Parkinson disease (PD) is a progressive neurological disorder that affects approximately 1% of the population. Patients with PD develop both motor and nonmotor symptoms. Motor symptoms are characterized by rigidity, slowness of movement, and tremor as well as difficulty with gait and balance. Nonmotor symptoms can encompass sleep, speech, swallowing, cognitive, and emotional problems. Parkinson disease develops as dopamine production in the brain is depleted, although other neurotransmitters are also affected.1 The mainstay of treatment of PD has been medication to compensate for the lack of dopamine. Different classes of medication either replace dopamine, inhibit breakdown of dopamine, or mimic the effects of dopamine. Patients with PD initially respond well to medications. Over time, medication doses and frequency may have to be increased with more complicated regimens as motor fluctuations and dyskinesias develop. In the more advanced stages, patients require significant effort in the outpatient setting to maximize “ON” time without side effects. Often, this results in complex regimens that require strict adherence.
When patients with PD are hospitalized, their medication regimen may be overlooked because most enter the hospital for non–PD-related issues.2,3 This can result in detrimental effects. Up to 75% of patients with PD admitted to the hospital miss medications, and of these, more than 60% develop hospital-related complications including worsening confusion, dysphasia, and falls, which can prolong length of stay.2,3 Other factors compounding the lack of adherence to medication regimen include unavailability of medications in hospital formularies as well as use of common medications with relative contraindications in PD. As such, the Parkinson's Foundation has been advocating for greater attention to medication management in the hospital.4
The Joint Commission Disease-Specific Care Certification
Disease-specific care (DSC) certification from the Joint Commission for the accreditation of hospitals (Joint Commission on Accreditation of Healthcare Organizations) has been used to develop a systematic approach to the care of specific inpatient populations.5,6 This certification demonstrates a commitment to patient care and safety, which is transparent to the public and can improve quality of care.7–12 Although the Joint Commission offers advanced disease-specific certification in 14 predetermined areas, hospitals and other healthcare facilities can seek DSC certification for the care of patients in virtually any chronic disorder.13
At Hackensack University Medical Center, a large tertiary referral center with 775 beds, a pediatric hospital, a level 2 trauma center, and a large cancer center, 24 programs have been certified by the Joint Commission. The purpose of this quality improvement project was to formalize our efforts to improve the care of patients with PD admitted to the hospital by using the DSC certification pathway as an established route for tracking selected quality measures with continued assessments of the program.
The process of application for DSC is described in the “Disease-Specific Care Certification Guide,”13 which describes 3 key elements for developing a DSC. These elements are (1) compliance with 28 national standards that include standards for program and clinical information management, standards for delivery of care, and those for assessing and improving performance measures; (2) integration of clinical practice guidelines with the program to improve care; and (3) a collection and analysis structure to track performance measurement data, identify variances, and develop plans to mitigate these findings.
The application to the Joint Commission requires the design of a performance improvement plan, the selection of clinical practice guidelines, and the defining of measures or data to be collected. One year of collected data are then included in the ongoing application process and submitted before the survey.
Several authors have reported their specific programs' improvement of quality of care and outcomes for patient populations included in the program and their efforts in achieving DSC certification.6,12,14–16 Here, we report our experience of completing this process in receiving DSC certification for PD as the first acute care hospital to receive such certification. This may serve as a guide for other institutions seeking to develop this pathway. Table 1 summarizes the timeline for our program.
Our organization uses the Plan-Do-Study-Act (PDSA) improvement model, and this model was used as the structure to gain DSC certification. The PDSA is an approach to continuous process improvement and is used across industry for testing and implementing improvement.17 In the following sections, we describe the steps in achieving our DSC certification using the PDSA format.
The Plan Phase: Defining the Problem, Assembling the Team, and Performance Measure Selection
The Plan phase of the PDSA cycle begins with the development of a thorough understanding of the problem. The organization of a team, research of best practices, analysis of the gaps in current care processes, and development of actions to address these failures complete the Plan phase.
