Identification of Issues Contributing to Longer Length of Stay and Higher Readmission Rates for Parkinson's Patients Admitted to Hospital

ABSTRACT

Background

People with Parkinson's disease (PD) are a vulnerable cohort of people, more likely to suffer serious health‐related problems when admitted to hospital. Literature suggests that health service improvement utilising a robust health care redesign framework, can improve local service delivery and outcomes for hospitalised PD patients.

Aim/Objectives

This healthcare redesign project aims to identify the issues that contribute to PD patients experiencing a longer length of stay (LOS) and (re)admitting to a tertiary hospital in Sydney, Australia. Quantitative analysis of hospital data previously identified comorbidities present on admission that impact LOS and acquired complications that significantly extend LOS. This paper demonstrates the benefits of utilising mixed methods to provide a comprehensive picture of the PD patient's inpatient experience.

Methods

Mixed‐methods healthcare redesign diagnostic tools were used to gather evidence and understand the issues.

Results

Seventy‐eight percent (n = 831) of PD patients admitted to the emergency department were triage category 1, 2 or 3. 58.5% of PD patients have their PD medications charted within 4 h of admission. Their average LOS was 13 days. Data triangulation identified several barriers to optimal care, with prioritisation activities identifying three high‐impact, feasible targets for improvement: PD medication management during nil‐by‐mouth periods, timely medication charting and timely discharge planning. Root causes (lack of formalised care pathways, limited access to resources and poor coordination of PD services) were identified as contributing to PD patients experiencing a longer LOS and higher readmission rates. Poor communication between clinicians within the hospital, fragmented transitions between hospital and community services and limited access to specialist resources were identified as key system‐level barriers requiring prioritisation in the subsequent redesign phase.

Conclusions

The use of mixed methods provided a rich understanding of the PD patient experience of a hospital admission and prolonged length of stay. This study identified system‐level barriers to optimal Parkinson's disease care, providing clear targets for service redesign to improve patient outcomes and hospital efficiency. Addressing gaps in Parkinson's disease medication management, discharge planning and interdisciplinary communication may improve inpatient outcomes, reduce avoidable complications and decrease hospital length of stay and readmissions.

Implications for Nursing Practice

Nurses play a critical role in advocating for and leading improvements in the quality, safety and efficiency of care for PD patients. This subsequently improves the PD patient's hospital experience. Nursing practice should focus on prioritising accurate and timely medication management, strengthening communication between clinicians to expedite discharge planning and advocating for PD‐specific knowledge and education to improve patient outcomes, reduce length of stay and service efficiencies.

Patient and Public Contribution

Patients and members of the public were not involved in the design, conduct, analysis, reporting or dissemination of this healthcare redesign project.

1. Introduction

Parkinsons disease (PD) is a progressive neurological disorder characterised by motor symptoms of tremor, rigidity, postural instability and bradykinesia and non‐motor symptoms including autonomic and gastrointestinal dysfunctions, mood disturbances, cognitive impairment, sleep disorders and pain. These symptoms progress over time, increasing disability, resulting in higher hospital admission rates (Kalia and Lang 2015; Okunoye et al. 2020). Recent studies have identified four main reasons for hospitalisation among people with PD. These are infections, such as urinary tract infections and pneumonia, worsening motor features contributing to reduced mobility, falls and fractures, delirium, dementia and associated neuropsychiatric symptoms and autonomic features of PD including gastrointestinal complications, orthostatic hypotension related syncope and adverse drug events (Okunoye et al. 2020; Hommel et al. 2022; Lubomski et al. 2015).

An estimated 2.0% of the Australian population aged over 55 live with PD, and 3.2% of the population over the age of 65 (Mellick 2024). One Australian study found PD has more than doubled over the past generation due to the increasing numbers of older people, environmental factors such as the use of pesticides and fungicides and longer disease duration (Ayton et al. 2019). PD patients are a vulnerable patient cohort when admitted to hospital, more likely to suffer serious health problems, including delirium, adverse drug reactions, syncope, falls and fractures than patients of the same age without PD (Lubomski et al. 2015). The length of stay (LOS) for PD patients ranges from 6.8 to 24 days (Williams and Prior 2024; Lovegrove and Marsden 2020; Azmi et al. 2020; Carroll et al. 2020; Hobson et al. 2019; Lance et al. 2021; Moore et al. 2022). An Australian study examining NSW Ministry of Health data determined that PD patients have a significantly longer median LOS (7 days) than a control group of the same age (1 day) (Lubomski et al. 2015). PD patients are also 31% more likely to be readmitted within 30 days than non PD patients (Fullard et al. 2020) and a first admission is an indicator for further admissions (Hobson et al. 2019; Nance et al. 2020). Therefore, it is imperative to understand the health service issues that contribute to poorer outcomes for PD patients whilst hospitalised, if services are to improve service delivery, health‐related outcomes and the patient experience.

