Does a specialist unit improve outcomes for hospitalized patients with Parkinson's disease?

Custom order entry for Parkinson's medications in the hospital improves timely administration: an analysis of over 31,000 medication doses

Background

Patients with Parkinson's disease (PD) are at increased risk for hospital acquired complications. Deviations from home medication schedules and delays in administration are major contributing factors. We had previously developed a protocol to ensure adherence to home medication schedules using "custom" ordering. In this study we are assessing the impact this order type may have on reducing delays in PD medication administration in the hospital.

Material and methods

We reviewed 31,404 orders placed for PD medications from January 2, 2016 to April 30 2021. We evaluated the orders to determine if they were placed in a Custom format or using a default non-custom order entry. We further evaluated all orders to determine if there was a relationship with the order type and timely administration of medications. We compared medications that were administered within 1 min, 15 min, 30 min and 60 min of due times across custom orders vs. non-custom default orders. We also evaluated the relationship between ordering providers and type of orders placed as well as hospital unit and type of orders placed.

Results

14,204 (45.23%) orders were placed using a custom schedule and 17,200 (54.77%) orders were placed using non-custom defaults. The custom group showed a significantly lower median delay of 3.06 minutes compared to the non-custom group (p<.001). Custom orders had a significantly more recent median date than non-custom default orders (2019-10-07 vs. 2018-01-06, p<0.001). In additional analyses, medication administration delays were significantly improved for custom orders compared to non-custom orders, with likelihoods 1.64 times higher within 1 minute, 1.40 times higher within 15 minutes, and 1.33 times higher within 30 minutes of the due time (p<0.001 for all comparisons).

Conclusion

This is the largest study to date examining the effects of order entry type on timely administration of PD medications in the hospital. Orders placed using a custom schedule may help reduce delays in administration of PD medications.

More than medications: a patient-centered assessment of Parkinson's disease care needs during hospitalization

Background

Parkinson's disease (PD) increases the risk of hospitalization and complications while in the hospital. Patient-centered care emphasizes active participation of patients in decision-making and has been found to improve satisfaction with care. Engaging in discussion and capturing hospitalization experience of a person with PD (PwP) and their family care partner (CP) is a critical step toward the development of quality improvement initiatives tailored to the unique hospitalization needs of PD population.

Objectives

This qualitative study aimed to identify the challenges and opportunities for PD patient-centered care in hospital setting.

Methods

Focus groups were held with PwPs and CPs to capture first-hand perspectives and generate consensus themes on PD care during hospitalization. A semi-structured guide for focus group discussions included questions about inpatient experiences and interactions with the health system and the clinical team. The data were analyzed using inductive thematic analysis.

Results

A total of 12 PwPs and 13 CPs participated in seven focus groups. Participants were 52% female and 28% non-white; 84% discussed unplanned hospitalizations. This paper focuses on two specific categories that emerged from the data analysis. The first category explored the impact of PD diagnosis on the hospital experience, specifically during planned and unplanned hospitalizations. The second category delves into the unique needs of PwPs and CPs during hospitalization, which included the importance of proper PD medication management, the need for improved hospital ambulation protocols, and the creation of disability informed hospital environment specific for PD.

Conclusion

PD diagnosis impacts the care experience, regardless of the reason for hospitalization. While provision of PD medications was a challenge during hospitalization, participants also desired flexibility in ambulation protocols and an environment that accommodated their disability. These findings highlight the importance of integrating the perspectives of PwPs and CPs when targeting patient-centered interventions to improve hospital experiences and outcomes.

Establishing a framework for quality of inpatient care for Parkinson's disease: A study on inpatient medication administration

BACKGROUND

The complexity of antiparkinsonian medications makes patients vulnerable to medication deviations. This study examines the frequency and outcomes of deviations between outpatient and inpatient medication administrations in patients with Parkinson's disease (PD).

METHODS

We included hospital admissions of patients with PD during a 12-month period at the Cleveland Clinic Main and Fairview campuses. Outpatient regimens were compared with hospital medication administration records to establish rates of deviations in terms of levodopa equivalent daily dose (LEDD) difference, timing deviations/omissions of time-critical medications, substitution of levodopa compounds, and administration of antidopaminergic medications. Logistic regression analyses were used to investigate associations with length of stay (LOS), readmission rates, and mortality.

