Benchmarking to improve the delivery of time critical medication at South Tyneside and Sunderland NHS Foundation Trust: best practice case study
South Tyneside and Sunderland NHS Foundation Trust is benchmarking against the 10 recommendations for time critical medication to make sure that people with Parkinson’s get their medication on time, every time.
Read on to find out how the team has listened to patients and focused their work.
- Care strategies
- Inpatient care and medicines management
- Service improvement
- Case studies
- Doctor (Geriatrician)
- Doctor (Neurologist)
- Doctor (Other)
- Nurse (other)
- Nurse (Parkinson's nurse)
- Pharmacist
- Complex
- End of life
- Maintenance
South Tyneside and Sunderland NHS Foundation Trust has used internal audit data to identify the areas of the hospital that need more support to improve the delivery of time critical medications. Working collaboratively with these areas and the 10 recommendations for time critical medication has made a significant difference. The results show the impact that targeted support can make.
Read the 10 recommendations for time critical medication.
We spoke to Dr Fionnuala Johnston, Consultant Geriatrician and Parkinson's Specialist, about the steps the team has taken and what they have learned from the project.
The Parkinson's team at South Tyneside and Sunderland NHS Trust.
What we've done to improve the delivery of time critical Parkinson’s medication
People with Parkinson’s and their relatives tell us that coming into hospital can be a difficult experience. We're using the 10 recommendations from the Parkinson’s Excellence Network to help us make sure that people with Parkinson’s get their medication on time, wherever they are in the trust. We've broken down the recommendations one by one making it easier to plan how we'll meet each of them.
This is an ongoing trust-wide collaboration between senior colleagues from nursing, pharmacy, training, and quality improvement. My neurology colleague Dr Hannah Steel and I have highlighted the issue within the trust with the Clinical Governance Steering Group, the Medicines Governance Group and the Mandatory Training Panel.
Everyone in our Parkinson’s team has been involved in helping with policy changes or developing training. Our medical director has been very supportive. The Time Matters: It's Critical training video, developed by the NHS Professionals - living and working with Parkinson's group, has helped us get the message across to lots of different groups of people.
Watch the Time Matters: It's Critical video on Vimeo.
Our progress so far
For the last few years, we've been monitoring whether people with Parkinson’s get their medication on time. We use e-prescribing in our trust allowing our data warehouse automated feed to identify every dose of Parkinson’s medication given and whether it was given within 30 minutes of the prescribed time.
In 2022, we audited wards where people with Parkinson’s are more likely to be admitted. We found that our orthogeriatric ward and care of the elderly (COTE) ward needed more help.
The help each ward received was different, based on what the teams felt the barriers were. Orthogeriatrics needed more help from my pharmacy colleague Xinyi Thun to make sure they knew that medication is always available in the emergency drug cupboard, along with more training. The COTE ward manager provided education to staff and reinforced expectations that medication would be given outside normal drug rounds.
The table below shows the difference that additional support made. For comparison, the admission unit did not receive any extra help.
| Ward | Percentage of Parkinson's medication given on time (December 2022 to March 2023) | Percentage of Parkinson's medication given on time (May 2023 to June 2023) |
| Admission unit | 78.57% | 62.35% |
| Parkinson's COTE ward | 86.56% | 84.60% |
| Medical ward | 86.90% | 80.00% |
| Orthogeriatrics | 54.79% | 81.85% |
| COTE ward | 59.51% | 93.55% |
The time critical medication pledge has inspired us to look wider. In November 2023, we reviewed data from everywhere in the trust. We recorded the percentage of doses given on time and how many doses were given in total. This allowed us to target areas of the hospital that need more support.
Dr Jade Yong, our Foundation Year 1 doctor, asked those wards what the barriers were to giving medication on time. They told us that patient factors, drug availability and clinical pressures made it difficult to give medication on time.
- 32% said clinical pressures mean timely administration is not prioritised.
- 24% said medication was unavailable on the ward and took time to get.
- 23% mentioned patient factors, such as people who refuse medication or cannot swallow.
- 15% said timings were easily forgotten.
- 3% said they weren't aware the medication was time critical or were unsure when it should be administered.
- 3% gave other reasons, such as the patient was in end of life care.
As a result, we've signposted the wards to our critical medication guideline. This explains that people with Parkinson’s who can’t take their medication need to have a medication review by a doctor. The doctors can use our inpatient management of Parkinson’s guideline to help them.
Our Advanced Pharmacy Practitioner, Sharlene Hindmarsh, is developing training for pharmacy technicians trust-wide. This will allow technicians to signpost nursing staff to the fastest way to get medication.
We asked ward managers to look at strategies on their wards to help staff remember to give medication within the 30 minute window. There is ongoing quality improvement work around this.
