Analyzing Quality of Care for Hospitalized Patients with Parkinson’s Disease
TimeThursday, April 152:00pm - 3:00pm EDT
DescriptionBackground and Significance of the Problem:
According to the Parkinson’s Foundation, approximately 60,000 patients are diagnosed with Parkinson’s disease (PD) each year, and the prevalence of patients diagnosed with PD in the United States is expected to reach approximately 1.2 million by 2030. There are over 4,000 patients currently diagnosed within the state of Nebraska alone. Past studies have found that patients with PD are hospitalized 1.5 times more frequently and typically stay 2-14 days longer than patients that do not have PD. During their stay, patients with PD have common acute events that occur during their hospitalization that can range from decubitus ulcers to fractures due to falls. Furthermore, management of PD patients’ medication regimen can be demanding and complex as regimens are individualized to each specific patient based on their current disease status and tolerance of side effects. According to the Parkinson’s Foundation, three out of four PD patients do not receive the medications they need when hospitalized. When regimens are not followed, patient symptoms such as tremors, rigidity, loss of balance, confusion, agitation, and difficulty communicating can worsen. The American of Academy of Neurologists (AAN) developed quality metric guidelines in 2010 and updated them in 2014 for use by providers in the proper management of patients with PD. Additionally, the Parkinson’s Foundation created the Aware in Care campaign in 2011 that led to the recent development of the Aware in Care kit and Aware in Care: Hospital Action Plan document. This document is intended to be used by patients and caregivers to help inform them about their condition and provide educational materials to share with healthcare staff upon hospitalization and help optimize the patient’s care. Such materials that can be provided to staff include a “Fact Sheet” that emphasizes medication schedule adherence, contraindicated medications, concerns related to possible imaging, and importance to monitor for physical symptoms such as dysphagia and hypokinesia.
Hypothesis, Problem or Question:
For this study, our overarching goal is to determine how patient-specific information and just-in-time PD educational information (such as material from the Aware in Care kit created by the Parkinson’s Foundation) could be incorporated into the EMR system or workflow for medical staff by identifying variability within the workflow of PD patient care and opportunities for improvement of management in accordance with AAN guidelines and Aware in Care kit recommendations.
Experimental Design: Hospital stays of 39 patients with PD over 45 admissions were analyzed through workflow analysis within the EMR. This was performed through a retrospective chart review of hospitalized PD patients in 2018 within the Internal Medicine, Neurology, and Family Medicine departments. Data was collected to determine if AAN guidelines were being met prior to and/or during the admission of the patient, evaluate possible concerns identified in literature (i.e. medication schedule adherence, length of stay, etc.), and evaluate general patient care analysis (i.e. number of staff involved with admission, consultation of neurology, etc.).
In regard to AAN guidelines, our study found that >70% of patients met 4 out of 5 guidelines (Annual evaluation of PD symptoms, Cognitive Assessment, Psychiatric Assessment, Autonomic Dysfunction Assessment, and Sleep Assessment) meant to occur on an annual basis for evaluation with the exception being “Sleep Assessment,” which only occurred in ~37% of patients in the previous year. Additionally, the same annual guidelines for assessment of patients with PD were evaluated during the inpatient stay, which demonstrated only ~44% of patients being evaluated for “Autonomic Dysfunction” and ~7% of patients for “Sleep Assessment.” Patients were evaluated for “Fall Risk” on evaluation and recommended for physical and occupational therapy in >80% of hospital stays. In evaluation of workflow analysis, we identified that the average number of physicians involved during an inpatient stay for the patients analyzed was ~12, number of nurses ~13, average time from admission process completion to delivery to admission floor was ~295 minutes, and the average number of missed medication doses during admission was ~2. Lastly, based on literature and general patient concerns, swallow assessments were performed in ~24% of admitted PD patients and Neurology was consulted in ~14% of admissions.
Overall, our research found that much of the care provided to patients with PD prior to and during admission was following the majority of recommendations made by AAN and avoiding many of the concerns identified within literature. However, particular opportunities were identified to help mitigate poor outcomes and improve holistic care for patients with PD. A few key areas identified for improvement were “Sleep Assessment” during outpatient visits and admission, “Autonomic Dysfunction Assessment” during admissions, evaluation of “Fall Risk” and referral for therapy during admission. Suggestions to help improve these areas are changing note templates to serve as a reminder for providers and help with documentation of areas such as “Sleep Assessment” and “Autonomic Dysfunction Assessment”. Additionally, evaluation of “Fall Risk” and referral for therapy during admission was >80%, this is an area that has been identified in literature to be a major concern. Further research is needed to determine whether this is an appropriate finding as many factors may preclude a patient from being evaluated for a “Fall Risk” or referral for therapy such as being non-ambulatory or in ICU. Furthermore, our research found that PD patients will come in contact with many different providers and staff during their stays, and often times, Neurology is not consulted. While it is reasonable for Neurology to not be consulted for every PD patient admission as patient care information can be found within the EMR from past visits to help guide care, this may leave patients vulnerable to oversights in their care that may come with an increased number of staff involvement or staff inexperience with PD patients. For this reason, incorporating the Aware in Care kit materials into the clinical workflow, particularly the “Fact Sheet” for staff, could be helpful to provide reminders and information to staff to help provide the best care for patients. Additionally, modifications to the “Fact Sheet” could include guidelines/recommendations for when and when not to consider a consult for Neurology to assist with patient care. In conclusion, the care provided to the patients with PD exceeded our expectations given the number of difficulties and concerns identified within literature for PD patient care. Yet, there is always opportunity for improvement and even the smallest change may advance patient outcomes. Continuing to address the areas identified within our research and implementing the materials provided in the Aware in Care kit into the clinical workflow, through the EMR, will help medical staff provide the best care for patients with PD.