1. Improvement of Medical Management of Parkinson’s Disease in Inpatients Tom Stoker MA (hons.) MB B.chir MRCP(UK) Learning To Make a Difference

2. To increase the proportion of levodopa doses administered on time (no later than 30 minutes before or 30 minutes after scheduled time) to Parkinson’s disease patients admitted to care of the elderly wards, to 90% over a 6 month period Project Aim(s)

3. Process mapping Accurate drug history obtained, including dose and timing Patient registered onto electronic drug chart system Drug prescribed correctly on electronic drug chart Drug ordered from pharmacy / available on ward Nursing staff administer medication in timely manner

4. Driver Diagram Secondary DriversPrimary DriversObjective To increase the number of levodopa doses administered on time to Parkinson’s disease patients on care of the elderly wards Medical staff: Prescription Pharmacy: Drug supply Nursing staff: Administration Accurate drug history (patient, relatives, GP, clinic letters) Patient registered on electronic drug chart Medical team awareness of importance of administration time Drug stocked on ward / readily available from pharmacy (including out of hours) Drug-highlighted as time-critical on electronic dug chart Nursing staff awareness of importance of time of administration Nursing staff awareness of patients on the ward on levodopa (handover)

5. Collected data over 2 week periods Reviewed electronic drug charts of all patients on care of elderly wards Recorded time of administration for all doses of levodopa Interventions followed by further periods of data collection Procedures Awareness – Meetings with senior sisters on each ward Introduction of “get it on time” clocks Recommendations circulated to nursing and medical staff

6. Results Red = Doses given more than 30 minutes early / late Green = Doses given on time

7. What difference has been made? Modest improvement in proportion of levodopa doses being given on time Increased awareness of importance of administering these medications on time

8. Compliance – Unclear how consistently the clocks are being used The “difficult” patient Unable to access electronic drug chart at the time of administration Difficulty establishing the prescribed regimen at admission Staffing levels and handover processes Limitations

9. Next Steps Involvement of pharmacy team – Supply of common preparations on the wards to avoid missed doses due to lack of availability – Levodopa prescriptions to be automatically marked time critical – Pharmacists to be able to mark levodopa prescriptions as time critical Root cause analysis of doses consistently not given on time Educational sessions to medical team Alarms on each ward for dosing reminders Expansion of use of “get it on time” clocks to all wards

10. Team Members T. Stoker – Project lead (Core medical trainee 1) N. Al-Khudairi (Foundation year 1) V. Russell (Foundation year 1) J. Harvey (Consultant supervisor)