Improving the delivery of time critical medications at Bradford Teaching Hospitals NHS Foundation Trust

Bradford Teaching Hospitals NHS Foundation Trust is carrying out an improvement project to improve awareness and delivery of time critical medications for people with Parkinson’s. 

We spoke to Zoe Ridewood, Parkinson's Nurse Specialist, and Sophie Detraux, Pharmacy Lead for the Outstanding Pharmacy Services Programme, about the steps the team have taken and what they have learned from the project.

Why did you work to improve the delivery of time critical Parkinson’s medications for your patients?

Sophie: A person with Parkinson's was admitted to the acute medical unit and his wife expressed concerns to me, as the ward pharmacist, regarding Parkinson's medication that she felt was being given at the incorrect times.

We know that for people with Parkinson's not receiving their medicines on time can have a huge impact, potentially resulting in reduced mobility and swallowing, and leading to an increased hospital stay. I contacted Zoe, the Parkinson's nurse specialist, and we identified that we had to do something to improve care for people taking time critical medications, particularly in the acute medical unit, but also in the wider trust.

What have you done to improve the delivery of time critical Parkinson’s medications? 

Zoe: We worked with the person with Parkinson's and his wife who had expressed concerns. We implemented solutions at a ward level, providing Parkinson's clock posters, wash bags and education training sessions.  

We've also linked in with the local Parkinson's support groups to spread awareness of the resources and wash bags and encouraged patients to have a wash bag to take to hospital if they attend accident and emergency (A&E) or are admitted. Patients can put all their medication in the wash bag and it serves as a visual reminder for staff on the wards.

Sophie: We've also been looking at how Zoe and the pharmacy team can work together to implement the 10 recommendations from Parkinson's UK as a collaborative effort.

Read the 10 time critical medication recommendations for hospitals.

Can you tell us more about how you used electronic prescribing and medicines administration (ePMA)?

Sophie: The 10 recommendations for acute hospitals includes a recommendation that hospital systems, including electronic prescribing, should be maximised to support time delivery of critical medications. We started thinking about alerting the Parkinson's specialists when patients are admitted to hospital so that could receive a specialist Parkinson’s review.

Myself and Zoe were talking about how to do this and I linked in with the ePMA team to see if this could be done electronically. Our fantastic ePMA team have built a report that the Parkinson's nurses can run daily to identify the people who have been admitted to hospital on Parkinson's medications.

Zoe: So this has been really great, because getting alerts is something that Paddy, my fellow Parkinson's nurse, and I have wanted to look at for a long time but we hadn’t thought about how pharmacy could help. 

Having the ePMA report has allowed us to review people with Parkinson's medication remotely and provide specialist assistance and advice. It highlights missed doses, we can make sure timings are correct, make recommendations for any switches of medication and it allows us to work proactively rather than reactively. Now we run the report daily. 

We do get referrals from wards direct on the system to us but not every patient is referred. The report means that we can look and if a patient hasn't been referred already and we weren't aware that they were in, we can quickly go on the record and just check that their medication is all prescribed correctly.

We can work much more proactively and not wait for a problem to arise.

If we hadn't been working with Sophie we wouldn’t have known how to make this happen and we’d be getting a lot more calls from A&E. Post-pandemic patients spend longer in that department than they used to so they could be missing 2 or more doses of medication. Our thinking was that if we can get it right there, then that should carry on to the wards.

How did you work to educate your colleagues about time critical Parkinson’s medication?

Zoe: Our aim is that all staff who support and care for people with Parkinson's understand the importance of their time critical medication.

The Parkinson’s nurses linked with a senior nurse responsible for emergency unplanned care to get the Time Matters: It’s Critical educational video rolled out to all of the unplanned care wards and the care of the elderly ward. In total 5 wards have watched it, plus A&E staff and advanced care practitioners, that’s a total of 161 people. I think that's really positive and the message is getting over. Next, we plan to roll out to speciality medicine and then hopefully to planned care.

The Parkinson’s nurse team have been involved in delivering training for emergency department staff. They run what they call sweeper sessions, training sessions over a 3 to 4 month period to capture different staff and Paddy and I have been involved in attending those sessions. We've noticed a big difference there.

Sometimes patients don't need to be admitted. Perhaps they’ve had a fall while they were out shopping and missed their medication. So they come in, very tremulous, very symptomatic and we might advise that we give them their medication, a cup of tea and a sandwich, and let's just see how they are.

We try to get them home and then Paddy or I will contact them the day after by phone, visit them at home, or invite them to a clinic. We try to manage patients at home as it’s generally accepted, and research indicates, that it is the best place for them to be treated if their condition allows.

Sophie: We have organised a 'learning at lunch' training session with the pharmacy team. These sessions are meetings over lunch where colleagues come together to learn about a particular subject. They are a great way to capture a large number of colleagues at one time. Our colleagues also watched the video and received training from the Parkinson’s nurses.

