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[00:00:36] Dr. Georgia Richard:
Thank you very much for having me.
[00:00:38] Dr. Sara Schaefer:
Why don't we start with what inspired you to look at this particular problem? Why do you think that is important to look at medication prescribing and administration in Parkinson's patients who are admitted to the hospital?
[00:00:52] Dr. Georgia Richard:
Sure. So I suppose as I was initially inspired to look at this just from my clinical work on the wards. You know, we manage Parkinson's patients every day. And oftentimes when they come in unexpectedly through the emergency department due to the time of day, pharmacy, opening hours patient characteristics, that can be very difficult to initially get their medications correct. And my anecdotal experience was that this can significantly impact these patients and their management in the hospital, despite our best efforts. So really I wanted to look a little bit more into this. I know from reading around in the literature, it's known to be associated with an increased length of stay and possibly morbidity and mortality.
So I really wanted to see how we were doing in our center, how we measured up against previously published research and really to identify where we were going wrong and to see if there was any ways that we could address this.
[00:01:47] Dr. Sara Schaefer:
Your study focuses on unplanned admissions for Parkinson's patients. To your knowledge have planned admissions been assessed previously? Why did you choose to focus on unplanned admissions?
[00:01:59] Dr. Georgia Richard:
Yeah. So to my knowledge, planned admissions, haven't been looked at previously. I suppose we decided to focus on the unplanned aspect really, because my experience on the ward was with these patients predominantly. We had the impression that during planned admissions, the physician can prepare for the patient's arrival, including making sure the medications were prepared. And similarly families would be able to plan for the admission and, you know, bring appropriate documentation.
So really we felt that the vulnerability was there in the unplanned cohort. And that was really where we wanted to see if that was any way that we could improve to try and address this kind of vulnerable cohort of patients.
[00:02:44] Dr. Sara Schaefer:
You know, we will get to your data of course, but I do wonder if there is potentially surprisingly or unsurprisingly, a lot of room to go, even for planned admissions for these patients.
[00:02:58] Dr. Georgia Richard:
I wouldn't be surprised at all. I think what we do see is that these medications aren't necessarily all that well prescribed when patients come in. They're on complex regimens often. And there's a lot of scope for error and a lot of scope for improvement, I think. So it's not something that we looked at, but I do think looking at planned admissions would also be very informative.
[00:03:21] Dr. Sara Schaefer:
So tell us abouthow you went about your research. What was your methodology?
[00:03:27] Dr. Georgia Richard:
Sure. So we performed a retrospective study and we looked at patients admitted to our center, which is a very large teaching hospital in central Dublin. And from a period from November, 2018 to March, 2020. And we looked at patients admitted who carried a diagnosis of idiopathic Parkinson's disease, who were on time-critical Parkinson's disease medications, which we defined as levodopa- containing preparations.
We excluded patients with Parkinson's plus diagnoses and we excluded patients with, for example, drug induced Parkinsonism. From that, then the first thing we looked at was the initial prescribing of these medications and the accuracy. So we compared the prescribing of these medications in the drug chart or the drug codex to documentation of their patient's ideal regimens or their regimens at home that was recorded in the medical notes, in outpatient clinic letters, or with the ward pharmacist following a medication reconciliation.
The second aspect of the study was then looking at the accuracy of the administration of these drugs once they'd been prescribed. So assessing how often these medications were given on time. And if there was any delay in the administration of these medications, how long that delay was, and the reason for that.
[00:04:44] Dr. Sara Schaefer:
And what did you find?
[00:04:46] Dr. Georgia Richard:
So during this period of time, we found 102 admissions of 70 patients who fit our inclusion/exclusion criteria that were included for analysis. In terms of the demographics of this cohort, the average age was 79 and two thirds of them are men. The average number of Parkinson's disease medications they were on was just under two with an average number of daily administrations of four.
