Improving the monitoring of bowel habit in patients on Clozapine in 2gether NHS Trust

Quality Improvement Poster Download

Background & Problem

Constipation is a common side effect of the antipsychotic drug Clozapine. It affects 1 in 3 patients and in 3 cases out of every 1000, causes life threatening complications such as paralytic ileus or bowel obstruction. There is poor awareness of this amongst health professionals therefore its side effects are rarely discussed with patients or actively managed. The aim of this project is to improve monitoring of constipation, which will lead to benefits in the patients’ quality of life, mental state, and risk of severe complications.

Aim

For 75% of patients on Clozapine to have their bowel habit monitored by March 2016.

Method

We undertook a baseline audit of bowel monitoring for Gloucester Assertive Outreach team who look after patients on Clozapine in the community and also an audit of junior doctors’ awareness of Clozapine’s side effects. We carried out a number of implementation changes as follows:

• Lecture to Junior doctors at induction
• Edited trust clozapine guidelines
• Rewrote trust clozapine initiation document
• Dissemination of leaflets to aid patient and carer awareness of constipation
• Presented information at Doctor’s medical education session
• Raised awareness with article in newsletter
• Presentation to Assertive Outreach Team

Addition to the guidelines included:

• Section about recording baseline bowel habit at initiation, and giving prophylaxic laxatives if needed
• Regular monitoring of bowel habit during Clozapine treatment

Psychiatry team responsibility for these side effects (not GP).

Results

Initial audit found 0/15 junior doctors were aware of this side effect, rising to 13/13 on a repeat survey 1 month later. Initial audit of 16 patients in Gloucester Assertive Outreach Team found 0/16 patients having bowel habit monitored December 16 – June 17. New guidelines including our edits were published in December 2017, and re-audit in March 2018 being undertaken. This has shown that 9 out of 14 patients on Clozapine were monitored actively for constipation (64%). 2 were constipated and treated appropriately.

Implications

A number of measures such as guideline changes and staff education sessions can make a difference to patient care. We will continue our project by education of other community teams who look after patients on Clozapine so that this has a wider effect.