RESULTS

The study included 492 patients with 725 admissions. Of those on time-critical medications, 43% had a LEDD deviation and 19% had levodopa formulation substitutions. Of the admission days with known outpatient timing regimens, 47% had an average deviation of more than 30 min and 22% had at least one missed levodopa dose. LOS was longer with each additional day of over-dose (4%), under-dose (14%), missed dose (21%), timing deviation (15%) and substitution (19%), (all p < 0.0001). Administration of antidopaminergic medications (9.9% of admissions) was associated with increased 30-day readmission/death (OR 1.85, p = 0.041), 90-day mortality (OR 2.2, p = 0.018), and LOS (7.6 vs. 3.8 days, p < 0.0001). LEDD underdose was associated with 30-day readmission/death (OR 1.78, p = 0.025) and 90-day mortality (OR 1.14, CI 1.05-1.24, p = 0.002).

CONCLUSIONS

Deviations between outpatient and hospital regimens, and administration of antidopaminergic medications, were associated with poor outcomes.

Admission of kidney patients to a closed staff nephrology department results in a better short-term survival

BACKGROUND

The outcome of patients with chronic kidney disease (CKD) and acute kidney injury (AKI) is often dismal and measures to ameliorate their course are scarce. When admitted to the hospital, kidney patients are often hospitalized in general Medicine wards rather than in a specialized Nephrology department. In the current study, we compared the outcome of two cohorts of kidney patients (CKD and AKI) admitted either to general open-staff (with rotating physicians) Medicine wards or to a closed-staff (non-rotating Nephrologists) Nephrology ward.

METHODS

In this population-based retrospective cohort study, we enrolled 352 CKD patients and 382 AKI patients admitted to either Nephrology or General Medicine wards. Short-term (< = 90 days) and long-term (>90 days) outcomes were recorded for survival, renal outcomes, cardiovascular outcomes, and dialysis complications. Multivariate analysis was performed using logistic regression and negative binomial regression adjusting to potential sociodemographic confounders as well as to a propensity score based on the association of all medical background variables to the admitted ward, to mitigate the potential admittance bias to each ward.

RESULTS

One hundred and seventy-one CKD patients (48.6%) were admitted to the Nephrology ward and 181 (51.4%) were admitted to general Medicine wards. For AKI, 180 (47.1%) and 202 (52.9%) were admitted to Nephrology and general Medicine wards, respectively. Baseline age, comorbidities and the degree of renal dysfunction differed between the groups. Using propensity score analysis, a significantly reduced mortality rate was observed for kidney patients admitted to the Nephrology ward vs. general Medicine in short term mortality (but not long-term mortality) among both CKD patients admitted (OR = 0.28, CI = 0.14-0.58, p = 0.001), and AKI patients (or = 0.25, CI = 0.12-0.48, p< 0.001). Nephrology ward admission resulted in higher rates of renal replacement therapy (RRT), both during the first hospitalization and thereafter.

CONCLUSIONS

Thus, a simple measure of admission to a specialized Nephrology department may improve kidney patient outcome, thereby potentially affecting future health care planning.

Outcomes after neonatal cardiac surgery: The impact of a dedicated neonatal cardiac program

OBJECTIVES

Prematurity is a risk factor for in-hospital mortality after cardiac surgery. The structure of intensive care unit models designed to deliver optimal care to neonates including those born preterm with critical congenital heart disease is unknown. The objective of this study was to evaluate in-hospital outcomes after cardiac surgery across gestational ages in an institution with a dedicated neonatal cardiac program.

METHODS

This study is a single-center, retrospective review of infants who underwent cardiac surgical interventions from our dedicated neonatal cardiac intensive care program between 2006 and 2017. We evaluated in-hospital mortality and morbidity rates across all gestational ages.

