A hospitalwide initiative to address the hazards faced by Parkinson’s disease patients has led Hackensack University Medical Center, part of Hackensack Meridian Health, to become the first acute care hospital awarded a disease-specific certification designation for Parkinson’s from The Joint Commission.
A nervous system disorder, Parkinson’s includes symptoms such as tremors and muscle rigidity, and can negatively affect speech, explains Hooman Azmi, MD, a neurosurgeon specializing in surgical treatments for Parkinson’s. Seeking to reduce the risks faced by patients with this disease, Azmi led a team at the medical center.
“Parkinson’s is a very special disease in that patients become very dependent on the administration of their medications. They have both motor and non-motor symptoms, which can be very dependent on the timely administration of medications,” Azmi says. “Over time, this dependence can become stronger and they might require medication every two or three hours, and sometimes around the clock. Management of these patients becomes very difficult and revolved around maximizing their time without rigidity, being able to move, and with as little side effects from the medicine as possible.”
More so than most other patients, Parkinson’s patients require extreme attention to detail regarding medication regimens, Azmi explains. A patient may need a dose of medication at 6:15 p.m., for instance, and it will not be acceptable to provide it at 6 p.m. or 6:30 p.m.
“It’s a difficult feat to achieve. There are studies that show that most patients with Parkinson’s come to the hospital for other reasons like pneumonia or elective surgery, and their Parkinson’s gets lost in the shuffle,” Azmi says.
“When they come to the hospital and we put them on a default medication regiment for five times a day or eight times a day, it can really wreak havoc with that patient’s symptoms.”
Even a 15-minute delay in medication timing can result in hospital-acquired complications resulting from falls, dysphasia, and other risks, Azmi says, which can result in longer hospital stays. Parkinson’s medications also are sometimes not found in hospital formularies.
In addition, some common anesthesia medications, antiemetics, pain medications, and antipsychotics are contraindicated for these patients and can adversely affect Parkinson’s disease symptoms if administered.
Hackensack University Medical Center addresses these risks first by placing a marker in the patient’s electronic medical record (EMR). The Parkinson’s alert is one of the first things a clinician sees when opening the EMR, and it triggers a series of best practices in the record for nurses, emphasizing the importance of medication timing.
The EMR also was revised to allow more appropriate medication timing for Parkinson’s patients. Like other EMRs, it normally provides a prescriber with several common dosing and timing options for medications, such as twice a day or four time a day. Once the patient is flagged as a Parkinson’s patient and the disease-specific medication is selected, the EMR now adds a button allowing the prescriber to customize the timing for that patient.
“That has to be supported by education for nurses and doctors about why these medications have to be ordered in a custom fashion. You have to ask patients exactly what time they are taking these medications and enter that in the EMR,” Azmi says.
“Once we implemented that education, we saw a significant increase in the customized input of this information.”
The hospital’s EMR alerts clinicians to medications that are contraindicated for Parkinson’s patients. The hospital also added common Parkinson’s medications to its formulary even though the patients make up a relatively small percentage of the hospital’s population and the drugs can be expensive.
“It’s justified because we’re providing better care and it can reduce the length of stay. We have seen that over the past two years, with the length of stay for a patient with Parkinson’s dropping independent of the admitting diagnosis,” Azmi says.
“That’s a big accomplishment, and the savings can add up to the bottom line of the hospital.”
Hackensack University Medical Center is part of a 16-hospital system and has the lowest readmission rates for patients with Parkinson’s, and the lowest length of stay. It also has a slightly lower mortality rate for those patients.
Identifying Parkinson’s patients is key to reducing the risks they face when hospitalized, Azmi says, and the EMR is not the only option. He suggests using other methods common for identifying risks, such as the fall risk wristbands and notices on patient doors and by the bedside.
Azmi explains that such efforts must be hospitalwide because Parkinson’s patients are not grouped together in one unit. Because most come to the hospital for unrelated issues, they are placed on various units such as cardiac care or surgical.
“We need to involve champions that really care about improving care for these patients and are willing to drive this effort throughout the entire hospital,” Azmi says.
- Hooman Azmi, MD, Neurosurgery, Hackensack University Medical Center, Hackensack, NJ. Phone: (201) 342-2550.