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Parkinson's Outreach Service

Case study arrowOne person in every 500 has Parkinson's disease which is about 127,000 people in the UK. Most develop symptons at over 50 years of age but 1 in 20 develop their first symptoms at under 40.

Parkinson's disease is a progressive, neurological condition with core motor symptoms of bradykinesia (slowness of movement), rigidity (stiffness), tremor and postural instability. Non-motor symptoms such as anxiety, depression, sleep problems and fatigue co-exist with the motor symptoms. As the condition progresses, patients are more likely to experience motor fluctuations whereby they may be able to move around with ease at one point in the day, but be unable to function well at other times. Lack of knowledge of this phenomenon can lead to untrained staff misinterpreting this as intentional behaviour.

Studies have shown that patients with Parkinson's who are admitted to hospital are likely to have a longer length of stay than non-Parkinson's patients. A small Derby-based study examining outcomes for Parkinson's in-patients on a specialised Parkinson's ward compared to care on a general elderly care ward showed reduced length of stay, reduced medication delays and improved patient satisfaction. Parkinson's medication is often missed or given at the wrong time on wards, and omission can lead to immobility, and rarely, the potentially fatal neuroleptic malignant syndrome.

Parkinson's specialist therapists (a physiotherapist and occupational therapist) who are currently based in a specialist off-site Parkinson's outpatient service, are providing 2 half days on the Acute Trust wards, to provide outreach to Parkinson's patients. We set up an email alert system which flags known Parkinson's patients to the Parkinson's therapists who then check the electronic prescribing and medicines administration system to ensure medication is being given on time, before visiting on the ward. Ward staff can also contact the team directly to request advice and assistance. The ward staff are then able to liase with ward staff, including generic therapists, to offer support, training and joint therapy sessions wth the ultimate aim being to shorten length of stay and improve patient outcomes and satisfaction, as well as educate ward staff in management of Parkinson's, thus potentially improving the general standard of care and patient experience for the future.

For some cases nil-by mouth management has been necessary (e.g. swallowing problems) leading to them being unable to take oral medications. This can lead to motor complications and futher exacerbate swallowing difficulties, so it vital that alternative medications, delivered by patches, or naso-gastric tubes, are administered. The team have developed an algorythm to convert oral medication to equivalent patch or nasogastric dose delivery, which is available on the hospital intranet. The therapists are able to signpost ward staff to this information and provide further advice.

The therapists act as advocates for patients and carers whilst they are in-patients, aiming to ensure best quality inpatient stay and timely discharge. Providing timely information and education of these issues for staff caring for individual patients can improve quality of care for that individual and, potentially, reduce length of stay. Some discharges are delayed due to lack of understanding of non-motor Parkinson's symptoms and the therapists have been able to facilitate more timely discharge, as well as better management of the symptoms.

Unique selling point

The therapy angle of education is fairly innovative. It ensures gold standard Parkinson's care for patients as soon after admission as possible. It provides an advocate for the patient to access best care for the patients, and shorten length of stay. Many services may have Outreach whereby a neurologist or Parkinson's Specialist Nurse will visit a ward on request by ward staff, and there is an outreach service in Exeter which includes therapy intervention. Our service involves therapists being proactive in seeking out Parkinson's patients, and service improvement by educating staff. It provides access to the specialist therapy skills for both patients and staff, providing training and education particularly in areas where the staff may not be familiar with Parkinson's management.

Patient population

Parkinson's is the second most common neurodegenerative condition and affects around 127,000 people in the UK. When patients with Parkinson's are admitted to hospital they stay longer and are more likely then others to die in hospital. The cost of unplanned Parkinson's admission is in the region of £3,300.

Royal Derby Hospital is a busy 1100 bed teaching hospital linked to the University of Nottingham. It has a catchment population is about 500,000. There are around 700 Parkinson's admission per year. While most of these admissions are for reasons unrelated to Parkinson's, suboptimal management of co-morbid Parkinson's can lead to complications linked to reduced mobility and to slower recovery.