RESULTS

A total of 1238 subjects met inclusion criteria over a 11-year period. Overall in-hospital mortality after cardiac surgery was 6.1%. The mortality rate in very preterm infants (n = 68; <34 weeks' gestation at birth) was 17.6% (odds ratio, 3.52 [1.4-8.53]), versus 4.3% in full-term (n = 563; 39-40 weeks) referent/control infants. Very preterm infants with isolated congenital heart disease (without evidence of other affected organ systems) experienced a mortality rate of 10.5% after cardiac surgery. Neither the late preterm (34-36 ^6/7 weeks) nor the early term (37-38 ^6/7) groups had significantly increased odds of mortality compared with full-term infants. Seventy-eight percent of very preterm infants incurred a preoperative or postoperative complication (odds ratio, 4.78 [2.61-8.97]) compared with 35% of full-term infants.

CONCLUSIONS

In this study of a single center with a dedicated neonatal cardiac program, we report some of the lowest mortality and morbidity rates after cardiac surgery in preterm infants in the recent era. The potential survival advantage of this model is most striking for very preterm infants born with isolated congenital heart disease.

Identifying rates and risk factors for medication errors during hospitalization in the Australian Parkinson's disease population: A 3-year, multi-center study

BACKGROUND

Admission to hospital introduces risks for people with Parkinson's disease in maintaining continuity of their highly individualized medication regimens, which increases their risk of medication errors. This is of particular concern as omitted medications and irregular dosing can cause an immediate increase in an individual's symptoms as well as other adverse outcomes such as swallowing difficulties, aspiration pneumonia, frozen gait and even potentially fatal neuroleptic malignant type syndrome.

OBJECTIVE

To determine the occurrence and identify factors that contribute to Parkinson's medication errors in Australian hospitals.

METHODS

A retrospective discharge diagnosis code search identified all admissions for people with Parkinson's disease to three tertiary metropolitan hospitals in South Australia, Australia over a 3-year period. Of the 405 case notes reviewed 351 admissions met our inclusion criteria.

RESULTS

Medication prescribing (30.5%) and administration (85%) errors during admission were extremely common, with the most frequent errors related to administration of levodopa preparations (83%). A higher levodopa equivalent dosage, patients with a modified swallowing status or nil by mouth order during admission, and patients who did not have a pharmacist led medication history within 24 hours of admission had significantly higher rates of medication errors.

CONCLUSIONS

This study identified 3 major independent factors that increased the risk of errors during medication management for people with Parkinson's disease during hospitalization. Thus, targeting these areas for preventative interventions have the greatest chance of producing a clinically meaningful impact on the number of hospital medication errors occurring in the Parkinson's population.

Parkinson's disease and Covid-19: Is there an impact of ethnicity and the need for palliative care

Under the traditional models of care for People with Parkinson's Disease (PD, PwP), many of their needs remain unmet and a substantial burden of motor and non-motor symptoms they experience may not be tackled sufficiently. An introduction of palliative care (PC) interventions early in the course of PD offers profound benefits: it may improve quality of life of patients, their families and caregivers through the prevention and relief of medical symptoms, while, at the same time, emphasizing their emotional needs and spiritual wellbeing, establishing goals of care, and engaging in the advance care planning (ACP).

The ongoing Coronavirus Disease 2019 (Covid-19) pandemic poses an unprecedented set of challenges for PwP and has in many ways (both directly and indirectly) magnified their suffering, thus rapidly raising the demand for PC interventions. Covid-19, as well as the repercussions of prolonged mobility restrictions and limited health-care access might exacerbate the severity of PD motor symptoms and interact negatively with a range of non-motor symptoms, with a detrimental effect on quality of life. Greater motor disability, higher amount of levodopa-induced motor fluctuations with an increased daily off-time, fatigue, anxiety, depression, sleep disturbances, pain and worsening of cognitive complaints might dominate the clinical presentation in PwP during the Covid-19 pandemic, alongside raising psychological and spiritual concerns and anticipatory grief.

Here, we aim to provide a foundation for pragmatic and clinically orientated PC approach to improve quality of life and relieve suffering of PwP in the context of the current, ongoing Covid-19 pandemic.

Pharmacotherapeutic management of Parkinson's disease inpatients: how about asking hospital pharmacists?

