Lithium is a well-recognised treatment in Affective Disorders. Careful monitoring is required due to its narrow therapeutic index. Adherence to monitoring standards has been generally poor with high levels of incidents reported to the National Patient Safety Agency leading to financial settlements and inclusion in patient safety alert potentially selected on inspection by the Care Quality Commission. This audit aimed at mapping the provision of lithium monitoring for patients stable on Lithium in Vale Royal to facilitate implementation of quality improvements in ongoing transformation of community services. There are twelve general practices in Primary Care (PC) for this area, one specialist mental health Trust Cheshire and Wirral Partnership NHS Trust (CWP) and one Hospital Trust MidCheshire Hospital Trust (MCHT).

1. Systems inventory

No lithium central register was identified.

All lithium requests were processed by North Midlands and Cheshire Pathology services (NMCPS).

In specialist care lithium was managed by one Consultant Psychiatrist.

In primary care nine practices provided information, all supported by a software overseen by administrative staff working collaboratively with doctors.

b. Data collection.

Anonymised Lithium results for adult patients stable between November 2021–2022 were collected from NMCPS.

Plasma levels and frequency were compared to generally accepted standards of 0.4-1 mmol/L every 6 months for stable patients.

Ninety patients were identified, eighty in PC and ten with CWP, median age 58, females (53%)/males (47%) gender ratio.

Frequency was mostly 3 monthly for 74% of patients in PC and 80% for CWP.

Levels below 0.4 mmol/L were found in 22.5% of levels measured in PC and 27% for CWP, and over 1 mmol/L in 5% in PC and 0% CWP.

This audit revealed that lithium monitoring for stable patients was primarily managed in PC.

Lithium level was measured more frequently than recommended which could be due to automated cues. Levels were often maintained at the lower end of the range. Those findings could be medically related.

Both computer and clinician led systems allowed for meeting, if not exceeding, targets.

Electronic systems are likely cost savings over a specialist clinic but could generate potentially unnecessary automatic checks, still require data reviews and medical oversight. This could be addressed by system amendments and an audit programme.

The absence of formally recognised central register could be remediated by shared agreement and managed by NMCPS.

Systemic approach to lithium monitoring can be collaboratively extrapolated to other localities, medications, or targets .