Lastly, our Parkinson’s Nurse Specialists, Sister Vicki Rumis and Sister Lisa Renton, along with our ward Physiotherapist, Dave Johnson, have developed an e-learning module. This will be made available to all qualified nurses in the trust, especially on wards with high numbers of people with Parkinson's.
We plan to repeat the audit process regularly so that wards that perform less well can get the help they need to improve. Over time we hope to continue to drive standards up and maintain a culture of attention to detail in medication delivery. This is important for people with Parkinson’s, but also for people who take any time critical medication.
What impact has your service improvement project had on the delivery of time critical Parkinson’s medication in your hospitals?
In our most recent audit cycle, in July 2024, 88.3% of all doses of Parkinson’s medications were given on time trust-wide. 16 wards (42%) gave medication on time more than 90% of the time. Our highest performing ward delivered 750 doses of medication and was on time 98% of the time.
We aim to use the time critical medication pledge to keep the conversation going so that all areas of the trust improve and keep performing well. We plan for "outlier" wards to get support depending on the barriers they face and have developed resources and training to signpost them to.
How we are working with the 10 recommendations for time critical medication
Read on to find out how South Tyneside and Sunderland NHS Foundation Trust have benchmarked and approached each recommendation.
The recommendations have been summarised here. To read the full document, visit the 10 recommendations resource page.
1. Time critical medication is given within 30 minutes of due time and added to a risk register. Compliance is audited.
Our action:
The audit identified some areas and wards that were "outliers" and targeted actions were taken, including:
- contacting ward managers to let them know they are "outliers"
- surveying to gauge staff knowledge and identify barriers
- designing and implementing targeted interventions based on the identified barriers including developing a training package and rolling this out to other high traffic wards, exploring the use of medication reminders on wards, and continuing to raise awareness
- re-auditing.
2. All staff across the hospitals are made aware of time critical medication. Make the 3 minute video Time Matters: It's Critical mandatory viewing for all staff.
Our action:
The Mandatory Training Panel has agreed to include this in the trust induction for all staff prescribing or administering medication to adults.
3. Hospitals identify which staff must complete further Parkinson’s medication training.
Our action
As well as providing training to high traffic areas and wards identified through the audit, training is given to all new band 6 pharmacists, trainee pharmacists, nurses and allied health professionals. A training package for pharmacy technicians is also under discussion.
4. Hospitals develop, maintain and update a self administration policy.
Our action
A self administration policy for insulin is being developed. We hope to be able to adapt this for use in Parkinson’s when it's ready.
5. Hospitals identify all patients on time critical medication when they arrive in the emergency department (ED) or through an elective or emergency admissions unit.
Our action:
Emergency department (ED):
- All patients taking time critical medications are identified at the time of triage.
- When patients arrive at the ED main waiting area, a poster reminds them to let staff know about time critical medication.
Emergency assessment unit (EAU):
- All patients have a medication reconciliation by a pharmacist who identifies their time critical medication at the point of admission.
- EAU pharmacists screen critical medication for all admissions at 7.30am, provide real time reviews between 8am and 8pm, and screen expected admissions to EAU in ED at 7.30pm.
6. Patients with Parkinson's feel empowered to inform staff about their time critical medication.
Our action:
ED and EAU both use the critical medication standard operating procedure (SOP), which requires a 30 minute window for administering Parkinson’s medication.
7. Hospitals have a designated pharmacist responsible for ordering and keeping the time critical medication stocked.
Our action:
This recommendation has been implemented at all sites.
8. Prescribing a patient's time critical medication should reflect their normal daily schedule. Electronic prescribing, where available, should be maximised to support this.
Our action:
This is outlined in our Parkinson's inpatient guideline.
9. Ensure hospitals have a Standard Operating Procedure or guideline for all time critical medication.
Our action:
This is outlined in the Parkinson's inpatient guideline. Adherence to this guideline is subject to audit.
10. Staff are supported to administer all time critical medications outside of the normal medication rounds if self administration is not appropriate.
Our action:
Electronic prescribing and the critical medication standard operating procedure (SOP) support prescribing outside of normal medication rounds.
Medication delivery is monitored as part of the time critical medication audit.
Some final words
We haven't found a one-size-fits-all solution. We're trialling different solutions to suit different wards. For example, one ward is running a quality improvement project to trial the use of iPods because these devices allow staff to set multiple alarms and there's no risk of a data breach.
This work won’t ever be complete. We'll continue to work with colleagues across the hospital with ongoing training and new initiatives. Auditing is essential, as it gives us the data to see where to target our work.
Related resources
- Audit and awareness - how staff at Hexham General Hospital improved the delivery of time critical medication: best practice case study
- Self administration: a patient-centred approach to administering time critical Parkinson’s medication at University Hospitals of Leicester NHS Trust: best practice case study
- Improving the delivery of time critical medications at Bradford Teaching Hospitals NHS Foundation Trust: best practice case study
- Time critical medication and Get It On Time resources