INTRODUCTION

Parkinson's disease (PD) is considered to be the fastest growing neurological disorder in the world. Patients with PD are hospitalised more frequently, have longer admissions and experience more complications during hospitalisation than age-matched control groups. The incorrect timing of levodopa administration and prescription of contraindicated antidopaminergic drugs are the most important risk factors for motor function deterioration during hospital admission, and have been associated with longer hospital stays and even increased mortality. Despite their crucial role in pharmacotherapy, little attention has been paid to the perspective of hospital pharmacists. The objective of this study was to identify key issues in the pharmacotherapeutic management of inpatients with PD by the implementation of a national Spanish survey specifically designed to analyse the perspective of hospital pharmacists.

METHODS

An internet-based questionnaire covering the following areas was designed: hospital and participant characteristics, drug formulary, medication compliance and reconciliation, protocols and contraindicated drugs and areas for improvement.

RESULTS

A total of 76 pharmacists from 59 hospitals answered the survey. Some weaknesses were identified in the availability of drugs: (1) pharmacy services closed at certain times (86.4%); (2) low variety of antiparkinsonian drugs (18.4% store >21 different drugs); (3) delay in antiparkinsonian drug administration if unavailable (>12 hours in 39.5% of cases); (4) lack of flexibility in administration times; (5) low availability of transdermal rotigotine and subcutaneous apomorphine (<50%). The participants ranked highly the designing of specific protocols for patients with PD and implementation of concrete actions to optimise PD inpatient pharmacotherapy.

CONCLUSIONS

The participants detected some improvement opportunities and proposed realistic and applicable recommendations and strategies aiming to enhance the safety of patients with PD. Protocols for antiparkinsonian drug interchange, administration timing and nil by mouth status, medication reconciliation, and handling nausea/vomiting or psychotic symptoms are considered the main improvement areas.

Predictors of long length of hospital stay among elders admitted with seizures in a tertiary centre: a prospective study

OBJECTIVE

Population ageing is a global phenomenon, and life expectancy in Brazil is growing fast. Epilepsy is the third most important chronic neurological disorder, and its incidence is higher among elderly patients than in any other segment of the population. The prevalence of epilepsy is greater among inpatients than in the general population and it is related to long length of hospital stay (LOS), which is associated with hospital mortality and higher healthcare costs. Despite these facts, reports of elderly inpatients admitted with seizures and associated outcomes are scarce. To identify predictors of long LOS among elderly inpatients admitted with seizures.

METHODS

We prospectively enrolled elders admitted with epileptic seizures or who experienced seizures throughout hospitalization between November 2015 and August 2019. We analysed demographic data, neurological disorders, clinical comorbidities, and seizure features to identify risk factors.

RESULTS

The median LOS was 11 days, with an interquartile range (IQR) of 5-21 days. The frequency of long LOS (defined as a period of hospitalization ≥12 days) was 47%. Multivariate analysis showed there was an exponential increase in long LOS if a patient showed any of the following conditions: intensive care unit (ICU) admission (OR=4.562), urinary tract infection (OR=3.402), movement disorder (OR=5.656), early seizure recurrence (OR=2.090), and sepsis (OR=4.014).

CONCLUSION

Long LOS was common among elderly patients admitted with seizures, and most predictors of long LOS found in this cohort might be avoidable; these findings should be confirmed with further research.

Get Parkinson's medications on time: the Leeds QI project

Parkinson's disease (PD) is a common neurodegenerative disease. Delayed administration of PD medications is associated with increased risk of life-threatening complications including choking, aspiration pneumonia and neuroleptic malignant syndrome. In 2016, the spouse of a patient with PD wrote to Leeds Teaching Hospitals Trust (LTHT) to highlight that multiple medication delays and omissions had occurred during his recent admission. In response, LTHT formed a PD quality improvement (QI) Collaborative of multidisciplinary members committed to ensuring timely PD medication administration. The faculty used Institute for Healthcare Improvement Model for Improvement QI methodology. Interventions were tested on pilot wards and the most successful were scaled up and spread across all 90 adult inpatient wards as an 'intervention bundle'. Between January 2016 and June 2020 mean delays in the time from admission to first dose of medication dropped from over 7 to under 1 h. The mean percentage of omitted PD medications reduced from 15.1 to 0.6%. Project success was multifactorial but due to: Simplicity of interventions.Multiprofessional ownership by frontline teams to make changes and take prompt action.The spouse of the patient taking a leading role in the Collaborative, bringing her unique personal insight and experience, which facilitated behavioural change.