In particular, some people with Parkinsons's are sensitive to the timing of their medication and experience uncomfortable "off" periods when they are unable to move if their medication is omitted or delayed. It is important for staff to realise that Parkinson's patients abilities can fluctuate and to be familiar with golden rules of Parkinson's rehabilitation: "big and loud" ideation for movement and speech, doing only one thing at a time (walking and talking reduces quality of gait and increases the chance of freezing of gait and falling), and making use of external prompts. It is unrealistic to expect all staff on general wards to be expert in Parkinson's care when Parkinson's patients may account for a relatively small proportion of the cases they see.

For this reason we piloted a specialist Parkinson's unit on one of the elderly care wards (Skelly R, et al. Parkinsonism Relat Disord. 2014 Nov; 20(11); 1242-1247). Although patients had more medication on time, better experience of care and shorter length of stay, many patients missed out because of limited bed availability or because they needed specialist expertise on another ward (e.g. Trauma ward). We hoped the introduction of a roving outreach team would help meet the needs of some of these patients. We hope to see less omitted Parkinson's medication given on time, better informed and more confident staff, adherence to golden rules in Parkinson's rehabilitation and short length of stay.

Using staff from the outpatient Parkinson's multidisciplinary team as part of our roving team has obvious additional advantages: prior knowledge of particular patients' physical and cognitive function and social situation, and easy access to other Parkinson's specialists.

Improving patient outcomes

Improves quality of care by providing and improving staff education and awareness of Parkinson's therefore improving medication management, patient experience, shortening length of stay/more timely discharge also resulting in financial benefits for the Trust. The therapists also ensure that future follow-up for Parkinson's management is in place. This may be able to reduce the possibility of re-admission. Our innovation can improve quality of care by providing specialist Parkinson's services to the wards to advise on management of the patient with Parkinson's. We can ensure that the staff are aware of, and where necessary, implementing the nil-by-mouth algorythm to convert oral Parkinson's medication to 24 hour patches. The therapists can provide a printed algorythm and also ask the Parkinson's Consultant or Parkinson's Specialist Nurse to visit the ward to provide further support.

System/cost benefits to the NHS

Our innovation can improve quality of care, reduce length of stay costs, and improve patient outcomes and satisfaction. The cost per unplanned Parkinson's admission is in the region of £3,300. The costs of delivering the current service is approximately £170 (the cost of two Band 7 therapists for half a day each) per week.

Evidence

The intial pilot 6 month period has just been completed and data is still being collated. From May to September 2015, there were 138 email alerts for patients with Parkinson's who presented at Accident and Emergency Department or were admitted to the Royal Derby Hospital. The specialist therapists saw 48 of these, but also advised and/or treated a further 75 patients who were referred by ward staff or the Parkinson's Specialist Nurse, making a total of 103 patients seen over 30 sessions (there were some weeks where either one or both therapists were on annual leave so no sessions were covered), patients were seen on 25 wards. Nine patients had more than one admission, with 1 patient being admitted 4 times during the 6 month period for orthopedic-related issues.

The therapists delivered training and advice to ward staff on 30 seperate occaisons, 19 of which were to nurses and doctors regarding the importance of Parkinson's patients getting medication on time and the possible implications of missing medication. For example, on one occasion a patient had been given 2 doses of medication at 10pm instead of seperating them by 4-6 hours and the patient was confused and at risk of falling. The therapist liaised with the Parkinson's nurse and was able to advise the ward on correct dosing which resulted in the patient being less confused and his mobility improved.

Training and joint therapy sessions were also given to the ward occupational therapists and physiotherapists on management of Parkinson's including cues and strategies to manage fluctuations in the patients mobility and prevention of falls. The therapists were able to facilitate discharges on 3 occasions where ward staff were intending to keep the patient on the ward longer partly due to misunderstanding of the impact of Parkinson's non-motor symptoms such as anxiety and low mood. One of these patients was displaying anxiety symptoms but the ward therapy staff did not understand that this was part of her condition and were concerned about sending the patient home in this state. The Specialist Occupation Therapist was able to explain and advise that the patient's symptoms were exaccerbated by being an in-patient, and this facilitated a sooner discharge.

Obstacles

One barrier is funding for more sessions on the wards with back-up staffing to cover the outpatient service while the Specialist Therapists are on the wards. We also need more support and help in data collection and analysis to ensure that we are collecting and collating the right data.

Small arrow PROJECT CONTACT

Contact Name Fiona Lindop Email address fiona.lindop@nhs.net



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