Health service improvement utilising a robust framework, such as healthcare redesign, can improve service delivery and outcomes for PD patients admitted to hospital (Williams and Prior 2024). Previous work has shown improved identification of PD patients (Carroll et al. 2020; Lance et al. 2021), reduced medication incidents for PD patients (Azmi et al. 2020; Carroll et al. 2020; Lance et al. 2021; Moore et al. 2022) and more timely pharmacy reviews (Lance et al. 2021), improvements in medication administration workflow (Nance et al. 2020) and timely administration of PD medication (Carroll et al. 2020; Lance et al. 2021; Moore et al. 2022; Nance et al. 2020; Corrado et al. 2020). These outcomes reduced overall PD patient length of stay (LOS) between 8% and 50% (Azmi et al. 2020; Carroll et al. 2020; Lance et al. 2021; Moore et al. 2022) with cost savings of up to $8600 per person per year in Australia (Bramble et al. 2021). Experience‐related outcomes showed improvements in patient and carer experience (Lovegrove and Marsden 2020; Carroll et al. 2020; Nance et al. 2020; Corrado et al. 2020) and improved staff satisfaction (Lovegrove and Marsden 2020; Carroll et al. 2020). Other outcomes include improved service delivery (Lovegrove and Marsden 2020; Carroll et al. 2020; Corrado et al. 2020), access to specialised services (Hobson et al. 2019), timely interventions and discharge advice (Hobson et al. 2019), reduced complication rates and a reduced need to increase care after discharge (Lance et al. 2021). While these studies demonstrate that healthcare redesign can improve outcomes for people with Parkinson's disease, the factors contributing to poor outcomes vary across healthcare settings. Understanding local drivers of prolonged length of stay and readmissions is therefore essential to inform the development of targeted, context‐specific improvement strategies.

1.1. Local Context

Northern Sydney Local Health District (NSLHD) has 181,210 residents over the age of 65 years, suggesting there are 7350 people living with PD in SLHD (Mellick 2024). Royal North Shore Hospital (RNSH) is the main tertiary referral centre for SLHD. Previous work conducted between 2022 and 2023 found that PD patients experienced a 128% longer LOS (8.73 days) compared to the hospital average (3.8 days) (Dinh et al. 2025). PD patients also had a higher readmission rate (within 28 days) of 11.3% compared to the hospital‐wide rate of 5.8% (Dinh et al. 2025). It was reported that factors contributing to the longer length of stay and high readmission for PD patients in this setting were comorbidities present on admission and hospital‐acquired complications (Dinh et al. 2025). Comorbidities such as delirium and infection can impact LOS by up to 74%. Medication adverse effects, hypotension and constipation can impact LOS by up to 69%, 41% and 40% respectively. Hospital‐acquired complications that significantly influence LOS include delirium, hypotension, pneumonia and medication adverse effects extending LOS by 218%, 120%, 96% and 80% respectively (Dinh et al. 2025).

The Parkinson's Inpatient Experience (PIE)—medication management project (PIE 1 Project) was a healthcare redesign project conducted in 2022–2023 at RNSH (Williams et al. 2025a). This project focused on improving the medication management for people with PD who were hospitalised. The interventions included routine identification of PD patients, staff education, prescriber alerts and prompts for timely administration of PD medication in the electronic medical record system and a review of ward PD medication stock (Williams et al. 2025b). Despite improvements in medication management, PIE 1 did not reduce LOS (Williams et al. 2025b). A subsequent retrospective analysis of the same patient cohort utilised administrative hospital data to quantify LOS and identify clinical factors associated with prolonged admissions, including comorbidities present on admission and hospital‐acquired complications. However, organisational workflow and service‐level factors contributing to these outcomes remained poorly understood. The present study forms part of the PIE2 redesign project and uses a pragmatic mixed methods approach (Creswell and Creswell 2017) to investigate these factors. While some organisational datasets overlap with the previous retrospective analysis, the staff focus group data, thematic analysis, data triangulation, prioritisation process and root cause analyses reported here are novel and have not been previously published.

The aim of the PIE2 project is to explore and understand issues that contribute to increased LOS and reasons for (re)admission for people with Parkinson's disease admitted to YSH. This study builds on previously published work (Dinh et al. 2025) that focussed solely on quantitative data analysis.

2. Methods

2.1. Healthcare Redesign

The PIE2 project utilises the healthcare redesign approach to report on findings from the diagnostic phase of redesign (Figure 1) with the aim to identify and support issues experienced by PD patients at RNSH that potentially contribute to longer LOS and high (re)admission rates.

FIGURE 1.

Phases of healthcare redesign.

2.2. Scope

The project included three wards at the RNSH: the Emergency Department (ED), Neurology Ward (7F) and Aged Care Ward (9E) with data collected between 1st January 2022 and 31st December 2023. These wards were supported by the department heads to participate in the study.

2.3. Data Collection

This mixed methods project utilised three main datasets (Table 1). Organisational data was collected to demonstrate the characteristics of the population and understand admission factors. Qualitative data was collected through face‐to‐face focus groups with participants recruited through invitation and line management approval. Staff were invited to voluntarily participate in focus groups during work time. A participant consent form was signed. Staff were informed that the groups were audio recorded for the purposes of transcription. Transcription included the staff members' role, but no other identifiers were recorded maintaining staff confidentiality. Focus groups were scheduled for 1 h in work hours, facilitated by the Parkinson's disease Clinical Nurse Consultant and audio recorded. While some participants may have been familiar with the facilitator through previous professional interactions, she did not hold a managerial or supervisory role over participants. Her clinical expertise and knowledge of local service processes supported the exploration of issues relevant to Parkinson's disease care. Staff from each ward representing nurses, medical and allied health were invited to participate. Participation was voluntary. Each group was presented with the same PowerPoint slide deck which outlined the achievements of PIE1 and continued longer LOS and high readmission rates. Staff were asked to describe the issues that contribute to this patient experience and identify the barriers and enablers to quality service delivery from their frame of reference.