Measuring Medication Adherence in Parkinson's Disease: A Systematic Review of Contributing Components in Rating Scales

Background

Poor medication adherence in chronic illnesses such as Parkinson's disease (PD) is a significant but potentially addressable issue if core components are systematically measured.

Objective

To assess whether rating scales used in PD adequately cover essential components of medication adherence.

Methods

We accessed 5 databases targeting articles published before October 2019 and using rating scales to measure medication adherence in PD. The ABC Taxonomy from the European Ascertaining Barriers to Compliance Consortium and World Health Organization recommendations were used as the evaluation standard of 5 essential adherence dimensions (patient-based, health system-based, social-based, therapy-based, and health condition-based), 3 phases (initiation, implementation, and discontinuation), and 2 factors (intentional and nonintentional).

Results

We screened 192 and selected 16 studies, collectively using 5 medication adherence rating scales. No scale covered all essential components of medication adherence (dimensions, phases, factors). The Morisky Medication Adherence Scales were the most frequently used (11 studies), but they measure only 2 dimensions and phases. The Stendal Adherence to Medication Score (used in 1 study) measured all phases but only 2 dimensions, and the Brief Medication Questionnaire (used in 3 studies) measured 3 dimensions and 2 phases. Distinctions between intentional and nonintentional factors were not completely considered in any scale.

Conclusions

Although multiple studies target medication adherence in PD, the used scales did not measure all recommended components, highlighting the need to develop a sensitive, specific, and comprehensive tool for measuring medication adherence among patients with PD.

Factors associated with hospitalisation among people with Parkinson's disease - A systematic review and meta-analysis

INTRODUCTION

Parkinson's disease (PD) is associated with an increased risk of admission to hospital; however data on the main reasons for admission are lacking. Our objective was to determine the pooled prevalence of the most common factors leading to admission among people with Parkinson's disease.

METHODOLOGY

A systematic literature search was conducted in 11 electronic databases. We included all studies providing reasons for admissions among PD patients without restrictions to diagnostic criteria of PD, language or year of study. In the included studies, methodological quality, publication bias and heterogeneity were assessed. Meta-analysis was performed using random-effects models to calculate the pooled estimates of the identified top factors that lead to admission among people with PD.

RESULTS

A total of 7283 studies were identified of which nine studies including 7162 people with PD were included in this review. There was a high degree of heterogeneity between studies regarding reasons for hospitalisation. The pooled prevalence of the topmost reasons for hospitalisation among people with PD was 22% (95%CI 16.0%–30.0%) for infections (mainly urinary tract infections and pneumonia); 19% (95%CI 13.0%–27.0%) for worsening motor manifestations of PD; 18% (95%CI 14.0%–21.0%) for falls/fractures; 13% (95%CI 9.0%–18%) for cardiovascular co-morbidities; 8% (95%CI 4.0%–13.0%) for neuropsychiatric and 7% (95%CI 4.0%–11.0%) for gastrointestinal complications.

CONCLUSION

The main reasons for hospitalisation among people with PD are infections, worsening motor features, falls/fractures, cardiovascular co-morbidities, neuropsychiatric and gastrointestinal complications. Further research is needed on targeting and implementing preventative strategies.

Quality Improvement in Parkinson's Disease: A Successful Program to Enhance Timely Administration of Levodopa in the Hospital

BACKGROUND

Patients hospitalized with Parkinson's disease (PD) require timely delivery of carbidopa-levodopa (C/L) medication. Ill-timed administration of C/L doses is associated with greater morbidity and longer lengths of stay.

OBJECTIVE

To understand the barriers to timely C/L administration, and implement strategies to improve the administration of the drug to hospitalized PD patients.

