A Comprehensive Program to Enhance Inpatient Care for Patients With Parkinson Disease

The Cleveland Clinic (CCF)'s Parkinson's Inpatient Program comprises of system and patient level interventions aimed to promote recovery in patients with Parkinson disease (PD). System level interventions took place at both enterprise and individual hospital levels. Enterprise level changes comprised electronic health record modifications including best practice alerts and notification of PD contraindicated medications. Hospital level interventions included creation of a PD inpatient census, a dedicated PD inpatient consult team, clinician education, changes in PD medication stocking/administration, and changes to Speech Therapy documentation templates.

A new study showed that the CCF's Parkinson's Inpatient Program was an efficient and effective way to correctly identify and prevent or correct common clinical errors that could lead to lesser outcomes and further complications in hospitalized patients with PD.¹ In the analysis, all charts of patients with PD admitted at CCF's Main Campus and Fairview hospitals were prospectively pulled into a census utilizing a custom EHR tool starting in January 2023. After confirmation of PD diagnosis, researchers followed the patient’s charts throughout the admission. Authors monitored their charts for PD contraindicated (CI) medications, deviations from home PD medication regimen, worsening of motor and non-motor symptoms, and other complications.

These findings were presented at the 3rd Annual Advanced Therapeutics in Movement and Related Disorders (ATMRD) Congress, held by the PMD Alliance from June 22-25, 2024, by lead author Patricia Clark, CNP, and colleagues. During the Congress, Clark, a nurse practitioner of the Center for Neurological Restoration at the Cleveland Clinic, sat down with NeurologyLive^® in an interview to talk about how the program accurately ensures patients with PD receive their home medication regimen while hospitalized. She also talked about the types of interventions that were most frequently required for the patients in the program. Moreover, Clark spoke about how education and awareness among hospital providers impacts the effectiveness of the program.

NeurologyLive: What specific measures did the program take to ensure that hospitalized patients with PD receive their home medication regimen accurately?

Patricia Clark, CNP: The program is designed to improve quality and safety of care for patients that have PD who come into the hospital and are inpatient; they may be hospitalized for any reason, it's usually not because of their PD, it could be a planned surgery or an infection. It's a program that Benjamin Walter, MD, and my colleague, Shannon Shaffer, CNP, had done for a while, the intervention part. With a grant from the Parkinson's Foundation, they standardized it more, adding other changes, and are now doing an evaluation of the program.

We created an inpatient team that consists of myself and Shannon, so 2 nurse practitioners, and we have about 2 hours of our day total [dedicated to the program]. She does it 3 days a week. I do it 2 days a week. It's about 10 to 12 hours of clinician time a week. We created a census where we get a list of anybody in the hospital that has PD, Lewy body dementia— anything like that in their history, so not necessarily their admission diagnosis. What we do is confirm their diagnosis. We usually read one of their last notes from their neurologist. We'll look at their medication and see what their most recent home regimen is. Then we go to their hospital chart, and we make sure that their hospital medical record, that their schedule matches their home regimen.

Typically, medications are maybe ordered 3 or 4 times a day in the hospital, and those default to certain times. We make sure that those times are specific to the patient. One of the changes that we made is that a hospital provider has to enter those as custom times. They can't just say 3 times a day, and it defaults to hospital times. They have to specifically enter say, 9am, 1pm and 5pm. This helps keep patients on their home regimen. We try to intervene if, for example, someone is in the emergency room for several hours. We make sure that as long as it's not contraindicated, that they're still getting their home regimen and they're not missing doses. We make sure that patients aren't ordered or given any contraindicated medication.

There's a lot of medications that are used for nausea and confusion that can block patients Parkinson medication and make Parkinson symptoms worse. We look at charts every day and make sure none of those are ordered. For about 40% of those patients we get, it's really just monitoring, looking every day that nothing is contraindicated. There's nothing going on that we need to intervene with. For the remaining 60% of those patient this past year, we've actually had to intervene. This includes contacting the provider, letting them know you ordered Compazine that's actually contraindicated. Maybe suggest that they change their timetable so they're not getting their last dose when they've been asleep for 3 hours.

