The aim of this article is to reflect on the role of the Parkinson's nurse specialist (PNS) with a non-medical prescribing (NMP) qualification, and its impact on people with Parkinson's (PWP) when admitted to hospital in terms of their experience and outcomes. This is based on an evaluation that was undertaken to improve hospital care for patients with Parkinson's.
Non-medical prescribing
In July 2000 the Department of Health (DH, 2000) published the NHS Plan. This included strategies to develop traditional roles, allowing nurses opportunities to evolve and challenge boundaries in their career in ways that had not been accepted before. The development of independent NMP was one of the strategies created to do this. For nurses, the introduction of NMP has encouraged autonomous practice within a structured national framework. This can enhance patient care, improve the patient journey, and provide support to other healthcare professionals. Courtenay (2010) highlights the anticipated benefits of NMP, including improved accessibility and choice in accessing medications, improvements to patient care, and a greater use of health professionals' skills (Bradley and Nolan, 2007; Carey et al, 2010)
Consequently, nurses with a NMP qualification can enhance care for patients with long-term conditions such as Parkinson's, by using expert knowledge of treatments as well as monitor and manage medications (Raymond, 2006).
Overview of Parkinson's
Parkinson's disease is a progressive neurodegenerative condition. It is estimated that 145 000 people are living with Parkinson's in the UK, which is expected to rise to 168 582 by 2025 (Parkinson's UK, 2018). This has implications for healthcare services due to the anticipated increased needs for institutional care (Whetten-Goldstein et al, 1997; Hagell et al, 2002; Vossius et al, 2010).
Parkinson's is a complex condition due to it being an umbrella of illnesses affecting several body systems. There is currently no cure, but medication is prescribed to manage symptoms.
Traditionally, the motor symptoms of Parkinson's were discussed and managed, these include tremors, rigidity and bradykinesia (Rahman et al, 2008). However, there is increasing recognition of non-motor symptoms and the negative impact on quality of life (QOL) (Rahman et al, 2008; Heisters, 2011). The symptoms include difficultiy swallowing, constipation, anxiety and depression, as well as cognitive changes including hallucinations. Parkinson's generally progresses slowly; however, PWP can often experience huge disability and reduced QOL, if not managed effectively (Chapuis et al, 2005; Rahman et al, 2008).
Although there are symptoms typical of Parkinson's, the condition varies from person to person (Heisters, 2011); therefore, one person's trajectory will be very different to another. Subsequently, medication regimes are individualised, and over time, as the condition progresses, straightforward drug regimes can become complex due to managing motor symptoms (Magennis et al, 2014). For Parkinson's symptoms to be controlled, accurate medication concordance is required (Raymond, 2006).
Any disruption in concordance can cause an acute decline in Parkinson's symptoms, which will impact on recovery and rehabilitation. PWP have higher hospital admission rates than the general population (Low et al, 2015). Low et al (2015) recommend interventions to improve hospital care for PWP. The availability of a specialist healthcare professional has been previously argued by Raymond (2006), advocating the role of the PNS to support the management of the condition and medication during a hospital admission.
Parkinson's and the specialist nurse
The importance of the PNS was endorsed by guidelines for the management and treatment of Parkinson's disease published by The National Institute for Health and Clinical Guidance (NICE, 2006; Raymond, 2006). Furthermore, The Get it On Time campaign (Parkinson's UK, 2006), highlighted the importance of timely and accurate drug administration for PWP. This report focused on hospitals (as well as care homes), advising that PWP admitted to hospital often experience prolonged length of stay (LOS). The explanation offered for increased LOS included poor understanding of the condition by staff, along with errors with the complex medication regimes (Parkinson's UK, 2006). This is further documented by Gerlach et al (2011) who showed that PWP who are admitted to hospital often have a negative experience. This includes delayed, inaccurate drug prescription and administration, as well as a lack of knowledge of the contra-indicated medications (Martignoni et al, 2004; Antonini et al, 2008).
When PWP are admitted to hospital they will be experiencing other health issues such as an infection or other comorbidities this may result in a secondary deterioration in Parkinson's symptoms (Lieberman and McCall, 2003; Magennis and Corry, 2013). Accompanied with the change in environment and risk of medication errors, disability and reduced QOL is possible (Gerlach et al, 2011).
