HHE Emergency and critical care 2019 | Page 20

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