When we looked at the initial prescribing of these medications, we actually found that 50% of them were prescribed incorrectly on admission. And the most common areas were around timing. So just over 30% of all of these patients admitted, had errors in timing noticed. Then there were also sort of 10% of patients had had errors in dose, and 10% had errors of omission of a drug.
We found that female sex an increased number of medications and an increased number of daily administrations, but all associated with an increased risk of an error in their admission prescribing.
And we noticed a trend towards an increased length of stay in patients with prescribing errors. Although this didn't reach statistical significance.
Then looking at a analysis of administration accuracy, we looked at a subset of 46 admissions. And this accounted for 1,273 individual drug administrations. So we found that only 41% of drug administrations were given within 30 minutes of that prescribed time, with more than 50% given over 30 minutes late, and 7.5% of doses were omitted overall.
[00:06:20] Dr. Sara Schaefer:
I wonder if you have any thoughts as to why there might have been a difference between men and women that was actually statistically significant, where women were more likely to have errors than men?
[00:06:33] Dr. Georgia Richard:
So I think there's a number of reasons. We didn't delve into this in any great depth, and we didn't look at if women had, say, more medications on average than the male cohort. It wasn't really something we delved into significantly unfortunately, but I think it would be really useful to look into further.
[00:06:52] Dr. Sara Schaefer:
Your results indicate that the largest chunk of errors in incorrect prescribing on admission were in the timing; as you said, over 30%. But you also mentioned that the majority of admissions couldn't be assessed in terms of timing accuracy, because pre-admission timing was not clearly documented. Do you take this to mean that the errors in timing may in fact be much, much higher than you found?
[00:07:16] Dr. Georgia Richard:
Unfortunately, this may be the case. So from looking at the data, unfortunately timing can be assessed in, in over 40% of the admissions, because nowhere within either the outpatient clinic letters, the pharmacy note or the medical notes, there was no documentation of pre-admission timings.
Now this could be reflective of the fact that perhaps these medications were just prescribe correctly and at the right times in the codex or the drug charts. But I think that might be a very over optimistic interpretation. And I think it might stem from the fact something, I think we mentioned in the article that there isn't a very firm protocol for who's responsible for documenting these medication timings within the notes, separate from the prescribing of the medication. So I think that's something we can pick off on and some way we can really improve.
[00:08:08] Dr. Sara Schaefer:
For those of us who are not from Ireland, I was just wondering how integrated are your inpatient and outpatient medical record systems? Are the outpatient notes from these patients' neurologists generally freely available to the inpatient team on admission, or generally not?
[00:08:28] Dr. Georgia Richard:
So, unfortunately it varies hospital to hospital. And so I could only really comment on this and the hospitals in which I've worked in the country because the hospital systems are not integrated and they have their own protocols, their own computer systems, and everything is very separate. What I know from working in this hospital St. James's is that it's an entirely computerized system. So the inpatient notes, the outpatient notes, blood results prescribing, is all done electronically. So it's a much more integrated system than in potentially other hospitals around the country. James has being the first hospital to have fully computerized records, the first sort of acute inpatient hospital to have done so. So, unfortunately, that kind of limits the applicability of our findings to other centers because the systems are so diverse between each hospital.
[00:09:25] Dr. Sara Schaefer:
That actually increases the alarm a bit. Even in an integrated hospital system where outpatient records are potentially more available, there are such profound deficits in correct prescribing and administration of medication.
[00:09:42] Dr. Georgia Richard:
Absolutely. And I think one thing that should be noted though, is although the majority of these patients were followed in James's, there was a significant minority whose Parkinson's disease were followed in other centers. And we don't only have access to our own outpatient.
[00:09:58] Dr. Sara Schaefer:
What systems are currently in place in Ireland? And you also mentioned some other medical systems, like the British medical system, that are already there to help address the issue raised by your study.
