NIMC (clozapine titration)

1. NIMC (clozapine titration) Presented by __________________ Facility/Unit____________________ Prepared by the Australian Commission on Safety and Quality in Health Care

2. NIMC (clozapine titration) Background • A 2011 national survey of National Inpatient Medication Chart (NIMC) users in psychiatric acute services found that charting clozapine titration was problematic. • Clozapine titration prescribing was non-standardised and found variously in the Once Only / Variable Dose section and the Regular sections of the NIMC. • Non-standard practices created increased opportunity for harm to our consumers.

3. Non-standard charting of clozapine on the NIMC

4. Non-standard charting of clozapine on the NIMC

5. Non-standard charting of clozapine on the NIMCClient A

6. Non-standard charting of clozapine on the NIMCClient B

7. NIMC (clozapine titration) • A standard national adult clozapine titration chart is intended to: • improve patient safety by reducing risk of medication error • assistprescribers, dispensers and administrators with charting clozapine titration on the NIMC • standardise recording of clozapine titration orders • It incorporates decision support, guidance and checklists • The NIMC (clozapine titration) is based on the Queensland Health Adult Clozapine Titration Chart which was developed jointly by Medication Services Queensland and Queensland Psychotropic Medication Advisory Group

8. National Adult Clozapine Titration Chart

9. Facility identification and CPN • Ensure facility identification is complete including ward or unit details • Complete year • Clozapine Patient Number (CPN) must be recorded on the facility identification space

10. Patient identification • Affix the current patient identification label (with the consumer’s name printed underneath by the first prescriber) to pages 2 and 4. OR • As a minimum, print legibly the patient’s first and family names, UR number, address, date of birth and gender written in legible print.

11. Cross-referencing with the NIMC • Note that the patient has a NIMC (clozapine titration) in use by ticking Other in Additional Charts on the patient’s NIMC • Write Clozapine titration next to the box to alert clinicians that the patient has an additional chart in use for clozapine titration

12. Additional patient identification • A space for hand writing patient identification is provided on page 3. • It is designed for health services that use medication chart scanners. • Health services that do not use scanners may use the identification space as an additional safety device.

13. Adverse drug reactions (ADRs) • All patients should have details of previous adverse drug reactions (ADRs) recorded on their NIMC (acute) or NIMC (long-stay) • Attach an ADR sticker to the NIMC (clozapine titration) section provided if the patient has an ADR recorded • Refer to the NIMC for details of previous ADRs and allergies.

14. Clozapine monitoring • A check list of investigations required for clozapine monitoring is provided on page 1. • These are suggested guidelines only and the treating psychiatrist may request further tests depending on clinical results or local policy.

15. Clozapine registration reminder • Contact the Clozapine Monitoring Centre for approval • Obtain the Clozapine Patient Number and record it in the Facility Identification box

16. Prescribing • Prescriber signature is a legal requirement • Prescriber identification (including contact details) is a safety requirement

17. Administration record

18. Blood test reminder • A red coloured square is printed on days 7, 14, 21 and 28 as a reminder that patients require blood or metabolic monitoring on a weekly basis as indicated on the Clozapine Commencement Monitoring: Baseline Measurements section of the chart. • Additional tests may be indicated by the doctor drawing a darkened line around the day box on the required testing day.

19. Recommencing dosing after an interruption to therapy • If a dose is missed for greater than 48 hours, a psychiatric review must be performed prior to recommencing clozapine treatment. • Additional guidance is provided.

20. Reasons for not administering doses • When it is not possible to administer the prescribed clozapine, a reason for not administering code must be recorded and circled.

21. Clozapine blood results monitoring system • The chart provides an alert system which gives guidance on whether therapy should be continued or ceased according to the patient’s blood results.

22. Clozapine pre-commencement guide • All patients, prescribing doctors, dispensing pharmacists, clozapine coordinators and centres using clozapine must be registered with the Clozapine Patient Monitoring Service (CPMS).

23. Blood test monitoring after an interruption to therapy • All patients recommencing clozapine following an interruption in treatment must have a pre-treatment blood test. This includes patients with therapy interruptions of less than a week.

24. Nursing observations • Patients must be kept under close supervision and their vital signs monitored for six hours following the first dose of clozapine.

25. Management of side effects • A list of some side effects, as well as the time course and action, has been included on page 4. .

26. Questions