Despite the limited research on the management of this group of patients in a hospital setting (Woodford and Walker, 2005), there is evidence to suggest that PWP are more frequently admitted (Pressley et al, 2003; Guttman, 2003; Guttman et al, 2004; Gerlach et al, 2011), and experience prolonged LOS compared with controls (Huse et al, 2005; Woodford and Walker, 2005; Louis et al, 2007; Klein, 2009; Gerlach, 2011). Gerlach et al (2011) further suggest that theories have been offered to improve the management of PWP in the acute setting, however, limited research exists to support these concepts. In a systematic review to explore the care of PWP during hospital admissions, Gerlach et al (2011) recommends early consultation with a specialist in Parkinson's to work across the various specialities, to ensure accurate medication reconciliation that supports patients and staff.
Initial audit and changes
To examine the management of PWP in a district general hospital, an audit was undertaken. The following areas were examined; the average length of stay (LOS), delays with initial doses of medication being prescribed or administered, any contraindicated medications prescribed, and the number of patients assessed to self-medicate. The findings highlighted that the average LOS was 24 days, the first dose of Parkinson's medication was often delayed or missed, and contraindicated medications were prescribed. The audit highlighted areas for improvement and subsequently, the following changes were implemented:
- The development of a digital system to alert staff when PWP were admitted to hospital
- A hospital PNS to coordinate admissions, to provide an overview of medications and support patients and staff.
A further audit was undertaken after the changes were implemented and were fully operational.
Methods
A retrospective observational audit of medical notes of PWP who were admitted to hospital was undertaken. Medical notes along with prescription charts were examined of 31 consecutive patients who were admitted to hospital. The variables measured included LOS, delays in prescribing and administration of medications, contraindicated medications, and assessment to self-medicate.
31 patients were chosen in the initial audit as it was difficult to locate patients as this predated the digital alarm system. To illustrate comparable results the follow-up audit examined a further 31 patients.
After the second audit, a further audit was undertaken for the PNS annual report to evidence the effectiveness of this role for the trust. A random selection of 100 patients were taken from the 251 referrals made to the service to establish the average length of stay within this population.
Results
The audit revealed a 50% reduction in LOS (Table 1). There was a 24% increase in accurate prescriptions written and a 20% decrease in contra-indicated medications (Table 2). The initial audit highlighted a 60% delay in the first dose of Parkinson's medication being prescribed and administered; after the changes this had been reduced to 3%. The number of patients assessed to self-medicate had increased to 34%. This is illustrated in Table 2. Table 3 demonstrates the cost savings based on 30 patients for the three audits undertaken.
Table 1. length of stay comparison
| 2010 | 2014 | |
|---|---|---|
| Average LOS | 24 days | 12 days |
| Mean age | 79 | 77 |
| Readmission rate | 4 | 4 |
LOS: Length of stay
Table 2. Summary of findings
| 2010 | 2014 | |
|---|---|---|
| Medications reconciled within 24hrs | 40% | 81% |
| Accurate timings on drug chat | 73% | 97% |
| Delay in first dose | 60% | 3% |
| Contra-indicated medications | 27% | 10% |
| Assessed to self-medicate | 30% | 65% |
Table 3. Overview of costs
| 2010 (30 Pts) | 2014 (30 pts) | 2015 (100 pts) | |
|---|---|---|---|
| Average LOS | 24 days | 12 days | 9 days |
| Cost per patient | £9190.32 | £4595.16 | £3 446.37 |
| Total costs per 30 patients | £275 709.60 | £137 854.80 | £103 391.10 |
| Total Savings from 2014-2015 (based on 30 pts) | £310 173.30 |
LOS: Length of stay
Discussion
The results from this audit demonstrate how changes implemented at this NHS Trust have helped decrease LOS and reduce medication errors. The focus of this article was to examine the impact of the PNS on changes implemented.
Early identification of PWP allowed for review and liaison with specialist teams to ensure accurate reconciliation of medication to help prevent error during a hospital admission. This reinforces Gerlach's (2011) findings that an early review by a neurologist or specialist in Parkinson's can significantly improve outcomes for PWP when admitted to hospital. Further support is offered by Ortiz (2020) who found early identification of PWP admitted to hospital, by using a nurse navigator. This improved medication management, and bridged departmental and professional barriers, with accurate medication routines, identifying contraindicated medications, and identification of patients to self-medicate.
The initial audit results correspond with Parkinson's UK (2006) findings that PWP admitted to hospital encountered an inadequate experience. Explanations offered included; limited staff knowledge, medication errors and in turn increased LOS. The implementation of PNS has allowed for early assessment on admission involving medicine reconciliation as well as psychological support, for both the patient and carers. Lennaerts et al (2017) recommend a dedicated PNS to coordinate patient care across a range of service providers, as this allows focus on the patient's healthcare journey as well as their healthcare needs (Ortiz, 2020).
