Inpatient management of Parkinson’s disease medication in a tertiary hospital: an audit

Medication error is not uncommon in hospital setting. Adherence to timing of Parkinson’s medicine especially and minimising dosing errors are quite crucial in the management of the care of the patients with this complex debilitating illness. The NICE guideline advises that anti-Parkinson’s medicines should not be withdrawn abruptly or changed suddenly on admission to the hospital.

Upon attending the 1st module of Parkinson’s Disease (PD) MasterClass in June this year and becoming aware of the “Get it on time” campaign by Parkinson’s UK, I returned home quite excited at looking at the prospect of assessing this PD medication management at my local hospital. I was keen to see the extent of the awareness amongst the staff both medical and nursing about the timeliness and accuracy aspect of the medication use.

Wellington Regional Hospital (WRH) is a tertiary teaching hospital under Capital & Coast District Health Board (CCDHB) and serves the catchment area of Wellington, Porirua and Kapiti of about 300,000 people. While doing the ground work for this project, I was unable to locate any previous record of the data looking at PD medication error in the in-patients at WRH. Little is known locally about the prevalence of any error in prescribing & dispensing of PD medicines and if any subsequent complication from this error in our patients admitted either electively or acutely via Emergency Department (ED) or Medical Assessment & Planning Unit (MAPU). Following discussion with my supervisor I devised a study to gather information around admission of the PD patients to look at their medication administration and also a wider aspect of issues around their admission.

Objective

The main aim of this audit was to look at how well the PD medications are managed for our patients during their inpatient journey across the various services in the hospital. The main questions I tried to answer were:

1. Is there any delay or omission of doses of PD meds?
2. Is there any complication as a result of the error (if any) and any effect on length of stay?

Method

I looked at the hospital admission in the 6 month period between 1^st of February 2017 and 31^st July 2017 for all patients with a diagnosis of Parkinsonism. The hospital clinical audit committee approved the audit. The hospital coding department identified 80 patients using the ICD -10 code of G-20 and G-21 and I reviewed the notes to collect the data on a wide range of domain using a proforma tool. The information collected included age/ gender/residence/length of stay/ service admitted/reason for admission/stage of PD/number of PD meds/any delay in administration/ reason for delay if any/any complication/availability of medication list/referral to PD specialist/whether NBM/Swallow assessment. Any assessment on impact on length of stay was based on my own judgment.

Fifty-one case notes were included in this retrospective audit and 29 were excluded as either there was no formal diagnosis of PD or were not on PD meds and few were just outside the study period.

Results

PD medicine doses were missed or delayed in 8 cases – 2 cases due to being NBM, 2 due to patient being delirious and refusing meds, 2 due to drugs being not available for 2 doses. There were delays by 3 hrs in 2 cases of 2 evening doses. There was no prescription error and the medication list was available to the admitting doctor in all the cases. PD medications: Majority were on multiple doses of either Madopar or Sinemet. Very few were on Pramipexole, Amantadine, Ropinirole and one patient was on Selegiline. 2 patients were on Apomine infusion.

Complication – In one case length of stay was possibly increased due to effect on swallow in a case of aspiration pneumonia in an advanced PD patient

The other details that I looked into included the following information:

The age of the patients ranged from 39 – 95 years with Male/Female being 31/20

Majority were from their own home (40/51), 7 from Hospital level care facility, 4 from rest home facility. The length of stay ranged from 0 days (for ED unit admission) to 34 days (1 case who had acetabular fracture), average of 8.7 days. Sixteen cases had length of stay over 10 days (cause attributed to frailty, fracture, delirium, BPSD). Thirty-three patients brought their own medicines to hospital and self administered either in ED while waiting for a bed or while waiting for the hospital pharmacy to dispense their meds afterhours. Thirty-eight patients were referred and seen by a Geriatrician experienced in PD or Neurologist and 28 were in the complex phase of their disease. The different services that the PD patients were admitted were as below:

23 under General Medicine, 8 under Neurology/Neurosurgery, 4 under Orthopaedics, 6 under Geriatrics and remaining cases under General Surgery, ENT, Vascular, Haematology, Cardiology, Emergency care unit.

Discussion

This study cohort of small number of cases has not shown any major incidence of medication discrepancy either in terms of timing or doses. There has not been any discernible untoward consequence as a result of the minor errors that has been picked up in the audit apart from the one that had probably increased length of stay.

As I reflect on the outcome of this audit I note some positive impact of the services that has been put in place over the recent years in the DHB. The medication list is easily available at the time of admission from the “Shared care” link which provides access to the patient’s medical information from their Primary care practitioners. The majority of the patients bring their own medications when they present to the hospital which has prevented delay in administering medicines and offered self administering in most cases. Also the simple drug regime comprising of common PD drugs in most cases (Madopar and Sinemet) meant increased familiarity amongst the staff and ready availability in the hospital pharmacy. The admitting doctors have often documented “time specific medicines” against the PD drugs on the drug chart which has brought awareness amongst the nurses for timely administration of the PD medicines. The recent introduction of Geriatric Liaison service at the front door at WRH lead by Geriatrician experienced in PD management has made the review of majority of PD patients on admission possible.

This study was reassuring for now but it could have missed some cases of drug error with negative consequences outside of the study period. This study has its inherent limitations due to the fact that it had a small study cohort, the inability to judge hidden secondary effects, such as “missed or delayed dose, “more stiff that day” Declined physio” small increased length of stay. Again we cannot assume that patient would bring their medication every time they present to the hospital and a system needs to be in place where essential and common PD drugs are stocked in ED to prevent any delay in administering the dose.

Recommendation

As this audit is the first step of the QI cycle the next action will be presenting these findings to the wider audience from General medicine, Geriatrics and Neurologist in their forum and to the Medical Directorate. After those consultations, I will look to implement changes which I anticipate will involve a campaign of awareness raising for junior and senior doctors focused on ED, MAPU and a review of the ED drug cupboard. I will also look at encouraging the practice of patients bringing their own medications to hospital and clear documentation of phrases like “time specific meds” or “give meds on time” in the drug charts.

It will be useful to repeat the audit in the future to see the impact of the campaign and to see if there has been improvement in the management of the PD patient’s medications at WRH.

References

1. Parkinson’s disease – NICE clinical guideline 2006
2. Parkinsons Academy project – by Dr Asim Majeed and Dr Huma Naqvi, by Dr Wasim Aziz Khan, by Dr Victoria Haunton, by Dr Jacob Daniel