Defining the Problem
Delays in administration of PD medication of even 30 minutes or less or the administration of contraindicated medications can complicate hospitalization of patients with PD.2,3,18 Targeting these gaps at our institution required initially identifying inpatients with PD. Because most such patients come to the hospital for non–PD-related issues,2,3 identification based on a primary diagnosis of PD alone would be inadequate. With the help of our IT team, we developed a report that identifies any patient with a primary or nonprimary diagnosis of PD. Once a patient with PD is admitted to the hospital, regardless of the admitting diagnosis, the team caring for the patient is alerted to the diagnosis of PD, and a care plan is triggered. The care plan includes items covered in the extensive educational modules that have been made available to the staff and can serve as a reference point for a nursing team that is actively taking care of a patient with PD.
Assembling the Team
Initially, the core PD team included a lead physician and a lead nurse practitioner as well as a member of the Quality Improvement Department. As the scope and goals were better defined, and the clinical practice guidelines were curated, the team expanded to include other stakeholders. The involvement throughout the hospital is both a testament to the commitment to the better care of patients with PD and an assurance that the program has the components to be successful.
This team was then tasked with selecting performance measures, educating staff, developing strategies for tracking these measures, and creating action plans to address variances. The team physicians represent the departments of neurosurgery, anesthesia, and neurology, with the lead physician being a neurosurgeon. The nursing component is led by the neurosurgical advanced practice nurse. The full team is described in Table 2.
Although currently there are no defined clinical practice guidelines, there is ample evidence in the literature that deviation from or delays of medication schedules, substitution of alternative medications, or administration of contraindicated medications increases the risk of hospital-related complications and of longer lengths of stay.2,3,18–28 This point has been further highlighted by a Parkinson's Foundation campaign to ensure timely administration of medications to patients admitted to the hospital.4 The DSC process seeks to develop an evidence-based monitored program, with measures to improve the care of a specific patient population. Our selection of these measures or metrics was informed by published data, our own experience, and the campaign of the Parkinson's Foundation.4 The committee identified a list of possible measures and reduced it to the following that are most congruous to the clinical practice guidelines.
“Custom” Ordering of PD Medications
The goal is to ensure that patients with PD admitted to the hospital receive their medications just as they would at home. These medications are often not on a standard schedule and have been refined with much effort. A patient who takes carbidopa/levodopa 5 times daily may take it at 6:00 AM, 9:00 AM, 12:00 PM, 3:00 PM, and 9:00 PM. Once in the hospital, if the medications are ordered 5 times daily, the usual default will be different (5× daily defaults to 6:00 AM, 10:00 AM, 2:00 PM, 6:00 PM, and 8:00 PM) from the patients' home schedule. Even delays less than 30 minutes can have a detrimental effect. This measure assesses all orders for PD medications to determine how many were placed in a custom fashion.
Avoidance of Contraindicated Medications
Patients with PD who receive contraindicated medication are negatively impacted. Our goal with this measure was to reduce these occurrences. We evaluate all patients with PD in the hospital during each review cycle to determine which ones had orders for medications that were contraindicated.
Mobility After Deep Brain Stimulation Surgery
Early mobilization is important for any hospitalized patient, particularly after surgery,29,30 and also for procedures such as deep brain stimulation (DBS). Our aim was to ensure patients are mobilized as soon as safely possible after DBS. Delays in mobilization result from omission of the orders, lack of therapists, or patient readiness. We sought to overcome these issues by requiring post-DBS patients to be mobilized within 6 hours of the order placed, to remind the care team of the importance of mobilization. For this measure, all patients undergoing the DBS procedure were assessed to determine how many had early mobilization.