TABLE 1.

Data collection tools.

Diagnostic tool	Purpose	Source
Organisational data Quantitative	To identify the number of PD patients admitted and (re)admitted to RNSH To identify triage category To identify any delays in prescribing PD medications in ED Discharge destinations Average length of stay Conditions impacting LOS	RNSH ‘Stay level’ and ‘Episode level’ admissions data from 1st January 2022 to 31st December 2023 Triage category data Medication administration record (MAR) data
Face to face focus groups Qualitative	To map out workflow processes, identify issues, gain staff perspective on caring for PD patients	Nurses, Junior medical staff, Geriatricians, Neurologists, Pharmacists, Speech Pathologists, Occupational Therapists, from acute care and community settings Audio recorded and transcribed into Excel spreadsheet

The Northern Sydney Local Health District Human Research Ethics Committee provided ethics approval for data collection: HREA 2023/ETH02162.

2.4. Data Analysis

Quantitative and organisational were analysed using descriptive statistics in Microsoft Excel (Version 24.10) and included percentages to summarise numerical data and analysis of time stamps.

Qualitative data from staff focus groups were transcribed verbatim and line‐by‐line codes were collated in Microsoft Excel by one member of the research team. A second team member independently reviewed the coded data and undertook a general inductive thematic analysis (Peerally et al. 2017). Codes were grouped into categories and then refined into broader themes through discussion between the two researchers. Any differences in interpretation were discussed until consensus was reached. To enhance the trustworthiness of the findings, the preliminary themes were presented to project stakeholders for verification and further refinement. Representative participant quotations that clearly illustrated each theme and reflected commonly expressed views across participants were selected to support the results.

2.5. Data Triangulation

Findings from all data sources were collated and reviewed collectively by the project team. Quantitative data (including organisational performance metrics and patient flow data) and qualitative findings (including staff interview and focus group data) were compared to identify areas of convergence, complementarity and divergence. Rather than prioritising one data source over another, findings were considered together to develop a comprehensive understanding of factors influencing patient flow and length of stay within the local context. Divergent findings between qualitative and quantitative datasets were considered informative during triangulation. Rather than attempting to reconcile discrepancies by prioritising one data source over another, the project team explored whether differences reflected underlying system issues. For example, while organisational data demonstrated that most patients with Parkinson's disease were appropriately triaged, staff perceived these patients as receiving a lower clinical priority. Examination of other data sources suggested that this perception contributed to delays in Parkinson's disease‐specific care following triage, including medication charting, nil‐by‐mouth management and referral processes. These delays may contribute to worsening symptoms and potentially avoidable admissions. Consequently, the discrepancy itself became an important finding that informed root cause analysis and prioritisation of improvement activities.

Following this process, identified issues were prioritised according to two criteria:

1. Impact: the potential of an issue to improve hospital service delivery and patient outcomes if addressed

2. Influence: the practical likelihood or feasibility that an intervention could be implemented given available resources, organisational readiness and local constraints

Issues assessed as having both high potential impact and high influence were prioritised for subsequent improvement activities.

2.6. Prioritisation

A prioritisation matrix (Gangidi 2019) was utilised to assess and prioritise identified key issues and root causes for further investigation. The matrix considered ability to influence on the vertical axis and impact on key performance indicators on the horizontal axis (Figure 2). Following data triangulation, the project team reviewed each identified issue and root cause against these criteria. Priority ratings were determined through discussion and consensus, drawing on available evidence, clinical expertise and knowledge of the local service context. Consideration was given to the likely impact on patient outcomes and service delivery, as well as the feasibility of implementing potential solutions within existing organisational structures and resources. Issues considered to have both high influence and high impact were prioritised for the subsequent solutions phase. This information was presented to sponsors from the hospital executive representing medical, nursing and allied health services for consideration and endorsement.

FIGURE 2.

Prioritisation matrix.

2.7. Root Cause Analysis

Root cause analysis is a process that identifies changes that need to be made to systems and processes by digging deeper into why the issues occur and how to prevent them from continuing (Uberoi et al. 2007). It is an interdisciplinary process that must involve experts from the frontline services and organisational leadership (Uberoi et al. 2007) to be thorough. Root cause analysis in health care often focuses on the analysis of a single incident which limits the organisations' ability to assess its vulnerability to recurring events (Peerally et al. 2017). This is compounded by the problem of many hands, where many actors and their actions may be contributing to the problem, making it difficult to address the hazards that arise at a systems level (Peerally et al. 2017).

