alternative measures to allow symptom control.
Deterioration was not detected in these patients
whilst in the department. These early
deteriorations in PD symptoms which were
excluded by previous studies may play important
roles in preventing hospital admission, and as
this study was not designed to assess this, further
work might be required.
Length of inpatient stay
No conclusive effect was observed in regards to a
reduction in inpatient stay in this study. A visual
trend was observed where a higher percentage of
dose omissions were observed in patients who
were admitted for longer, though no statistical
significance can be determined from these
results.
Furthermore, no particular relationship was
observed between more co-morbidities and
increased length of stay. There was a noted
potential relationship between increased age and
longer length of stay, with a higher percentage of
patients over the age of 70 requiring inpatient
stays of over seven days.
A recent study 18 found that a specialist PD unit
within secondary care reduced APM omissions,
increased timely administration and, importantly,
demonstrated a reduced length of stay compared
with other non-specialist ward areas. The specific
effect of the number of dose omissions on the
total length of stay was also explored in another
hospital 19 finding a significant increase in length
of stay in patients who had a delay or missed at
least one APM dose. These studies demonstrate
potentially drastic implications on patient safety
in secondary care, as well as financially in terms
of reduced admissions lengths and flow through
hospitals.
A recent larger scale study 20 was conducted to
determine the effect of delayed administration of
APM on total length of stay. Ultimately the study
did not demonstrate a statistically significant
relationship between dose omissions and length
of stay. Despite the lack of an association, the
authors were keen to highlight that dose
omissions were still detrimental to the best
patient care. It was notable, however, that all
studies included inpatient areas only and made
no analysis of patient’s assessment and stay
within EDs. A short retrospective audit 17
examined APM omission and found 76% of
patients experienced delays or omissions during
attendances to the ED. An important and highly
relevant discussion point from this study was
raised around how poor medicines reconciliation
early in the patient’s journey in ED has the
potential to cause extended inpatient stays and
poorer outcomes. Very little literature is available
exploring this effect.
APM vs other time critical medications
Prompt identification of patients suffering from
PD and requiring continuation of their therapies
was identified as a key limiting factor in
preventing dose omissions. Compared with other
time critical medications explored in our previous
analysis, 15 APMs have relatively few clinically
justifiable acute contraindications to their use.
This differs considerably from insulin or
anticoagulants, for example, where the diagnostic
process within the ED can require specialist
20
HHE 2019 | hospitalhealthcare.com
clinical consideration and potentially be more
clinically justifiable to temporarily suspend
treatments.
This may partly explain how pharmacists
might have such a high impact in these patients
within the ED, considering the main adjustment
to therapies made acutely were to convert
formulations in light of swallowing difficulties or
convert to dopamine agonist patches because of
the clinical decision for a patient to be kept nil by
mouth. Both of these interventions are typically
regarded as requiring specialist clinical
pharmacist input, which was not only readily
available in this case, but actively provided and
prioritised.
Limitations
The methodology of this study has several
limitations, the key being the relatively small
sample size. This sample size does not provide
enough data points to generate statistical power
to prove a hypothesis, and thus this study was
described as hypothesis generating.
Data gathering by free text keyword search
may exclude a population of patients who had not
been documented as having PD, and thus patients
identified may be an underestimation.
Furthermore, the methodology in this study
assumed no documentation as an omission,
whereas patients might have actually taken their
own medication while in the department. Equally,
when doses were signed administered, these were
assumed to be given on time, where poor practice
of not documenting the time administered might
have changed these occasions into delays.
Information around the severity of the
presenting complaint was not taken into account,
because the spectrum of the acute presenting