Patient and Family Satisfaction With Medication Management
This measure recognizes patients and caregivers as stakeholders and gives them a venue to express concerns and suggestions. Here, we measure their satisfaction or lack thereof with how they received their medications in the hospital. A random sampling of both surgical and medical patients is evaluated to assess this measure. Once the four quality measures were established, the team progressed to planning improvement interventions or the “Do” portion of PDSA.
The “Do” Phase: Patient Data Collection
We track patients with PD in the hospital in several ways: A daily list of inpatients with PD is generated through EPIC, our electronic health record (EHR) system. A PD patient dashboard generates a report based on discharges with a primary or nonprimary diagnosis of PD. The DBS schedule for surgical patients is also reviewed for patient identification.
Performance measures are evaluated on a “real-time” basis. The daily list of patients with PD admitted to the hospital is reviewed, and patients' charts are evaluated for the performance measures by the lead advanced practice nurse as well as the transitions-of-care pharmacists, whose role is to address medication-related issues in the hospital to help minimize medication errors.31 The data are validated by having a second team member review a sample of the charts to ensure accuracy.
The “Study” Phase: Data Review
During the monthly DSC meeting with all stakeholders present, the data are reviewed and analyzed, variations are discussed, and action plans for the correction of variances are developed. Smaller work groups are developed on an “as-needed” basis. Patient care staff are educated on the results of the data and action plans. This multidisciplinary team meets regularly to review data and to develop actions for addressing underperforming measures. The effectiveness of the planned interventions is also regularly reviewed using the PDSA format.32 The measures, outcomes, and action plans are then reported to the neurosurgical quality council on a quarterly basis, which in turn reports annually to the hospital-wide performance improvement council.
The “Act” Phase: Action Plans
If chart reviews reveal variances in the performance measures, the care team is informed and will seek to mitigate issues if the patients are still in the hospital. Variances are recorded as such via a variance collection tool. Follow-up emails are sent, and further meetings are arranged as needed.
The DSC team then reports data on a quarterly basis to the neurosurgical quality council and annually to the Performance Improvement Coordinating Committee. The phases of the PDSA as well as our collection tool and reporting are summarized in Supplemental Digital Content 1 (available at http://links.lww.com/JNN/A191).
Other Critical Components of the Program
Education and Staff Awareness
While we developed performance measures, we also used several resources to educate our staff. Our efforts were informed by clinical practice guidelines, our own experience, and the campaign of the Parkinson's Foundation. Unit-based PD nurse champions served as liaisons between the DSC committee and staff nurses. We displayed posters in medication dispensing areas that delineated PD medications, the importance of on-time administration, and a list of contraindicated medications. Nursing grand rounds and other lectures and unit-based in-services were another crucial component of our efforts, as was a webinar regarding PD disease and the timely drug administration and avoidance of contraindicated medications, as well as the “Parkinson's care plan” available to all nursing through EPIC. Educational sessions were also arranged for the pharmacy.
We then directly targeted nurse managers, nurse directors/leaders, education specialists, nurse educators, Magnet champions, and unit-based council chairs who in turn would reach out to the staff nurses. We also directly reached out to staff nurses by doing walking rounds.
Patient education and continued education is also a crucial component: A registered nurse–executed care plan was developed in the EHR to be triggered for use in each patient with a PD diagnosis (Supplemental Digital Content 2, available at http://links.lww.com/JNN/A192).
Performance Improvement Structure
The Hackensack Meridian Health Hospitals Corporation overseas the Hackensack Meridian Health Quality and Safety Committee, which in turn oversees the performance improvement coordinating committee. The PD DSC team reports to the Neurosurgery Quality Council. All quality councils (behavioral health, OB, GYN, children's hospital, critical care, emergency and trauma center, internal medicine, heart and vascular, oncology, department of surgery, orthopedic surgery, neurosurgery, perioperative services, urology, and geriatrics) report to the performance improvement coordinating committee.