In this study a root cause analysis of each key issue was conducted by the project lead and a team member using 5 Why's analysis addressing occurrence, human and systemic issues that contribute towards the problem (Gangidi 2019) rather than on a single incident. Root causes were ranked according to impact and influence. Impact was rated high, medium or low according to how much addressing that root cause would improve the key issues. Influence was rated based on the extent to which the project team could make changes or affect that root cause. Findings were fed back to participants from the staff focus groups for validation or further refinement, until agreement was reached. As an example, delayed discharge planning was identified as a priority issue. Using the Five Whys technique, the project team asked:

1. Why are patients experiencing delayed discharge? Because discharge planning often occurs late in the admission

2. Why does discharge planning occur late? Because multidisciplinary discussions are not initiated early.

3. Why are discussions not initiated early? Because roles and responsibilities are not clearly defined.

4. Why are roles unclear? Because there is no standardised discharge planning process

5. Why is there no standardised process? Because discharge planning procedures have evolved inconsistently over time.

This process identified the absence of a standardised discharge planning pathway as a key root cause requiring further attention.

This study is reported in accordance with the Good Reporting of A Mixed Methods Study (GRAMMS) framework which includes the mixed methods design, quantitative and qualitative components, triangulation of findings, integration of datasets and limitations (Munce et al. 2026).

3. Results

3.1. Organisational Data

3.1.1. Demographic Data

The total number of PD patient admissions between 2022 and 2023 in shown in Table 2 The majority were male (62%) and the mean age = 79 years.

TABLE 2.

Number of readmissions.

Number of days between admissions	Number of admissions
< 28 days	119
29–60 days	60
61–90 days	38
91–120 days	30

3.1.2. Triage Data

Seventy‐eight percent (n = 831) of PD patients admitted to the emergency department were triage category 1, 2 or 3 and should have been reviewed in < 30 min (Table 3). Triage is defined as the process of rapid and focused patient assessment on arrival at the ED to determine the priority for treatment based on the clinical urgency of the patients' presenting condition. It enables prioritisation of resources to ensure safe outcomes for all patients. The purpose of triage is to determine the patients' clinical urgency, and based on this assessment the Triage nurse assigns an Australian Triage Scale (ATS) category so that the patient with the highest clinical urgency is seen first (NSW Health System Performance Support 2024).

TABLE 3.

Proportion of admissions via the emergency department by triage category.

Triage category (time to review)	Number of admissions	Proportion of admissions (%)
1 (< 2 min)	58	5.51
2 (< 10 min)	358	34.00
3 (< 30 min)	415	39.41
4 (< 1 h)	211	20.04
5 (< 2 h)	11	1.04

3.1.3. Time to PD Medication Prescribing

A total of 212 first Parkinson's disease (PD) medication prescriptions were identified across patient admissions. To distinguish usual home medications from medications likely initiated during admission, prescriptions charted within 12 h of triage were considered part of the patient's usual PD medication regimen, while those charted more than 12 h after triage were considered likely to represent newly prescribed therapies.

Of the 222 first PD medication prescriptions, 58.5% (n = 130) were charted within 4 h of triage, 26.5% (n = 59) between 4 and 8 h and 6.8% (n = 15) between 8 and 12 h. Overall, 92% (n = 204) of first PD medication prescriptions were charted within 12 h of presentation. The remaining 8.1% (n = 18) were first charted more than 12 h after triage and were therefore considered likely to represent newly initiated PD medications rather than delayed charting of pre‐existing therapy (Figure 3).

FIGURE 3.

Time from triage to time first PD medication order is placed.

3.1.4. Discharge Destinations and Average LOS

Discharge destinations or ‘mode of separation’ are pre mandated fields completed on discharge from the hospital (Table 4). The largest cohort was those ‘discharged by hospital’ to their home or usual place of residence, which may include a residential aged care facility, with an average LOS of 12 days. However, the PD patients discharged to a residential aged care facility had the longest average LOS at 23 days but only accounted for 3% (n = 31) admissions. Those who died in hospital accounted for 5% (n = 50) of admissions, with an average LOS of 22 days. PD patients transferred to other accommodation 1% (n = 10) or facility 7% (n = 80) each had an average LOS of 16 days. Those who discharged at own risk 1% (n = 14) did so on average at 11 days.

TABLE 4.

Mode of separation.

Mode of separation	Proportion of admissions	Average LOS (days)
	N = 1083	(Mean)
Whole PD cohort		13
Discharge by hospital	83% (n = 899)	12
Transfer to other facility	7% (n = 80)	16
Deceased	5% (n = 50)	22
Transfer to residential aged care facility	3% (n = 31)	23
Other	1% (n = 10)	16
Discharge own risk	1% (n = 14)	11

3.1.5. Conditions Present on Admission

Hypotension (20.1%) and delirium (17.8%) were the most common conditions present on admission to the emergency department for people with PD (Table 5). Hypotension (4.2%), falls (2.1%) and delirium (2.0%) were the most common conditions acquired during admission for people with PD.

TABLE 5.

Incidence of conditions present on admission and acquired during admission.