METHODS

Several key strategies were employed in 2015 to improve the timely delivery of C/L doses: 1. three kinds of nursing alert in the electronic medical record (EMR); 2. staff in-service education; 3. stocking immediate-release C/L into automated medication dispensing machines on key hospital units; 4. reports to nurse unit managers on timeliness of C/L administration; and 5. reconciliation of inpatient and outpatient levodopa orders by the hospital pharmacist upon admission. The primary outcome was the percent of C/L doses administered within 60, 30, and 15 minutes of scheduled time.

RESULTS

Our urban hospital, affiliated with a Parkinson's Foundation Center of Excellence, had 5,939 C/L administrations in 2018. There was sustained improvement in timely delivery of doses, from 89.3% in 2012 to 96.5% in 2018 (within 60 minutes of the scheduled time), 65.5% to 86.4% (30 minutes), and 42.3% to 71.1% (15 minutes) (all p < 0.001).

CONCLUSIONS

With multifaceted but relatively simple measures, we were able to "change the culture" so that hospitalized patients with Parkinson's disease receive levodopa on time.

Interventions to minimize complications in hospitalized patients with Parkinson disease

Background

In this study, we sought to evaluate the efficacy of inpatient interventions on hospitalization-related complications in patients with Parkinson disease (PD). Hospitalized patients with PD have an increased risk of complications. Although several interventions have been suggested in the literature, data-driven recommendations are limited.

Methods

This study was designed as a prospective cohort study. A hospital-wide alert system was incorporated into the electronic medical record (EMR) system. The alert was triggered when a patient with PD or on dopaminergic therapy was admitted prompting the inpatient pharmacy to confirm medication details. A warning was also triggered if antidopaminergic medications were ordered. In-services were performed for nursing staff and physicians regarding these measures. Charts of patients with PD admitted 6 months before and after the intervention were reviewed to serve as the 2 comparison groups.

Results

There were 73 patients (mean 73.2 years) preintervention group and 103 patients (mean 72.3 years) postintervention group. There were no significant differences in reasons for admission, admission to neurologic vs non-neurologic floor, or admitting service between the groups. The percentage of patients for whom contraindicated medications were ordered decreased from 42.5% to 17.5% (p < 0.001). Medication administration with doses given over 30 minutes late decreased from 46% to 39% (p = 0.068). Medications ordered correctly were 42.9% vs 54.7% (p = 0.131) before and after the intervention. Length of stay was 5.3 vs 5.2 days (p = 0.896), and mean complications were 0.38 vs 0.37 (p = 0.864).

Conclusion

An intervention involving EMR alerts and in-service didactics for nurses and physicians decreased the frequency of contraindicated medications ordered in hospitalized patients with PD, but it did not change other hospital outcomes or complications.

Specialist emergency care and COPD outcomes

INTRODUCTION

In exacerbation of chronic obstructive pulmonary disease (ECOPD) requiring hospitalisation greater access to respiratory specialists improves outcome, but is not consistently delivered. The UK National Confidential Enquiry into Patient Outcome and Death 2015 enquiry showed over 25% of patients receiving acute non-invasive ventilation (NIV) for ECOPD died in hospital. On 16 June 2015 the Northumbria Specialist Emergency Care Hospital (NSECH) opened, introducing 24/7 specialty consultant on-call, direct admission from the emergency department to specialty wards and 7-day consultant review. A Respiratory Support Unit opened for patients requiring NIV. Before NSECH the NIV service included mandated training and competency assessment, 24/7 single point of access, initiation of ventilation in the emergency department, a door-to-mask time target, early titration of ventilation pressures and structured weaning. Pneumonia or hypercapnic coma complicating ECOPD have never been considered contraindications to NIV. After NSECH staff-patient ratios increased, the NIV pathway was streamlined and structured daily multidisciplinary review introduced. We compared our outcomes with historical and national data.

METHODS

Patients hospitalised with ECOPD between 1 January 2013 and 31 December 2016 were identified from coding, with ventilation status and radiological consolidation confirmed from records. Age, gender, admission from nursing home, consolidation, revised Charlson Index, key comorbidities, length of stay, and inpatient and 30-day mortality were captured. Outcomes pre-NSECH and post-NSECH opening were compared and independent predictors of survival identified via logistic regression.