The role of our pharmacy in this endeavor cannot be overemphasized, because 3 of 4 performance measures in this DSC are medication related. Members of the pharmacy are critical team players in the multidisciplinary group, and the role of the transitions-of-care pharmacists has been important in identifying patients whose medications are not ordered in a custom fashion and in correcting those errors. In addition, their willingness to include most PD medications on formulary has been an essential factor in ensuring timeliness in the administration of the correct medications.
Role of Information Technology
Electronic health records can be powerful tools in streamlining the care of patient populations, with order sets, best practice recommendations, medication interactions, and so forth. The challenge for the PD patient population however is that more than 85% enter the hospital for non–PD-related conditions.2,33 With the support of our IT department, our target population, that is, every patient admitted to the hospital who carries a primary or nonprimary diagnosis of PD (ICD-10 G20), is identified. In this way, the team involved in caring for this patient who have been educated regarding the performance measures can recognize the need for addressing these issues regardless of the reason for admission.
In addition, the IT team has developed a report for the Parkinson's team where the daily census and location of patients with PD throughout the hospital can be accessed.
Provision of high-quality care has become an increasing concern for hospitals and physicians. Disease-specific care certification programs have allowed many hospitals to ensure better adherence to established standards and guidelines. This in turn has been demonstrated to improve quality.6,14–16 Other factors may also motivate a hospital's decision to achieve DSC,11 such as a desire for recognition or compliance with Centers for Medicare & Medicaid Services requirements.5,11
Hospital systems can identify DSC programs established elsewhere, to serve as guides for their own. That previously there has not been an acute hospital-based program for PD reflects the nature and variety of challenges in reigning in the gaps of care in this particular patient population. The challenges include the relatively small number of patients with PD admitted to the hospital and the difficulty addressing a heterogeneous population based on their nonprimary diagnoses. In addition, the consequences of delayed medication administration or of contraindicated medications may be underappreciated.2 This is compounded by the unavailability of all PD medications on hospital formularies and the identification of patients because they often enter the hospital for non–PD-related complaints. Other obstacles are default medication ordering schedules in EHRs, which make placing custom orders more laborious, and the inability to place all patients with PD in one specialized unit. Because these challenges span across departments and units, it is important to bring a varied range of stakeholders to the table to address these diverse issues and to ensure success of the program. The diversity of membership of the team illustrates this well.
We considered the DSC certification program an excellent vehicle for achieving improvement of the care of patients with PD admitted to the hospital. The DSC certification application provides a step-by-step approach to identifying the population and its risks, developing an interprofessional team, identifying evidence-based and meaningful performance measures, assessing these on consistent and frequent timelines, identifying variances, and then developing plans to address such variance.
Although the product of our interdisciplinary efforts is the achievement of DSC certification, the actuator of these efforts is still the bedside nurse. It is the bedside nurse who interacts directly with the patients, dispenses medications, and cares for this population. Our protocol is aimed to provide the framework of best practice for the care of this patient population and gives the bedside nurses the tools to best carry this out. The ultimate success depends directly on the efforts of nurses who are directly involved in the care of this patient population. In addition to the direct patient care role that nursing plays, most of the interdisciplinary DSC teams are nurses or have nursing backgrounds. It is needless to say this effort has relied heavily on nursing involvement from its inception to the daily routines of patient care.
Through the certification journey, we have been able to assemble a group of stakeholders with a common goal. We have already seen improvement in our tracked measures, although long-term benefits remain to be ascertained. To our knowledge, this is the first DSC for PD in the acute inpatient hospital setting. By outlining our journey, we hope to offer some guidance to other hospital systems interested in this patient population.
Disease-specific care certification from the Joint Commission offers a systematic and established platform and algorithm for a verifiable assessment of quality metrics for a specific patient population. It requires a commitment to continued improvement. We have used this platform to pursue our goal for improvement of the care of patients with PD. We hope this contribution can assist other hospitals interested in similar programs for PD patients with a detailed action plan.
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