Improvements to SALUS inpatient management system for patients with Parkinson’s

Introduction

The hospital is the largest in the southwest peninsula, providing comprehensive secondary and tertiary healthcare. Our geography gives us a secondary care catchment population of 450,000 with a wider peninsula population of almost 2,000,000 people who can access our specialist service. The population is characterised by its diversity – the rural and the urban, the wealthy and pockets of deprivation, and wide variance in health and life expectancy. There is an estimated 821 people living with Parkinson’s within NHS South Devon and Torbay CCG with 0.86% over 60’s. Our admission figures 2nd highest when compared to similar size areas (NHS South Devon and Torbay CCG 2017/18).

Until the appointment in 2016 of two Parkinson’s nurse specialists (PNS) the hospital had no system in place for identifying people with Parkinson’s (PwP) when they were admitted into hospital and there was no specialist team available to provide supportive care for the patient with more specialised Parkinson’s complex needs. Nor was there a service to provide specialised knowledge and expertise to support the medical and nursing professionals on the wards or the emergency department. The impact was low levels of patient satisfaction and sub-optimal medicines management. This was identified by both local and national audits. We initially instigated the use of the RAPA (repeat admission patient alerts) system (fig 1), a system that immediately alerts the PNS of an admission to the hospital of a PwP.

Through SALUS we are informed of admission date and ward, which ensures prompt review of the patient’s needs- and allows us to coordinate continuity of care for treatment and discharge. The implementation of the Parkinson’s RAPA (repeat admission patient alerts) and in house hospital SALUS (I.T system) meant that a PwP, regardless of admission cause or Parkinson’s need was automatically raised as a red alert to the PDNS service (Fig 2) requesting a specialist assessment.

However the retirement of a full time band 7 specialist nurse in July 2020, the COVID pandemic and change in face to face working, redeployment of Parkinson’s staff and complexity of PwP admissions for some patients coincided with extreme low staffing levels (medical and nursing) within all areas of the hospital resulting in an increase level of referrals to the PD team which were often inappropriate and unnecessary.

Objective

Over the last year it has become very recognisable that the wards demands on the reduced PD team were such that it was becoming unsustainable to maintain on a day to day basis while still providing specialist clinics often off site. COVID meant that our way of working needed to adapted as we were unable to physically to assess some patients face to face nor were we able to share paper assessments with our colleagues in ICU and HDU’s. Capacity and capability was reduced but it was important we maintain a quality of care for our Parkinson particularly in relation to medication and then need to get the medication on time.

With the present alert system, all PwP admitted within the hospital regardless of admission cause were flagged as red and therefore requesting a specialist PD team assessment. Though not all PwP required a Parkinson’s review particularly if admitted for an elective planned admission or admission for a non-related PD issue. It was also acknowledged that some PwP admitted on intricate drug regimes, with a range of motor and non-motor Parkinson’s complications and /or very elderly with multi-morbidities and polypharmacy did required certainly require a PD assessment but these reviews and coordinating of treatment management with the nursing and medical teams were taking approximately 90 – 120 minutes and additional follow up required while the PwP was an inpatient.

The reduction in GP and social service support has also impacted on both increased admission numbers and prolonged length of stay with PwP becoming more deconditioned and often developing hospital related infections / conditions. For some patients this has created increase symptoms (both motor and non-motor) where prior to their hospital stay there was none.