NMP has been beneficial in the implementation of this role as it allows the PNS to prescribe and titrate medications. The results also illustrate the beneficial cost implications. Lows et al (2015) recommend cost-effective interventions to reduce the burden of hospitalisation for patients carers and healthcare systems.
Muzerengi et al (2016) suggest that PWP care in hospital is often suboptimal, due to the primary cause of admission being the focus and disregard for Parkinson's management. This can be associated with poor patient outcomes and significant healthcare costs. Consequently, early identification of patients by a PNS has allowed for prompt assessment to ensure effective Parkinson's management, alongside the presenting medical or surgical condition.
Parkinson's nurse specialists in the hospital
Parkinson's UK funded a role for a PNS for 2 years; after this time the hospital took on the funding for this role. The findings from the audit demonstrated the cost savings. The aim was to improve a patient's journey when admitted to hospital and in turn, reduce LOS. Information from this audit has been useful in proving the worth of the PNS.
The role of the hospital-based PNS is relatively uncommon, as PNS are often located in the community setting. However, the publication of NICE (2006) guidelines and the Get it on Time campaign (Parkinson's UK, 2006) emphasised how this role would be beneficial for PWP when admitted to hospital. A comparable role to the hospital PNS is suggested by Ortiz (2020) of a nurse navigator, which demonstrated improvement in medication management and patient outcomes.
The audit findings provided evidence for a business case to employ a full-time PNS to work within the hospital setting. A secondary effect has allowed for the empowerment of other healthcare professionals with training days and ad hoc support when patients are admitted to hospital. The PNS has been involved in coordinating successful Parkinson's awareness days. This allows members of the Trust to attend a day focused on Parkinson's management, helping them to gain an understanding of this complex condition.
Aminoff et al (2011) endorse educational programmes to support interdisciplinary teams, as this improves outcomes for patients and generates cost savings. Staff from the ward can easily contact the Parkinson's team to carry out ad hoc training and get support with the various complex drug regimes.
Patients and relatives have provided informal feedback suggesting they feel more supported and have often met the PNS prior to admission and therefore feel comfortable with the medication regime, and the concept of the PNS supporting the ward staff.
Safety
Regular auditing was necessary to ensure that standards are being maintained. To ensure the PNS continues as a safe practitioner, professional development must be maintained. The Nursing and Midwifery Council (NMC) provide guidance and protection to support the practitioner to undertake appropriate and safe prescribing. The hospital trust also encourages regular CPD, with frequent updates supported by the NMP lead. To ensure that improvements have been made to practice, regular audits have helped identify what is happening in practice and its impact.
As a newly qualified prescriber, the multidisciplinary team (MDT) were essential to the development of a safe and effective service being implemented. The MDT for this service includes consultants, registrars, pharmacists and various therapists.
Bradley and Riley (2013), advocate MDT working, to promote confidence when working autonomously. This corresponds directly with the development of the PNS service.
Limitations
The reduction in LOS is based on all the changes that were made at this hospital. Therefore, the findings do not reflect the impact the PNS and NMP have had independently. In the future, it would be interesting to examine the unique impact of each of the measures introduced.
Future developments
It would be of interest to understand if other hospitals that have implemented similar changes have comparable results and look at whether there are findings from other studies that could be applied to this hospital.
It would also be useful to investigate whether an on-call system to manage patients when they are admitted out of hours would be beneficial. When reviewing the notes, many of the issues that occurred were out of hours. Also, these are the times when the patients reported not seeing a specialist.
Informal feedback from patients and relatives was received during clinic appointments and telephone consultations. Future projects involve producing a patient satisfaction questionnaire to gain more in-depth and qualitative data on perceptions of PWP in hospital.
Finally, to develop the MDT for the outreach ward rounds, having a physiotherapist or an occupational therapist when reviewing a patient may alter prescribing practice, to consider alternative strategies to manage symptoms alongside pharmacological treatments.
Conclusion
The implementation of the PNS with NMP has improved the outcomes for people with Parkinson's when admitted to hospital. Reducing the LOS has also demonstrated a cost-saving, which could be considered when recruiting specialist nurses. Whilst this is only one aspect of service development, it is recommended that it is considered when developing hospital services for PWP.