Condition	2022 and 2023 total episodes of care
	N = 1249
	Present on admission	Acquired during admission
Hypotension	20.1% (n = 251)	4.2% (n = 52)
Delirium	17.8% (n = 222)	2.0% (n = 25)
Infection	14.1% (n = 176)	1.7% (n = 21)
Falls	13.9% (n = 173)	2.1% (n = 26)
Dysphagia	12.7% (n = 159)	0.2% (n = 2)
Constipation	12.4% (n = 155)	0.5% (n = 6)
Injury	10.2% (n = 127)	1.0% (n = 13)
Social issues	7.3% (n = 91)	0.0% (n = 0)
Pneumonia	5.9% (n = 74)	1.8% (n = 23)
Medication adverse effects	5.2% (n = 65)	1.9% (n = 24)
Cognitive change	1.4% (n = 18)	0.1% (n = 1)
Antiparkinsonism drug adverse effects Rx use	0.6% (n = 7)	0.2% (n = 3)

3.1.6. Focus Groups

Fourteen focus groups were attended by 62 staff from Neurology, Aged Care and Emergency departments (Table 6). Attendance was voluntary, but conducted during regularly scheduled meeting times for convenience and ran for one hour. Staff were asked 3 questions: What issues contribute to PD patients having a longer than average LOS on your ward, compared to the overall hospital average LOS? What issues contribute to PD patients (re)admitting to hospital? What are the barriers/enablers to quality service delivery for people with PD? This last question was often rephrased as: What makes it easy or hard for you to do your job well? Participant characteristics were reported at an aggregated level to preserve confidentiality, as several professional groups contained small numbers of participants and further disaggregation could have enabled identification of individual staff members. The average time for the focus groups was 45 min.

TABLE 6.

Demographics of focus group participants.

Role	Number attended focus group
Nurses	24
Allied health	13
Medical officers	25
Total	62

Six hundred and twelve lines of data were coded. General inductive thematic analysis identified five themes (Table 7). Quotes included in the table are either representative of the theme or provide a significant insight.

TABLE 7.

Thematic analysis of focus group data.