RESULTS

There were 6291 cases. 24/7 specialist emergency care was a strong independent predictor of lower mortality. Length of stay reduced by 1  day, but 90-day readmission rose in both ventilated and non-ventilated patients.

CONCLUSION

Provision of 24/7 respiratory specialist emergency care improved ECOPD survival and shortened length of stay for both non-ventilated and ventilated patients. The potential implications in respect to service design and provision nationally are substantial and challenging.

Considerations for general anaesthesia in Parkinson's disease

Parkinson's disease is a common neurodegenerative disorder in the elderly which when present has a significant influence on surgical management. These patients necessitate additional perioperative and anaesthetic considerations across disease specific domains as well as in relation to the respiratory and cardiovascular systems. This brief review focuses on the factors which contribute to perioperative morbidity, including the use of medications that may exacerbate symptoms or adversely interact with treatments for Parkinson's disease. Recommended dosing practices to reduce complications during hospitalisation are covered. In addition, recent concerns regarding anaesthetic exposure in early childhood as a risk factor for the development of Parkinson's disease are discussed in light of data from animal models of anaesthetic neurotoxicity and epidemiological studies.

Enhancing Care for Hospitalized Patients With Parkinson's Disease: Development of a Formal Educational Program for Nursing Staff

Although not generally a primary admission diagnosis, Parkinson's disease (PD) can be a significant comorbidity during hospitalization. Hospitalized individuals with PD can experience a variety of complications, such as confusion, pneumonia, and urinary infections. More than 20% of patients experience deterioration in symptoms and hospital stays are extended by an average of 4 days. Late, omitted, or inappropriate medications are frequent culprits leading to serious consequences, including falls and aspiration. To address an identified gap in staff knowledge about PD, a formal educational program was developed to review its etiology, symptoms, treatments, and unique considerations in care and medication administration. This 2-hour intervention comprises a knowledge pre-test, PowerPoint® presentation, two concise handouts for reference, discussion of an unfolding case study, and review of the Aware in Care kit. Nurses can play a key role in educating staff to reduce avoidable hospital-related complications and enhance outcomes for this vulnerable group. [Journal of Gerontological Nursing, 43(5), 18-22.].

Medication errors in Parkinson's disease inpatients in the Basque Country

INTRODUCTION

Parkinson's disease (PD) medication errors, including both missing dopaminergic drug doses and antidopaminergic usage, have been suggested as risk factors for prolonged hospital stays. The objective of this study was to evaluate the prevalence of such errors in PD patients admitted to public acute-care hospitals in the Basque Country over a two year period and their association with clinically relevant adverse health outcomes, such as length of hospital stay and mortality.

METHODS

All PD patients admitted to any of the 11 public acute-care hospitals in the Basque Country in 2011-2012 were included. Medication errors involved incorrect timing or the complete omission of administration for dopaminergic drugs, and the administration of centrally acting antidopaminergics. A logistic regression and a competing risk analysis were applied to verify whether those errors affected intrahospital mortality and length of stay.

RESULTS

The study included 1628 patients admitted 2546 times. Medication errors, affecting almost one third of admissions and half of patients, were associated with higher mortality: inappropriately omitted dopaminergic drug doses OR = 1.92 CI 95% (1.34-2.76); inappropriate antiemetic administration OR = 2.15 CI 95% (1.36-3.39); and inappropriate antipsychotic administration OR = 1.91 CI 95% (1.33-1.73). Inappropriately omitted doses and both inappropriate antipsychotic and antiemetic administration were associated with a significant 4-day increase in median hospital stay.

CONCLUSION

Medication errors (missing dopaminergic drug doses and centrally acting antidopaminergic use) are not only associated with increased length of hospital stays in PD patients, but also with a higher mortality rate.

Models of Care Delivery for Patients With Parkinson Disease Living in Rural Areas

The elderly who suffer from chronic conditions have an increasingly difficult time accessing health care in rural areas compared with their healthy counterparts who seek and utilize less specialty care. Parkinson disease affects approximately 0.3% to 5% of the elderly population. However, a large portion of that population has difficulty accessing health care. The purpose of this study was to obtain an understanding of the access to care issues for patients with Parkinson disease and review solutions to aid their provision of care. A review of the literature found several models of care available to improve access to care issues for patients with Parkinson disease.

