Developing a Guideline for the Inpatient Management of Patients with PD

Like all those who attended the PD Masterclass in 2014, I left the first module challenged, enthused, and motivated to undertake a quality improvement project within my own NHS Trust. It quickly became apparent that the best QIPP would be to develop a local guideline for the inpatient management of Parkinson’s patients; the need for this having been highlighted by the sub-optimal management of several Parkinson’s patients recently admitted to the Trust.

I first discussed my plans for an inpatient guideline with my medical, nursing and pharmacy colleagues across the Trust who share an interest in Parkinson’s. This proved to be a key first step; there were a wealth of differing experiences and ideas, and an infectious mutual desire to make things better. Together we decided that the QIPP should have four main components: The first step should be to establish the scale of the problem within our Trust; how many patients with Parkinson’s are admitted each year, and why? Once this data was known, a retrospective audit of their inpatient care should be conducted. In tandem with the audit, a guideline should be developed to support the management of Parkinson’s inpatients. In due course a re-audit should then be undertaken.

Coding records were used to establish baseline data regarding the number of Parkinson’s admissions to the Trust each year. In brief, we identified all patients discharged from all specialties with a coded main or co-morbidity diagnosis of Parkinson’s. Although evaluation of the data highlighted several coding inaccuracies, and there was a concern that that we might be missing some patients due to the omission of Parkinson’s as a coded co-morbidity, our data suggested that there were approximately 1000 Parkinson’s related admissions to University Hospitals of Leicester NHS Trust in 2013, two thirds of which were emergency admissions and one third elective admissions. Common reasons for emergency admissions were respiratory disorders including pneumonia and lower respiratory tract infections, cardiac disorders, urinary tract infections and falls. Importantly, a significant number had also presented with surgical and psychiatric diagnoses. Elective presentations were most commonly for insertion an changing of urinary catheters, surgical and orthopaedic procedures, and oncology related disorders. The average length of stay was 10.1 days and 1.5 days for emergency admissions. Readmission disappointingly high; 208 within 28 days. This data raised several important issues. Firstly, Parkinson’s patients are presenting to a range of specialities and services across the Trust and not just to general medicine and neurology. Secondly, elective patients are often staying in hospital overnight, which has implications for the administration of medications. Length of stay and readmission data suggested room for improvement in service provision.

In devising an audit tool to evaluate these findings in more detail, I discussed with my Masterclass mentor who kindly shared his own inpatient audit tool which I modified for use in my own Trust. I also checked with our Trust audit team who informed me that an inpatient Parkinson’s audit had been conducted in 2010. By obtaining the details for this, I was able to incorporate some of their standards and elective respectively. rates were to enable comparison.

In drafting the guideline, discussion with colleagues across the Trust was again key. We were all agreed that the guideline should be an ‘acute’ guideline, able to support the management of all PD inpatients, and not simply a ‘nil by mouth’ guideline. We are very grateful to colleagues from across the UK, many from the PD Masterclass, who shared their own guidelines with us. Reviewing these proved invaluable, and made us look critically at other areas of our service.

The audit is now underway and the guideline is being refined. We hope to launch the guideline Trust wide in February 2015, to coincide with the launch of the Parkinson’s

Excellence Network, when PD will be highly topical. Plans for the future include an educational programme for nurses and junior doctors and aspirations to link up with mental health services. The quality improvement project has become a programme!

Key points:

1. Be clear about what you want to achieve and why. If this is a guideline, is it a nil by mouth guideline, or something with a broader scope?
2. Establish what’s been done already; are there pre-existing audits or guidelines within your Trust?
3. interested parties within your area. Differing backgrounds, ideas and experiences are invaluable and mutual enthusiasm is infectious. Meet regularly.
4. Obtain baseline data, although be aware that coding data may not always be accurate and reliable.
5. Don’t be afraid to ask colleagues elsewhere to share their own examples of audit tools and guidelines; the PD community is friendly, supportive and helpful and there is a current drive to avoid duplication of work.