Theme	Number of comments	Supporting quote(s)
Theme 1: Discharge barriers	176	A variety of barriers were described by participants that contribute to a delay in the discharge process
Sub‐theme 1: Slow discharge process	99	Forward planning for discharge is really tricky as they advance in their disease, it should be easier on Neurology, but it seems as if it's a new problem every time.—Senior Nurse Discharge planning is super complex—its referrals to rehab, waiting for them all to be declined from rehab, before you can then discuss whether they are for home with increased services, the time it takes to get services in place, do we need to do home modifications because their PD has progressed that they can no longer shower and stand. In the interim this patient is still in an acute bed in an acute hospital waiting to figure out what the next step or phase will be, and is this the best place for that?—Speech Pathologist Discharge planning—is more complicated for our patients it is a lot of work for the allied health—being older at a more advance stage of their PD higher care needs, at limits of medical therapy, takes a lot more to discharge them compared to a younger person at the start of their PD journey—Geriatrician
Sub‐theme 2: Disease progression/Change of baseline/Deconditioned	27	For our Parkinson's patients on (Neurology) sometimes they've come in because they have gotten worse mobility wise and I know, the medications will fix it to an extent, but maybe they've just gotten worse and it's something that medications can't fix. And so even though we're working with them for mobility, a lot of the discharge might be that the house isn't set up or they're needing more equipment, or, um, the family trying to organise the package and it's not happening.—Physiotherapist
Sub‐theme 3: Not cleared by Allied Health	22	Return to baseline mobility is longer than other patients, (discharge) often delayed waiting for physio clearance—Neurology Registrar I mean, OT, we kind of wait for them to get as good as they can get, because often that does change a bit. And then probably, then we're looking at, okay, well, what do they need at home, which then will extend things a bit more as well.—Allied Health
Sub‐theme 4: Acquired/inpatient issues	22	PD Patients often need Nursing home placement. That delay for them means they are at risk of developing hospital acquired complications and deconditioning—Aged Care Registrar Once they are unwell, they get delirium and can't swallow their tablets, this is because of the disease process, versus something like heart failure. If they can't swallow their tablets, they decondition further, they don't get up for the physio—Geriatrician
Sub‐theme 5: Awaiting placement (new home)	17	I did my training (elsewhere) and I have not seen delays like we have here. (Why?) Shortage of Nursing homes, affordable nursing homes, expectations. Families expect to have a choice and say no to nursing homes before they settle on the right one.—Aged Care Registrar Delays: multistep process, sort out the acute thing, talk to the family and patient, have a family conference sometimes, come to an agreement that that is the road we will take, then get the social worker involved, then if they don't have an ACAT assessment refer for that and wait for that to happen, once that happens, then you have to go through a process of picking which nursing home, they have to go out and see them work out which one, is there a bed available.—Geriatrician
Sub‐theme 6: Delay organising services	12	Thinking back to a long stay recently who had (multiple PD related issues) And then in the end, it was about equipment and home services and things.—Allied Health
Sub‐theme 7: COVID‐19	4	(COVID Isolation) Mobility is really affected. Mood is a lot lower, being here for a long time they get depressed, they don't want to go they get used to the level of care and the company of having the nurses around—Aged Care Registrar
Theme 2: Social issues	158	Social issues were described by participants as factors that impacted a patient, carer and or family's ability to manage at home
Sub‐theme 8: Lack of outpatient/community support	73	I still sometimes find it hard to work out who to link them into when they leave here. We look for PD classes, but I am sure there are other ones we don't know about. I feel like they are all private options. If someone doesn't have the money, then that kind of rules them out.—Physiotherapist If we had a better plan in place when they leave, there can be back up plans in the community that can prevent admission to hospital—Allied Health Patients get so much information these days and ultimately the ones most at risk of representing are the ones who don't have any supports or someone to help them with the information, because they can't navigate the system.—Allied Health
Sub‐theme 9: Poor Medical literacy/Underprepared for disease progression	33	There doesn't seem to be a plan in place for when you're getting close to not coping at home. What are we going to do when that time comes and then they come into hospital, and then we're like, okay, you can't go home. And then we start that process. Well, maybe that process could be started earlier—Allied Health The medical team need to explain the disease is evolving and access other services as early as possible—Community Allied Health They may not be very well educated in the whole process overall; we sometimes shy away from the hard conversations. At the end of the day, we don't really have those tough conversations about degeneration. So, it might come a bit the shock when the crisis hits. (Focus group facilitator—why don't we have those conversations?) Because we're sooks.—Neurologist
Sub‐theme 10: Not coping at home	22	Carer stress—using hospital for respite. Nothing medical keeping them here but family ask for something—more physio, another day etc.—Neurology Registrar Not coping with progression of the disease at home—Nurse
Sub‐theme 11: Carer stress	19	Carer fatigue—Services in the community. If you're over the age of 65, are pretty crap. You get a couple of hours a week. There's waiting lists of 18 months. People soldier on the hope that something will come on. In the meantime, the disease marches on.—Neurologist The families think they can cope. They take them home, then find they are too confused and they get tired, and they can't cope so they come back to hospital.—Aged Care Nurse Our elderly patient also has an elderly wife with some services, but not enough for the increased care needs of the individual.—Aged Care Nurse
Theme 3: Functional decline	110	This theme included a variety of factors that were described by participants as contributing to a PD patient's condition deteriorating
Sub‐theme 12: Medical issues present on admission	33	Blood pressure issues—significant postural drop takes longer than usual to adjust their medication to let them get back to acceptable level.—Nurse Delirium or Psychosis‐ takes time to work out what is going on.—Nurse
Sub‐theme 13: Disease progression/change baseline/deconditioned	27	Home environment and lack of suitable equipment—difficulty getting on and off the toilet. if there has not been an assessment of the home there could be risks, they are not aware of that they have just been doing—until it is unsafe.—Community Allied Health If they can't swallow their tablets, they decondition further, they don't get up for physio.—Geriatrician
Sub‐theme 14: Frailty	25	Readmitted for other medical issues but because of their PD they are not as robust.—Neurology Registrar Frail old patient has a trial of active management when that fails that could delay discharge. Hiccups in the road—leads to end‐of‐life care—Aged Care Registrar
Sub‐theme 15: Hospital acquired medical issues	25	Sometimes they come in with delirium sometimes they get it in hospital related to another infection. This increases LOS.—Aged Care Nurse
Theme 4: Medication Issues	49	Patient specific PD medication regimens were described by participants as complex with unique issues arising in their management
Sub‐theme 16: Medication management	38	Titrating Medication takes time, couple of weeks to get the right medication.—Aged Care Nurse Doctors need education as to how medications should be charted, they get it wrong most of the time. Nurses can only administer once it is charted correctly.—Neurology Nurse For our emergency patients—if they have the right care at the right time and the right medication it would expedite discharge from ED. Rather than asking me to come and see them and they have missed two doses, then the physio comes along and they can't walk and they have failed and then they are an admission when the problem is they haven't had their medications charted. This can be prevented. You can't send someone home if they care walk.—Emergency Nurse
Sub‐theme 17: Medication management when nil by mouth	11	We get a lot of consults—often nil by mouth asking what medications we need.—Neurology Registrar If they come in overnight and they can't swallow—then we have ask them to change the medications. If the doctor doesn't know how to do that then they call the overnight pharmacist to talk to them about charting the correct dose of patch. Time for the doctor to act takes a while. If you just list the task, it may never happen.—Neurology Nurse PD (symptoms) won't get better until they get the tablets, can't give the tablet until they are better. They are better being frozen than getting aspiration.—Neurology Nurse
Theme 5: Staffing issues	187	Staff related issues that impact quality of care were described by a variety of clinicians
Sub‐theme 18: Workload/Care	82	Workload effects PD pts. because they are predominately (Triage) Category 3 or 4 patients. If we have no beds inside, they will stay in the waiting room for a long time.—Emergency Nurse Everything with PD patients is quite slow. They can't swallow medications quickly or stand up and just walk like that, which means you need more time with them than the average patient. When the staffing is already down it makes it very difficult.—Aged Care Nurse Physios have to prioritise those going to rehab, and those ready for home. Those waiting for respite get less physio.—Aged Care Registrar Could do with more (social work) staff, incredibly busy with difficult family conversations, lot of patients, ACAT assessments, referral to Residential Aged Care.—Aged Care Registrar
Sub‐theme 19: Communication	79	At times it just feels like the team aren't all acting together, I think it right from the beginning we need to improve our communication, like having more regular MDT's with these patients.—Allied health MDT Family meetings are not proactive, they are reactive, have always been.—Neuro Allied health Community home assessments are labelled in EMR. Do hospital staff know to look for these notes?—Community Allied Health Complex medication regimes need very good communication in the form of discharge letters. Sometimes even on the discharge summary the intended medication changes aren't correct or the reason for the change is not documented. This makes it confusing for GP's.—Geriatrician It is quite complex when there is a new group of people looking after the patient after hospital who don't know what the treatment intention is (referring to end of life plans).—Geriatrician Private neurologist letters only go to the GP and do not ever appear in EMR where ARRT/aged care can access them.—Geriatrician
Sub‐theme 20: Lack of knowledge of PD	26	Other teams are not confident to manage these patients, so they keep asking for consults from neuro.—Speech Pathology Most clinicians lack the required expertise to adjust PD medications when patients are NBM.—Neurologist Poor knowledge of what services are available in the community. Information being provided to patients on discharge is limited to the knowledge of the staff involved.—Allied Health