Then also managing things like dysphagia, making sure people are getting up and active as soon as possible, getting moving, things like constipation, recommending regimens if they can't be on their particular Parkinson regimen. And so that was about 60% of cases. We're looking at those broader hospital and system changes that we made so alerts come up, changing so providers have to enter the medication schedule regularly, and seeing if that kind of diminished over time. Because those corrections now, a lot of them are happening before we even see it.

How long was the total data collection period for the program, including the break?

We did 6 months of data collection, and then we had a break for about 2 months where we continued the intervention, but didn't collect the data. And then we did 6 more months [of data collection]. And so that data collection will be complete at the end of this month (June). Overall, we'll have 12 months of data collection. But the other thing is, the whole time we've been doing the intervention, so that is data collection, where we're talking specifically about what our intervention recording their home medication regimen. But for the whole length of the study, we'll also have data from our medical records, and we’ll be able to see their outcomes. We just don't have where we specifically discussed what our intervention was.

How important is it for patients to understand medications that contradict their PD treatments?

A big part of our intervention as well is education. So educating our providers: we'll put in a note for a particular patient with our recommendations for that specific person. Just through our intervention, we're teaching people about the program that they can access, but also mistakes to watch out for in the future. And so a lot of times, people will say, “Well, what does that say about the providers? Around 20% of your interventions were discontinuing a contraindicating medication. Why was that ordered in the first place?” But if you look at the poster, you see the reasons for why people were admitted to the hospital.

The first reason is for an elective procedure, scheduled procedure, and then I think it's like cardiac. Really, none of our top 5 reasons that patients were admitted were for something neurological. These are providers that its not their main focus. The patients are thinking about the knee replacement and the other surgery, and “this is how I normally handle nausea”. And so that box for composing gets clicked, so now they see an alert. If they don't follow the alert, they get a little message or note from us. Overall, providers have been extremely receptive to the program. Admittedly, they reach out they say, “I don't know much about neurology. I don't know much about Parkinson specifically.” And so we're getting a lot of good feedback.

Another one of our interventions that I, as a former nurse, was really kind of nervous about, was medication delivery. Just because the medications were ordered to be given at the correct time doesn't necessarily mean it's given at the correct time. For most medications in the hospital, you have a 1-hour window on either side to give the medication for it could be considered on time. If the time is nine o'clock, it can be given any time between 8 and 10. A nurse normally starts with one of their first patients. By the time they get to their last patient, they're somewhere in that window.

One of the changes that we made was for Parkinson medications. If it falls 15 minutes out time of the outside of that scheduled time, a little alert pops up. From my perspective, it's just a matter of prioritizing. When you're a nurse on the floor, you get your patients, you get your patient load, and you look at everyone's blood pressures and vitals. Do they have insulin? Do they have a Parkinson medication? And so, it was just a matter of teaching nurses. This is something that needs to prioritize and be on time so well.

What were the biggest lessons learned from the study?

I think one of the biggest things I've learned in this study is that everyone really just has the patient's care and the best interest of the patient at heart. People are really receptive. I wouldn't necessarily take criticism, but they're receptive to someone who knows about the disease, getting involved and helping out. Patients are really grateful too, because they come into the hospital, they're overwhelmed, they want to do what their provider says, and in their mind, their medications are late, but they think, well, maybe my provider ordered it to be given at a different time, or maybe I'm missing it because I'm having this surgery. Overall, it's just been really a wonderful program to improve patient care.

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REFERENCES
1. Clark PA, Brooks A, Fernandez HH, et al. Improving the Quality and Safety of Care for Hospitalized Patients with Parkinson's Disease. Presented at: ATMRD; June 22-25, 2024; Washington, DC.