Zoe: I did an education training session for the trust’s advanced care practitioners (ACPs) in December. The ACPs were from both unplanned and planned care and because this group of staff can legally prescribe medication it is very relevant to their roles. We talked about the importance of the medication and timing, what medication not to prescribe alongside Parkinson's medication, the importance of giving the medication at the right times and alternatives available for patients unable to swallow.

The feedback from the session was that they found it really beneficial. I think that we will repeat that and target the ACPs who didn't attend and anyone new in post.

Sophie: Zoe and I make sure that we use every interaction with colleagues about patients with Parkinson’s as a teaching and learning opportunity. To share our knowledge and learn from each other as a team. 

This sounds like a real team effort, which teams have been involved in this project?

Sophie: The Parkinson's nurse specialists, the pharmacy team, acute elderly admissions and acute medical admissions were involved initially and now this work is spreading across the trust.

How have your colleagues across the hospital worked collaboratively on this project?

Sophie: We are fortunate that the trust has invested in an outstanding pharmacy services programme, which is a large 2 year transformation program. The program is owned and driven by the pharmacy service and the staff themselves. We work together to implement improvements and develop our pharmacy service.

Because we have this investment in pharmacy at trust level, it's given us the encouragement to do quality improvement projects and to reach out to others. In such a busy hospital, it’s quite easy for us to just focus on pharmacy, or perhaps for the Parkinson's nurses just to focus on Parkinson's. Establishing these links across the trust, and working collaboratively to improve the care of people using our services is the most important thing.

The link between the pharmacy team and the Parkinson’s nurses has been key to the success of the project. The collaborative working has helped us drive the project forward and raise awareness of time critical medicines across the organisation.

It's not just about one person doing it on their own, it's about us working together as a team. I knew that the ePMA system had the functionality to report on new admissions, so I can help Zoe. And Zoe is so passionate and knowledgeable about Parkinson's, she can deliver the education and training, spreading the word. It's about using the best skills that we have together.

Zoe: Bradford is a very friendly trust and people will pick up the phone and actually speak to each other. I know that I can do that with anybody whatever role they are in. People often comment that Bradford is like that. People are very willing to help and share their knowledge and we all strive to deliver the best care for our patients.

Our values sum it up: We care, we value people, and we are one team. They promote a culture where we are encouraged to reach out.

What impact has this project had on patients?

Zoe: We've had qualitative feedback from patients around self-medication. A person with Parkinson's who had been admitted to a ward previously a few years ago and then had a recent admission fed back that whatever training we’ve done has definitely had an impact. They could see a big difference from the experience that they had before.

This work has given reassurance to patients and their carers. When they see the clock face posters displayed they know that they're going to have good care.

It’s allowed more collaborative working across the organisation with planned admissions. Recently we were aware that someone was coming in for a planned admission because the lead pharmacist for planned care got in touch to let us know the patient had been admitted.

It’s given the nursing staff more confidence because I think it can be difficult for them when their knowledge of Parkinson's is limited. If a patient is coming in with an acute problem and their Parkinson's is not the main problem, naturally the ward nursing staff will focus on what they've come in with and rightly so. But they need to understand that not getting their medication on time as prescribed is going to have a potentially detrimental effect on them and some of those effects could be irreversible.

We know that people with Parkinson's have a much longer hospital stay compared to somebody who doesn't have Parkinson's admitted for the same thing. So doing the training and nursing staff knowing who we are has made a huge difference.

Sophie: The qualitative feedback from the patient's wife who attends the Parkinson's UK group has been important. The group has been in constant dialogue with the Parkinson’s nurses. We are listening to the patients and acting upon the concerns that were initially raised and then feeding back. So they can share any issues with us and see that we are doing something about it. That helps give them a little bit of reassurance and confidence.

Sophie: Getting time critical medication right is a lifelong piece of work and we’re not expecting a quick fix, but we're working hard to make improvements.

Zoe: Yes, we're far from perfect and due to the nature of this it will be ongoing work. We will continue to improve.

How did you get support for this work within your organisation?

Zoe: We’ve got the chief executive’s pledge on time critical medication. I went to our deputy director of nursing who sent it to all of the matrons under her asking them to filter it out to their wards.

Sophie: Having the outstanding pharmacy services programme has helped raise the profile of the project. Our CEO and 2 of our most senior doctors are supporting the programme. Having their support for the improvement work that we are doing with the Parkinson's nurses has been really beneficial. 

Our pharmacy team have been fully supportive of the project, and without the drive of the pharmacy admissions teams and nursing staff, this wouldn’t have been possible.

Is there anything you would do differently if you were going to do this again?

Zoe: You shouldn’t really wait for a concern to be raised to start an improvement project, but that was a powerful motivator for us. And so although you can look at it as a negative cause, at least we've acted on it and moved forward. That's often how changes are made, isn't it?

Sophie: And to me, that's what's kept me motivated. If we had done this project and we hadn't had the patient's experience and voice at the heart of what we were doing when you get your first no or you're busy, it's easy for things to fall by the wayside. Whereas as a professional in healthcare, that patient experience and wanting to do better for our patients has kept me motivated.

Zoe: Yes, striving to always achieve the best outcome for your patients and accepting when things have not been perfect and learning from it.