3.2. Identification of Key Issues

Through triangulation of the data we identified three key issues, described below:

3.2.1. PD Medications Are Poorly Managed When NBM

Speech pathologists noted PD patients who are unsafe to swallow often miss doses of their prescribed medication. They suggested that this delays oral administration of medication, causing symptoms to get worse, making the next dose of oral medication even harder to administer safely. Nurses in ED, Aged care and Neurology wards noted that when PD medication doses were missed patients would fail their physiotherapy assessments resulting in an admission rather than going home at their baseline level of mobility. Medical staff also reported lacking the knowledge to adjust oral medication regimes with confidence, which resulted in further delays and missed doses while waiting for a Neurologist to review the patient. Notably, dysphagia is more likely to be an issue on presentation to the hospital; 12.7% (n = 159) of patients rather than acquired during the admission 0.2% (n = 2).

3.2.2. PD Medications Are Not Charted in a Timely Fashion

Nurses in the ED reported that most patients with Parkinson's disease (PD) were assigned a triage category of 3 or 4, which they perceived resulted in reduced priority for medical review. They also identified delays in medication charting and subsequent missed or delayed PD medication doses. However, review of organisational data demonstrated that these perceptions were not reflected in triage allocation, with more than 80% of patients with PD receiving a triage category of 1, 2 or 3. According to New South Wales Health ED key performance indicators, these categories require clinical review within 30 min of presentation (Clinical Excellence Commission 2023). While organisational data did not support the perception that patients with PD were assigned low triage priorities, it did confirm substantial delays in medication charting, with only 41% of patients having PD medications charted within four hours of arrival. This discrepancy suggests that staff perceptions may relate less to triage categorisation and more to delays in the delivery of PD‐specific care following triage. As PD was the primary reason for presentation in only a small proportion of cases, the urgency associated with time‐critical PD management may not have been consistently recognised within standard emergency care processes. Consequently, delays in assessment, medication charting and treatment may contribute to deterioration in symptoms and functional status, creating a perception that patients with PD are not managed with sufficient urgency despite receiving an appropriate triage category. These findings suggest that the absence of clearly defined processes for the early identification and management of patients with PD may represent an important systems‐level contributor to care delays and informed the prioritisation of interventions focused on timely medication management, standardised care pathways and improved coordination of care across the patient journey.

3.2.3. Discharge Planning Is Not Conducted in a Timely Fashion

Common themes relating to discharge barriers included the belief that PD patients need to be medically stable to be assessed for discharge, combined with poor communication between medical teams and allied health services as to when the patient is medically stable. Staff reported discharge goals are then difficult to articulate, limiting the patient's ability to access appropriate services. There was also the misconception that waiting for aged care facility beds was a reason for most delayed discharges. However, the organisational data confirmed that while those going to a residential aged care do have the longest length of stay (average LOS = 23 days), only 3% of PD patients fit this category. Most PD patients, 83% (n = 899), are discharged by the hospital to their same address/home with an average LOS of only 12 days.

3.3. Root Cause Analysis

Root cause analysis of the three key issues identified four root causes. Three were considered to have high impact and three were considered to have high influence (Table 8).

TABLE 8.

Root causes listed in order of priority.

Key issue	Root cause (listed in order of priority)	Impact	Influence
1. Poor medication management when NBM	1. No resources providing advice for medication management when Nil by Mouth	High	High
2. Delayed prescribing in the first 48 h	2. Poor access to PD education and resources for clinicians	High	Medium
2. Delayed prescribing in the first 48 h	3. Charting of PD medication on arrival in ED is not prioritised	High	Medium
3. Slow discharge planning processes	4. PD services are disjointed and operating in isolation	Medium	Medium

Note: The shaded texts indicates priority.

4. Discussion

This healthcare redesign project sought to explore and understand the PD patient experience by identifying issues that contribute to their length of stay and reasons for (re)admission. This study also demonstrated the benefits of using mixed methods during the diagnostic phase of a redesign project. The additional information provided by the qualitative data identified gaps in service due to staff misperceptions. It also provided context for the organisational data. This provided a fuller picture of the PD patient experience of a hospital admission than if only qualitative or quantitative data was used in isolation.

Multidisciplinary stakeholders in acute care and community settings provided a wide variety of expertise and opinion as evidence to support the problem identified, an approach commonly utilised to bridge departmental and professional barriers (Moore et al. 2022; Azmi et al. 2019). Overall, the root causes of the issues presented in this study align with previously reported data from the same cohort (Dinh et al. 2025) suggesting that there are areas for significant service improvement to deliver better quality and safer care for patients with PD, reducing LOS and readmission.

