2025 Southeastern Residency Conference

Title: Initiative To Improve Lithium Safety Monitoring at Veterans Affairs Medical Center

Authors: Cydney Smalls, Carrie Sartin, William Erwin

Objective: To evaluate the effectiveness of recommendations provided by a pharmacist via chart review regarding lithium therapeutic drug levels and safety monitoring for Veterans.

Self-Assessment Question:

Background: Lithium is a well-established therapy for mood disorders, known for its effectiveness in mood stabilization and significant reduction in suicide risk. Despite its clinical benefits, lithium therapy is challenging due to its narrow therapeutic index, making patients susceptible to toxicity. Consequently, frequent monitoring of serum lithium levels and organ function (Scr, ECG, TSH, electrolytes, CBC) is critical. This quality improvement initiative aims to evaluate the impact of clinical pharmacist recommendations provided via chart notifications on enhancing lithium monitoring practices.

Methodology: This quality improvement project is designed as a multi-center, prospective cohort analysis, exempt from Institutional Review Board approval. It investigates provider responses to clinical pharmacist recommendations made through a chart-based review for Veterans on lithium therapy at the Fayetteville NC VA Coastal Health Care System (FNCVACHCS). Participants were identified using the Veterans Affairs Lithium Lab Monitoring Dashboard. Recommendations were communicated to providers using a standardized note template embedded within the computerized patient record system (CPRS). The primary outcome measures the percentage of recommendations accepted by prescribers, determined by new orders placed within one week of the note's documentation. Secondary outcomes include evaluating the average duration between note documentation and completion of recommended safety monitoring tests, incidence rates of supra-therapeutic lithium levels along with associated side effects, and the proportion of accepted recommendations not carried out by patients.

Results: Forty-six notes were entered to communicate recommendations to prescribers. Regarding the primary outcome, providers accepted 37% (17) of these recommendations. The average time from note entry to completion of recommended safety monitoring tests was 13 days. Notably, no supratherapeutic lithium levels were reported during the observation period. However, 47.1% (8) of provider-accepted recommendations were not completed by patients, indicating a significant gap between provider acceptance and patient adherence.

Conclusions: Despite the inconsistent laboratory monitoring parameters for Veterans on lithium therapy, the results showed that Veterans for whom lab values were reviewed showed no significant concerns. There were limitations with the initiative which included providers not acknowledging the recommendation within the computerized patient record system (CPRS), resulting in variability in the implementation of recommended monitoring practices. Identified barriers, including time constraints and alert fatigue, likely contributed to this inconsistency. Addressing these challenges through targeted education, streamlined workflows, and supportive feedback is essential to enhancing provider adherence, thereby ensuring consistent patient safety practices. Efforts to mitigate these barriers are crucial to sustaining the initiative without placing undue burden on healthcare providers.