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We’ve done several columns highlighting the problems that patients with Parkinson’s Disease run into when they get hospitalized for any reason (see our What’s New in the Patient Safety World columns for August 2011 “Problems Managing Medications in Parkinson’s Disease”, December 2012 “More on Hospitalized Parkinson’s Disease Patients” and June 2015 “More Risks for Parkinson Inpatients”). Patients with Parkinson’s typically require specific timing of their medications in order to minimize the “on-off” phenomenon and to avoid hyperkinesias. This results in their requiring multiple dosing throughout the day and often at unusual times. Meeting this very precise timing of doses is problematic for most hospitals and hospital units because they are used to their own standardized times for medication dispensing and administration. And most anti-Parkinsonian medications are available only in oral form so it is especially problematic when the patient is NPO or is otherwise unable to swallow. Some anti-Parkinson’s formulations are also of the extended-release variety and should not be crushed. Moreover, drugs that worsen extrapyramidal function are often used in the hospital and these may significantly worsen Parkinsonian features. Patients with Parkinson’s also seem to get temporary declines in function when they get a systemic problem, like an infection.
Recognizing these vulnerabilities when patients with Parkinson’s are admitted to hospitals is a first step in preventing complications, minimizing hospital lengths of stay, and avoiding functional deterioration.
HealthLeaders recently highlighted a program that has been successful in addressing these problems in inpatients witih Parkinson’s Disease (Cheney 2019). In 2017, Hackensack University Medical Center in Hackensack, New Jersey, formally launched a strict medication adherence protocol for inpatients with Parkinson's Disease. This resulted in significant improvements in several metrics. Length of stay for all Parkinson's patients at the hospital decreased from 7.125 days in 2017 to 6.750 days in 2018. The readmissions rate for Parkinson's patients decreased from 13.9% in 2017 to 12.8% in 2018.
There were four primary components of the medication adherence protocol:
1. Patient identification
2. Metrics to assess medication management
3. Metrics evaluation and implementation of action plans
Patient identification is a key to the process. They established a flag that appears any time someone opens the record of a patient with Parkinson’s Disease. That leads to care plans in the electronic record including the timing of medication and contraindicated medications.
Their metrics include patient identification, making sure all of the medicines are in the formulary, and making sure that patients get medication in the customized fashion that they get at home. It’s important in patients with Parkinson’s Disease that they don’t get put on the hsopital’s default medication administration times. They also track contraindication medications and attempt to intervene in real time if one is ordered.
They have a disease-specific committee that develops action plans. That committee looks at the data, assesses it, and comes up with plans to improve the compliance.
Education and training for the strict medication adherence protocol involves almost anyone that will come in contact with Parkinson’s patients (physicians, advanced practice practitioners, nurses, physical therapists, radiation technologists, and pharmacists).
In our December 2012 What’s New in the Patient Safety World column “More on Hospitalized Parkinson’s Disease Patients”) we noted a study from The Netherlands (Gerlach 2012) found that 21% of Parkinson patients admitted to a hospital experienced deterioration of motor function and 33% had one or more complications. Moreover, 26% received incorrect anti-Parkinson medications, which was the most significant reason associated with clinical deterioration.
In our June 2015 What's New in the Patient Safety World column “More Risks for Parkinson Inpatients” we highlighted an ISMP column (ISMP 2015) that began with two case examples that illustrate some of these critical problems. ISMP then provided a list of important actions that should be undertaken for inpatients with Parkinson’s Disease:
We encourage you to read the ISMP article for details under each of the above bullet points. Also, one of the interviewees in the HealthLeaders article on the Hackensack program has co-authored an excellent book for hospitalists managing Parkinson’s inpatients (Azmi 2018).
Our prior columns on problems related to Parkinson’s Disease patients as inpatients:
Cheney C. 4-Part Protocol Improves Care, Lowers Costs for Hospitalized Parkinson's Patients. HealthLeaders 2019; October 09, 2019
Gerlach OHH, Broen MPG, van Domburg PHMF, et al. Deterioration of Parkinson's disease during hospitalization: survey of 684 patients. BMC Neurology 2012, 12: 13 (8 March 2012)
ISMP (Institute for Safe Medication Practices). Delayed administration and contraindicated drugs place hospitalized Parkinson’s disease patients at risk. ISMP Medication Safety Alert! Acute Care Edition. March 12, 2015
Azmi H, Gupta F. Parkinson's Disease for the Hospitalist: Managing the Complex Care of a Vulnerable Population. Lioncrest Publishing (November 19, 2018)
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