
should ideally not exceed three months duration.
Further discussion on the appropriate use of antipsychotic
medicines in older people, including national antipsychotic
prescribing data, is available from: www.bpac.org.nz/report/2020/antipsychotic-medicines.aspx
We recommended that this article is read before completing the clinical audit
This audit identifies patients aged 65 years and over who are taking an antipsychotic to determine if this prescribing is appropriate
Finding eligible patients
You will need to have a system in place that allows you to
identify patients aged 65 years and over who are taking
an antipsychotic. Many practices will be able to do this by
running a “query” through their PMS.
Sample size
The number of eligible patients will vary according to your
practice demographic. It is unlikely that a large number of
results will be returned, but if so, take a random sample of
20–30 patients.
Criteria for a positive outcome
You will need to access and review the patients’ clinical notes
to complete this audit. For a positive result, each patient’s
notes should contain documentation of:
- An appropriate reason for prescribing the antipsychotic,
i.e. prescribed for a condition for which there is
evidence that antipsychotics are effective and a
recommended treatment
- Discussion and implementation (if appropriate) of nonpharmacological interventions
- Review of treatment effectiveness and adverse effects
in the past three to six months. Ideally, patients should
be reviewed frequently after an antipsychotic is first
initiated and again at three months
Any patient whose notes do not contain the information
described above should be flagged for review.
Data analysis
Use the sheet provided to record your data. A positive result is
any patient taking an antipsychotic who has evidence in their
clinical notes of an appropriate reason for prescribing the
medicine, a discussion of non-pharmacological interventions
and a treatment review. The percentage achievement can be
calculated by dividing the number of patients with a positive
result by the total number of patients audited.
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
Monitoring change and progress
It is important to review the action plan developed previously 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
This audit has been endorsed by the RNZCGP for CPD purposes for General Practitioners and 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. General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice; this may also be recorded as a reflection if suitable.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
The RNZCGP encourages 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).