[00:10:10] Dr. Georgia Richard:
Yeah. So the UK has the nice guidelines, which give sort of a proforma or standards for sort of a wide range of things, but specifically in the context of Parkinson's patients who are being admitted to hospital, and they have guidance on when the pharmacy medication reconciliation should be done, i.e., within 24 hours of the patient's admission and also on targets for Parkinson's disease time-critical medication administration being within 30 minutes of the prescribed time. So the UK do have the nice guidelines, which are great. I've never worked .In the UK, but they seem to work well. We don't have an equivalent set of guidelines in Ireland.
Hospitals would have their own protocols and their own guidelines and prescribers, manuals. There isn't a standardized protocol or a standardized set of guidelines for these patients, when they're being admitted, of standards or ways to go about prescribing and making sure these things are correctly done.
[00:11:14] Dr. Sara Schaefer:
So that segues well into my next question, which is that you identified significant breakdowns in both the original prescribing of medications, i.e., how they were entered into the system, and in the administration of medications by nursing staff. How do you envision these two issues being adequately addressed to improve patient care?
[00:11:36] Dr. Georgia Richard:
Specifically in St. James's the team that worked on this study were really able to work collaboratively with a number of other parties in the hospital and the medication safety pharmacists, and the nursing staff, to try and come up with some solutions to try and address some of the deficiencies we identified. So I think a large component of this is education. Our system is such that the majority of these patients would be admitted by general internal medical physicians or residents. And I think a focus on education, just a small piece around the critical nature of Parkinson's disease medications, is really helpful and it's something we put together, some posters and some informative pieces that have gone out to staff involved in these admissions. We're also working on getting a Parkinson's-specific pharmacist in the hospital whose role is to really identify these patients when they come in through the door and to try and correct any medication prescribing issues to start with, as early as possible.
And then we've also introduced a Parkinson's disease card to our clinic so that these patients who are known to St. James's hospital can carry a small card detailing all of their medications with them in the wallets to try and have a record that can be taken from site to site that will facilitate more accurate prescribing when they come in. In terms of administration I think what would be brilliant to work towards would be self-administration of these time-critical medications in selected patients in whom it would be appropriate, who are cognitively intact and not delirious and have the ability to do so on the wards. That's not something we've managed to implement yet, but I'd be hopeful that this would be something we could work towards.
We're also working on introducing alerts on the electronic patient record to just alert nursing staff and the people administering these medications of the time critical nature of them.
And we've also introduced an above-bed sign as well, just to allownursing staff and other medical staff that these patients are on time-critical medications to just highlight the importance of administration accuracy in this case.
[00:13:39] Dr. Sara Schaefer:
I love the idea of the Parkinson's medication card. I actually, upon reading your paper, sent that idea to our division chief saying we should do this.
[00:13:49] Dr. Georgia Richard:
Yeah, I'm actually trying to, I've since moved on from St. James's, but I'm chatting to some of the consultants to see if we can bring it in here as well. Because I think we identified the problem with these patients coming in in the middle of the night, pharmacies closed, difficult to contact family. I think oftentimes the list of medications might not be brought, but if we can get this little card to be kept in the wallet, I think very few people come into the hospital without at least a wallet on them.
So the idea is that this, this card is brought around everywhere they go and wherever they end up, unfortunately, being admitted, it's accessible and accurate.
[00:14:24] Dr. Sara Schaefer:
Almost like a medical bracelet.
[00:14:26] Dr. Georgia Richard:
[00:14:27] Dr. Sara Schaefer:
So are there any plans to take this quality improvement, all of these measures, to the next level in terms of assessing their effectiveness?
[00:14:39] Dr. Georgia Richard:
Absolutely. So these measures have been in place now for coming up to a year. So I think the next step for us really is to assess the efficacy of these things and to sit down and, and maybe even form some focus groups of the involved parties, nursing staff, pharmacy, and say, look, which of these measures are working and where can we improve again?
I think it's really important to close the loop and follow up on that.
[00:15:03] Dr. Sara Schaefer:
Well, thank you for bringing to light this important topic that really impacts our patients in huge ways.
[00:15:13] Dr. Georgia Richard:
Thank you so much for having me. It's been brilliant. A great first podcast experience for me.