Metabolic Monitoring of Pediatric Patients Prescribed Second-Generation Antipsychotic Medication: A Quality Improvement Project

Background: The prevalence of psychotropic medication prescription use in youth has increased over the past several years (Olfson, et. al, 2015; Patten, et. al, 2012; Pathak, et. al, 2010). National Health and Nutrition Examination Survey (NHANES) data, Centers for Disease Control and Prevention (CDC) found that between 2005 and 2010, approximately 6% of adolescents within the United States (U.S.) reported using psychotropic medication within the past month with 1% reporting use of antipsychotic medication (CDC, 2013). The American Diabetes Association-American Psychiatric Association (ADA-APA) provides best practice guidelines for SGA parameter monitoring given the prevalence of use and associated metabolic risks. However, despite formal recommendations and practice parameters being set forth, monitoring adherence of patients prescribed SGA medication remains inadequate, subpar and fragmented, overall.
Project Purpose: The purpose of this project was to implement an intervention, following ADA-APA guidelines, to improve in-patient metabolic monitoring adherence and to improve discharge recommendations for follow-up monitoring for pediatric patients prescribed SGAs.
Clinical Questions: In patients aged 5 to 17 years prescribed second-generation antipsychotic medication, will establishing a protocol for metabolic monitoring during psychiatric admission improve monitoring adherence during admission and affect recommendations for follow-up metabolic monitoring, compared to the current standard of care? And, Do clinician perceptions of importance and barriers to adherence to metabolic monitoring protocols affect adherence to new professional organization guidelines?
Participants and Setting: Participants included five medical doctors (MD) and three advanced practice psychiatric nurse practitioners (APRN-PMHNP) providing psychiatric care for pediatric patients at a small, in-patient mental health hospital situated in the Southeastern region of the United States.
Methods: Project design, Quality Improvement, was utilized to facilitate this project. Lewin’s Change Theory and Iowa Model-Revised was used to develop an intervention for improving metabolic monitoring and the Plan-Do-Study-Act (PDSA) Model was used to facilitate continuous evaluation of the implementation phase of the project. A metabolic monitoring organizational policy was developed to provide procedural guidance for SGA use, following best practice guidelines (Figure 5). An educational session and Likert Scale Survey and Questionnaire were designed to learn or gain an understanding of clinician opinions related to importance of and facilitators and barriers to metabolic monitoring.
Practice Implications: Implementing an organizational metabolic monitoring policy following ADA-APA guidelines may optimize impact on both clinician’s monitoring adherence and follow-up recommendations for pediatric patients prescribed SGA medication and thereby improve outcomes for this patient population.