S5E3: Parkinson’s Disease Quality Improvement Projects - Trainee Focus Bonus
Joining us on our Parkinson’s Disease bonus episode this month, EM trainees Henrietta Sabbagha and Gideon-Phil Meyer speak to Conor O’Gara about their Parkinson’s disease (PD) Quality Improvement Projects (QIP) they have supervised in Irish hospitals. We learn about their excellent audits to try and improve PD care in their emergency departments and pick up transferable tips for how to do so across the country. We run through their projects, discuss the highs and the lows, and we take home some hot tips to bring forward for our own QIP projects!
Listen now on Spotify or wherever you get your podcasts, and as always, be sure to follow along on Bluesky, Instagram, Facebook and X to keep updated with all things TCR.
You can download our infographics here:
Right then, let’s get to it!
Overview of the projects
Henrietta
Henrietta’s project was motivated by witnessing PD patients coming through the ED and the adverse events that could occur if they were to miss their medications.
Alongside the fantastic local pharmacy department, Henrietta carried out education sessions with nursing and medical staff and focused on maintaining a PD specific medication drawer in the treatment room in a busy ED.
The medication drawer was to aid nurses in accessing the medications and provide guidance to the administration of PD specific medication. Alongside this, highlighting PD patients from triage with the use of a sticker was audited.
Gideon
Gideon’s project was not dissimilar to Henrietta’s. Taking motivation from the “Get It On Time” campaign created by Parkinson’s UK, originally in 2006, Gideon’s project aimed to target several concepts noted in the ED.
Firstly, there was a lack of familiarity with the concept of how time critical PD medications were. The aim of this project was to rectify this - to ensure PD patients got their medications within 30 minutes of their designated due timings, and also to identify barriers and enablers to the safe and timely administration of PD medications.
Primary End-Points
Gideon
Time to triage
If PD patients were identified at triage
If this was denoted by a yellow sticker at the front of the chart
How long it took for patients to get their medications
Henrietta
Did PD patients get their medications on time? (within 30 minutes of their due time)
If not, how long were they delayed or were they missed altogether?
Provisional Results of Initial Audit
Gideon
40% of audited PD patients did not get the yellow stickers at triage.
50% of those patients did not get their medications on time.
Henrietta
69% of patients identified with PD were admitted to hospital from ED
1 in 4 of this cohort died during their admissions
Of the patients who died while in hospital, 60% had missed medications in ED**
**Not inferring causality but highlighting potential existing relationships and adverse outcomes associated with not getting PD medications on time
Learning points
Gideon
Gideon spoke about the individualised approach that is needed for caring for PD patients, and specifically their medication times. Impossible to fit into the usual “TDS or QDS”, Gideon highlighted the usefulness of the yellow sticker as an aide-mémoire to trigger unusual medication times and to ascertain when each patient individually required medication administration.
In addition to the stickers, Gideon spoke about posters and e-posters available to patients in the waiting room of the ED to encourage patients and caregivers of those living with PD to highlight to the triage nurses that they do in fact, have PD and will require medications.
Henrietta
The specific medication drawer:
Henrietta spoke about the specific PD medication drawer that was set up in the ED by the ED-specific pharmacist. From their experience doing medication reconciliation within the ED, it became apparent that a clear system for the medications and their substitutes was necessary. A drawer was created where medications were organised by category and a QR code was easily accessible for information on substituting po meds → transcutaneous patches. Super handy!
This was the topic of this month’s main case where we had a chat about the NPO Parkinson’s Disease patient and converting PO meds to NG/rotigotine patch which you can listen to here.
Re-audit
Reauditing is critical. It is important to corroborate, or indeed identify changes versus your original data with subsequent rounds of audit - strengthening and creating a robust dataset.
Gideon
At one year:
20% increase in amount of stickers being used
5% increase in PD prescriptions
16% increase in medications being given following the prescriptions
33% increase in medications being given within 30 minutes of their due administration time
100% increase in medication being given within 30 → 60 minutes of their due administration time
Henrietta
At three months:
Illuminating the importance of having a single robust factor measured throughout the quality improvement initiative, the Plan, Do, Check, Act (PDCA) method is referenced throughout Henrietta’s project. This Quality cycle can offer a structured framework to QIP’s.
For this specific project, an astounding 41-70% increase in medication compliance within 30 minutes was noted highlighting a significant improvement. Anecdotally, Henrietta also noted that walking around the ED, she felt there was more awareness and healthcare staff were making an effort to make a difference to PD care.
The yellow stickers were also made into yellow magnets for the main nursing station whiteboard to make it known to all healthcare staff (healthcare assistants, nursing staff, clinical nurse managers, NCHD’s, consultants, household staff, porters) that these patients are a priority and they may be a falls risk / require specific medication.
QI Plan & Action
Following the audits, both Henrietta and Gideon spoke about ways to further enhance the projects. Henrietta aims to identify a champion in the area to keep the motivation and project alive, run through a third wave of the audit and also carry out more education sessions for staff. Gideon echoed Henrietta’s sentiment of the champion and proposed the idea of a change leader or a champion across all groups of stakeholders (CNM’s, nurses, consultants, NCHD’s) to enable cultural change together. An expansion of this might also include grouping time critical medications together (antibiotics in sepsis, insulin, anticoagulation, PD medications) and highlighting this group more in the future. Gideon emphasised patient and public involvement in the project also - involving patient’s, their caregivers and understanding their experiences and barriers of the project.
Take-home points
“A one man show never works”
Gideon
Stakeholders want to know why it’s important they get involved, how it impacts their work and how their contribution plays a part
Change leaders are critical from the get go!
Keep it simple! The tendency to overcomplicate is real
Define the project
Define the idea
Get your team involved
RCEM have a very useful QIP framework that is available to use, use it!
Henrietta
Involving change leaders from the root up would help more
Including other stakeholders from the beginning
Enabling others to own it with her and not just contribute
Choose a topic for a QIP that you’re really passionate about, because you’re going to spend a lot of time at it!
Measurable outcomes are really important, make them transferable!
“ A QIP … If you’re passionate about it, it’s infectious to the people that you’re working with … If they see your passion they are going to try and follow you …Everyone is striving for excellence”
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Main case:
Dr Conor O’Gara (Interviewer)
Dr Henrietta Sabbagha
Dr Gideon-Phil Meyer
TCR Innovation Team-Show notes / infographics / website design / social media
Ms Sinéad Kelly
Dr Johnny Collins
Dr Genevieve Callander
Dr Liam Loughrey
