Back in 2013, two cases of myocarditis, a rare but dangerous inflammatory disease of the heart, were detected at St Paul’s Hospital within a period of just three months. Myocarditis is a known side effect of the antipsychotic drug, clozapine, the gold standard for treatment resistant schizophrenia (TRS).
The mental health team at St. Paul’s Hospital wondered whether more routine monitoring could have detected this potentially life-threatening adverse effect sooner, leading to an earlier intervention for reducing harm to the patients.
Standardizing monitoring, saving lives
Jump forward to today. Thanks to an interdisciplinary team of nurses, psychiatrists, cardiologists, and pharmacists, clozapine now has a robust toolkit and monitoring protocol that has been implemented throughout Providence and Vancouver Coastal Health (VCH), and is currently being rolled out in Saskatchewan. CHÉOS Scientist Dr. Joseph Puyat helped design the evaluation of the toolkit, in collaboration with Clinical Nurse Specialist, Michelle Carter, and other colleagues at St Paul’s and VCH.
While the effectiveness of clozapine for treating TRS is unparalleled, it does come with the potential for serious side effects. “Clozapine has a lot of logistical details,” explained Dr. Tamara Mihic, a Clinical Pharmacy Specialist at St Paul’s Hospital. “It’s easy for these details to fall through the cracks. The toolkit aims to standardize monitoring to make sure that we can quickly identify and treat all serious side effects.” Besides myocarditis, clozapine can also lead to agranulocytosis, a serious condition that results in a reduced white blood cell count and a compromised immune system.
Before implementation of the toolkit, analysis showed that routine lab work monitoring for myocarditis had only been properly implemented for about 30 per cent of patients on clozapine at Vancouver General Hospital, while adequate monitoring for signs and symptoms of myocarditis happened for less than 10 per cent of patients. Now with the toolkit, every patient who is prescribed clozapine will receive standardized and consistent monitoring over the course of their treatment in hospital.
A multidisciplinary team of clinicians and researchers gathered to pool their collective knowledge for developing this robust toolkit and educational module, which was piloted at St. Paul’s in 2015, then updated and improved following feedback from nurses and other team members.
“To me, this project perfectly exemplifies knowledge translation,” explained Dr. Mihic. Rather than reinventing the wheel, the clozapine toolkit brings together the collective knowledge of multiple practitioners. “By centralizing and streamlining monitoring,” Dr. Mihic continues, “the reliance no longer rests on any one healthcare professional; every specialty has their piece to review. This standardized monitoring process is the same for every patient and for every clinician.”
The clozapine toolkit also demonstrated an unprecedented collaboration between Providence and VCH. In 2018, the team received support from the PHC/VCH Knowledge Translation Challenge grant to expand the toolkit to Vancouver General Hospital’s acute inpatient psychiatry units. Having piloted and tested the toolkit at multiple sites in BC, it is now ready for implementation in other jurisdictions, such as the Dubé Centre for Mental Health in Saskatoon, Saskatchewan, where rollout began in November of 2020.
Empowering frontline staff
Beyond improving patient care, the toolkit also aims to educate and empower frontline staff. “Before the toolkit, we found that only about 30 per cent of nurses understood clozapine and the monitoring that goes along with it,” explained Dr. Katelyn Halpape, a Clinical Pharmacy Specialist involved in the initial adaption of the toolkit to VGH, and now leading the implementation in Saskatchewan.
Dr. Halpape found that the toolkit has served to empower nurses, not only by centralizing and standardizing monitoring, but also by educating frontline staff on the uses and potential side-effects of the drug. The toolkit includes an online training module for frontline staff, along with handouts and info sheets for patients. Informal feedback from nurses has shown an increase in knowledge along with more comfort administering and monitoring clozapine. “Nurses seem very proud,” said Dr. Joan Ng, a Clinical Pharmacy Specialist involved with implementing the toolkit at VGH. “They have taken ownership over it.” A formal survey assessing the impact on nurses is currently in process.
Implementing the toolkit at multiple locations in Vancouver also means that once nurses are trained, they carry this knowledge with them into new placements. “The toolkit is quite simple at its core,” continued Ng, “but it covers all important aspects of clozapine therapy.”
Detecting more cases
Since implementation, the number of cases of myocarditis detected at St. Paul’s has actually increased. But Drs. Mihic, Halpape, and Ng explain that this is a good sign: it means that the toolkit is working. Higher rates of myocarditis indicate that monitoring is improving, and that more cases are being detected.
Having already been testing, piloted, and improved following initial implementation at St. Paul’s, the toolkit is now ready to be implemented in other jurisdictions. “We have a completed toolkit with a nice bow on top that we’re ready to share with anyone who needs it,” said Dr. Mihic. Just in time for the holidays.