A standing agenda item to improve the patient’s experience on the monthly Methodist Hospital Patient/Family Advisory Council (PFAC) in 2013 led to the creation of a successful project that resulted in improving the timely receipt of Parkinson’s Disease (PD) medications for patients in the emergency center and while in the hospital. Ron Kitzmann, Park Nicollet Health Services Pharmacy Director, regularly met with the PFAC to discuss ways to improve the patient experience. One of the Council members, who was a retired physician with Parkinson’s Disease, asked an important question, “Why can’t we get Parkinson’s patients their medications on time when they are in the Emergency Department or in a hospital bed?”.
Ron took the question seriously and followed up with the advisor. He knew that it’s an important issue because delays in receiving PD medications (Caridopa/Levodopa) can swiftly cause problems that can mean a patient can’t move and can result in a longer hospital stay. Therefore, patients become very anxious when they do not receive their medications on time. In fact, 61% of PD patients who did not get their medications on time experienced serious complications that resulted in longer hospital stays than non-PD patients.
Based in part on a related significant incident that had occurred in another hospital in the system, the executive leadership was behind this project, and that helped the team get the attention and resources it needed. Figuring out how to improve timeliness of medication administration involved a number of steps:
First, collecting baseline information on how timely the administration currently was and how many patients and visits were affected was important. The pharmacy was fortunate to have a pharmacy resident skilled in extracting data from the medical records who could answer those questions quickly and also ran reports to see which units tended to care for these patients.
Second, an important factor was adopting the recommendation of a neurologist to define timely administration for PD medications as within 15 minutes of the patient’s dose schedule. This is different than the normal hospital definition of timely administration as being within one hour of the scheduled time. Also, rather than shifting home schedules to the hospital routine medication administration times, the goal was to keep the patient’s regular home schedule, which might be every three hours at a specific time of the day.
Third, several brainstorming sessions were held to identify possible interventions. Nursing staff from the two units that cared for the most PD patients considered ways to improve timely administration. The Medication Safety Committee reviewed the data and brainstormed ways to prevent delays.
Fourth, using information and the Aware Care kits for patients from the National Parkinson Foundation (NPF) was helpful, and collaborating with the Struthers Parkinson’s Center made a difference.
Early improvement efforts involved:
- Developing a monthly compliance scorecard that was posted on the units.
- Creating a 15” warning and instructions in the Epic eMAR. An overdue button was created that turned red one-minute after the administration due time. While it is challenging to get the resources to change the EMR, this was probably the single most important intervention to achieve improvement.
- Intensive staff education for nurses, pharmacists and physicians was implemented
- A daily report to identify patients receiving Carbidopa/Levodopa was developed. This allowed the pharmacists to talk with patients about their home dosing schedule and continue it in the hospital.
- PD medications were added to the floor automated dispensing machines.
- The Struthers Parkinson’s Center developed a card for patients to give to emergency department staff to identify themselves, their medication requirements and other medications that should not be prescribed. The Center also gave the pharmacy NPF Aware Care kits to provide to patients who didn’t have one.
These interventions resulted in significant improvement in on-time medication administration that held at 42.1-44.2% through 2014. Still the staff wanted to go farther. Additional interventions included:
- Doing a third “deep dive” to identify other potential interventions.
- Changing the eMAR 15-minute alert to 1 minute
- Modifying the daily report to identify patients with PD, rather than all patients receiving Carbidopa/Levodopa, which is also used for other indications. This allowed a more targeted focus and reporting process.
- Allowing patients to self-administer their medications in the emergency department as a component of improved workflow. To comply with hospital medication administration policies, the medication must be checked by a pharmacist or physician before being self-administered.
- The pharmacy department created a newsletter article that was distributed system-wide.
The result is that in 2016, two-thirds of doses are now given within 15 minutes of scheduled time and there has also been an improvement in medications given within 30 and 60 minutes. Another outcome of this project and its success is that The Joint Commission is proposing that this project be placed in its library of best practices.
Caution, look out ahead!
Some of the challenges faced and learnings from the project are:
- To achieve attention and focus on a medication process improvement project, choose projects that have a high impact on patients. Then it’s easy to convince care givers that it’s important.
- Having access to a person skilled in extracting and synthesizing information from the EMR is a huge benefit for a performance improvement project.
- Staff education is a never-ending need. While it is not sufficient to sustain improvements, it is important.
- The project was successful enough to want to extend to Regions Hospital. This extension will require additional work to make sure the solutions fit the new environment.
Finding patients who are not in their room can be a challenge. In 2017, an Epic EMR project will be to develop a way to tell where each patient is. This will benefit all areas of the hospital as well as helping find patients who need their PD medications.