H51 Project 564: monitoring electrocardiogram (ECG) in patients on antipsychotic medication admitted to psychiatric ward during admission period in october 2017 (re-audit of project 2057)

Abstract

Background Our multi- disciplinary team offer assessment and treatment for a wide range of mental health problems and neuropsychiatric disorders such as Huntington’s disease (HD). Although HD is a disease of the central nervous system, mortality surveys indicate that heart disease is a leading cause of death.1 The previous audit about the ECG monitoring was conducted in July 2013 (Project 2057). The monitoring of ECG abnormalities of inpatients involves an ECG which expected to be performed at admission, and repeated when patients are commenced on high-dose antipsychotics. The QTc is considered the most appropriate measure for ventricular repolarization. Interpretation of case reports of arrhythmia and sudden death in patients receiving these drugs is complicated because psychiatric patients are known to be at a high risk of cardiovascular death.2 Researchers assessed ECGs from a large cohort of patients with early HD found increased prevalence in cardiac conduction abnormalities and bradycardia. These results suggest caution is indicated in using medications that may have additive cardiac toxicity.3 Aims and objectives To establish the number of patients on the ward who have had ECGs done and documented. To investigate how long does it take for staff to apply the first ECG following admission? Standards There are currently no specific standards for monitoring ECGs in patients on antipsychotics. However, we used the same standards from the previous Audit which included; the trust guidelines for physical assessment for patients,4 The Royal College of Psychiatrists (RCPsych Consensus statement on high-dose antipsychotic medication5 and NICE guidance for Schizophrenia March 2009.6 Methodology Sample: A total of 23 patients were on our inpatients list during the 8 days period from 06/10/17 to 13/10/17 (included). The age of patient was ranged from 22 to 64 (Mean=38) years. 2 patients were admitted to the department with psychotic symptoms to HD during this period. Search Strategy: All of the information were collected from Amigos (patient’s electronic data). A manual search through patient’s clinical paper notes was also conducted. Findings/results All patients (23) audited were on a form of Antipsychotic medication (7 were on IM Antipsychotics Injection). 6 out of 23 did not have an ECG done (1 patient was agitated, 3 had refused and no documentation on why ECG was not done for 2 patients). The average time between admission and performing an ECG ranged from day 1 to day 174 (with a mean of 28 days and a median of 27 days). We noticed good documentation about ECG’s finding in Amigos, though only few ECG6 were documented in full details and included QTc. ECG machines become more readily available. Conclusion and recommendation Doctors should be made aware and reminded that ECGs are important in monitoring for any cardiac abnormality which could be detrimental in patients taking antipsychotics, and patients at high risk of developing cardiovascular problems such as Huntington’s disease. ECG should be performed on the admission day or as close to admission as possible. ECG results should be fully documented on Amigos (including QTc) and if there is any concern to discuss it with Cardiology team. We suggested to make another brief documentation about ECG on the front page of medication card for each patient. We recommended to re-audit this after one year. Abbreviation EGG: Electrocardiogram HD: Huntington’s disease Amigos: Patient’s electronic data QT interval: the time from the onset of ventricular depolarization to completion of repolarization QTc: QT interval with a correction for heart rate References . Abildtrupa M, Shattockb M. Cardiac dysautonomia in huntington’s disease. Journal of Huntington’s Disease2(2013):251–261. doi:10.3233/JHD-130054 (IOS Press 251 Review) . Low A, Das A. Audit on monitoring ECGs in patients on antipsychotic medications admitted in a psychiatric ward (Redwood) from 08/07/13 to 19/07/13: A standard based audit. Redwood ward, Park House, Mental Health and Social Care Trust NHS (Project 2057). . Stephen C, Hersch S, Rosas H. Huntington’s disease and the heart: Electrocardiogram abnormalities suggest cardiac involvement (P5.294) April06, 2015;84(14 Supplement):April22, 2015. . Guidelines for Physical Assessment of Service Users v3, Manchester Mental Health and Social Care Trust, 2013. . The Royal College of Psychiatrists (RCPsych Consensus statement on high-dose antipsychotic medication, CR138) . Schizophrenia Quick reference guide (NICE clinical guidance 82, 2009) Consensus statement on high-dose antipsychotic medication CR138 (RCPsych).