Delayed administration of dopaminergic drugs is not associated with prolonged length of stay of hospitalized patients with Parkinson's disease

Background

Punctual delivery of dopaminergic medication to Parkinson's disease (PD) patients may be important in optimizing disease control. We tested the hypothesis that prompt delivery of l-dopa medications to emergency hospital inpatients was associated with a decreased length of stay in hospital.

Methods

The study population consisted of all urgent hospitalizations for patients with a diagnosis of PD to the Royal Derby Hospital over a two-year period. Data were extracted on timing of delivery of drugs, number of co-morbidities and length of stay. Statistical analysis used linear regression adjusting for within admission clustering.

Results

431 individuals provided data from a total of 737 admissions. 39% of scheduled l-dopa doses were either not given or administered over 30 min later than the scheduled time. There was no association between the omission or timing of a dose of PD medication and length of stay in hospital. The number of coded diagnoses was strongly associated with length of stay with a dose-response association (p_TREND<0.001). Those with 10 concurrent diagnoses had a 11 day longer stay (95% confidence intervals: +2 to +21) than those with no comorbidities.

Conclusions

Delayed administration of dopaminergic drugs is not associated with prolonged length of stay of in patients with PD who were admitted to hospital as an emergency. However, the number of co-existing medical diagnoses was associated with length of stay, and early attention to these has the potential to improve patient care and decrease length of stay in hospital.

•

The study population was 737 emergency admissions of PD patients.

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39% of l-dopa doses were omitted or delayed more than 30 min.

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Delays to l-dopa administration in hospital do not prolong length of stay.

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The number of co-morbidities is positively correlated with length of stay.

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Weekends do not affect delays to dopaminergic medication administration.

Epidemiology of Parkinson Disease

Parkinson disease (PD) is a common progressive neurodegenerative condition, causing both motor and non motor symptoms. Motor symptoms include stiffness, slowness, rest tremor and poor postural reflexes, whereas nonmotor symptoms include abnormalities of mood, cognition, sleep and autonomic function. Affected patients show cell loss in the substantia nigra pars compacta, and accumulation of aggregated alpha-synuclein into intracellular structures called Lewy bodies, within specific brain regions. The main known non modifiable risk factor is age. The neuroepidemiology of PD is complex with susceptibility genes and a number of modifiable risk factors that can increase and others that can mitigate risk and outcome.

Missing dosages and neuroleptic usage may prolong length of stay in hospitalized Parkinson's disease patients

Background

Parkinson’s disease patients are more likely to be hospitalized, have higher rates of hospital complications, and have an increased risk of deterioration during hospitalization. Length of stay is an important underlying factor for these increased risks. We aimed to investigate potential medication errors that may occur during hospitalization and its impact on length of hospital stay.

Methods

A cross-sectional chart review of 339 consecutive hospital encounters from 212 PD subjects was performed. Medication errors were defined as wrong timing or omission of administration for dopaminergic drugs and administration of contraindicated dopamine blockers. An analysis of covariance was applied to examine whether these medication errors were related to increased length of hospital stays.

Results

A significant effect for dopaminergic administration (p<0.01) on length of hospital stay was observed. Subjects who had delayed administration or missed at least one dose stayed longer (M=8.2 days, SD=8.9 vs. M=3.6 days SD=3.4). Contraindicated dopamine blocking agents were administered in 23% (71/339) of cases, and this was also significantly related to an increased length of stay (M=8.2 days, SD=8.9 vs. M=3.6 days SD=3.4), p<0.05. Participants who received a contraindicated dopamine blocker stayed in the hospital longer (M=7.5 days, SD=9.1) compared to those who did not (M=5.9 days, SD=6.8). Neurologists were consulted in 24.5% of encounters. Specialty consultation had no effect on the medication related errors.

Conclusions

Missing dopaminergic dosages and administration of dopamine blockers occur frequently in hospitalized Parkinson’s disease patients and this may impact length of stay. These potentially modifiable factors may reduce the risk of a longer stay related to hospitalization.