High impact issues focussed on resourcing, access to education and clinical processes. Medication regimens for PD patients are currently not managed well, and staff lack the knowledge and resources to adjust oral PD medication regimens if the patient becomes nil by mouth (NBM). The consequences of missed oral doses of medication are worsening of PD symptoms, emergencies such as neuroleptic malignant‐like syndrome and adverse events (Clinical Excellence Commission 2023). This can include dysphagia, a common and clinically relevant condition in PD patients that has been shown to contribute to increased LOS through insufficient medication intake, malnutrition, dehydration, aspiration pneumonia and respiratory failure (Suttrup and Warnecke 2016; Sutton 2013). Our findings suggest that providing resources to inform medical, nursing, speech pathologists and pharmacists of their role in managing oral medications when a patient is unable to swallow their medications may minimise the impact of dysphagia, pneumonia and medication adverse effects have on LOS.

Delays prescribing PD medications on admission were shown to contribute to delayed or missed doses, consistent with other studies where delays in establishing the patients' home medication regimens in ED were shown to put PD patients at risk of adverse events (Harris and Fry 2017). Our findings highlight the impact of missed medications at the time of assessing patients for discharge, with worsening PD symptoms creating a need to be admitted rather than discharged from the emergency department. This is further supported by a study that demonstrated a reduced mean delay in first dose administration from over seven hours to under one hour in ED, reducing the need for patients to be transferred to the neurology ward for specialty care (Corrado et al. 2020).

Our study demonstrated that LOS is frequently prolonged due to inefficiencies in discharge planning and the fragmented nature of PD services within Royal North Shore Hospital (RNSH). Key barriers to timely discharge included inadequate communication between allied health professionals and medical staff regarding the point at which patients are deemed medically stable, as well as the practical requirements necessary to ensure safe discharge. Similar challenges have been reported in previous research, which identified poor interdisciplinary coordination as a contributing factor to extended LOS (Lovegrove and Marsden 2020; Carroll et al. 2020; Hobson et al. 2019; Moore et al. 2022; Azmi et al. 2019). Conversely, several studies have shown that LOS can be reduced and patient experiences enhanced through improved multidisciplinary communication and care coordination. Strategies such as the implementation of structured care pathways (Lovegrove and Marsden 2020), establishment of specialised PD teams (Hobson et al. 2019; Moore et al. 2022), appointment of PD specialist nurses to oversee care coordination (Moore et al. 2022) and facilitation of regular team meetings (Carroll et al. 2020) have all been associated with positive outcomes.

Within the local health district, allied health staff highlighted that PD services remain fragmented and operate in isolation. This lack of integration not only delays discharge when referrals are not initiated promptly but also restricts access for patients requiring community‐based support. We observed inconsistencies regarding the influence of residential aged care bed availability on LOS. Staff commonly perceived that extended LOS was attributable to patients awaiting placement in residential aged care facilities. However, organisational data indicated that while patients discharged to residential aged care did experience longer LOS, this accounted for only 3% of total admissions. In contrast, previous analyses of NSW Health data reported that 5.8% of PD patient admissions resulted in transfer to a nursing home, compared with 4.4% among age‐matched controls (Lubomski et al. 2015). These findings highlight the importance of critically examining staff perceptions alongside empirical data to better understand the relative contribution of residential aged care placement to LOS.

The significance of early and coordinated inpatient care has been demonstrated in previous studies, which show that timely interventions can reduce the risk of infection, slow symptom progression and prevent deterioration, including adverse impacts on mental health (Bramble et al. 2021). Our findings are consistent with common complications reported among patients with PD, including delirium, infection, medication‐related adverse effects, hypotension, constipation, dysphagia, pneumonia and falls (Dinh et al. 2025). These conditions align with the motor and non‐motor features of PD that typically worsen as the PD advances (Kalia and Lang 2015). Combining data from our cohort and existing studies (Dinh et al. 2025) indicates that the identification, early screening and documentation of pre‐existing conditions at the time of hospital presentation are often inadequate (Dinh et al. 2025). Poor recognition and attention to these conditions during admission contributes to prolonged length of stay (LOS). Furthermore, the worsening of motor and non‐motor symptoms, alongside adverse drug reactions, are well‐recognised reasons for emergency department (ED) presentations among PD patients (Suttrup and Warnecke 2016) and have been shown to significantly influence LOS (Lovegrove and Marsden 2020; Azmi et al. 2020; Carroll et al. 2020; Hobson et al. 2019; Lance et al. 2021; Nance et al. 2020; Creswell and Creswell 2017).

Our PD patient cohort had a readmission rate within 28 days of discharge that was more than double the hospital‐wide rate (Dinh et al. 2025). Staff in our study suggest that carer stress and inadequate support at home are significant contributors as families are not adequately prepared for the inevitable disease progression of PD. This, coupled with the number of comorbidities on admission and risk of hospital‐acquired complications, demonstrates the vulnerability of this cohort of patients and their impact on LOS. Other healthcare redesign projects have similarly identified the severity and complexity of PD symptoms, and the vulnerability of this patient cohort, listing falls, pneumonia, poor medication management, neuropsychiatry and postural hypotension as impacting LOS (Lovegrove and Marsden 2020; Azmi et al. 2020, 2019; Carroll et al. 2020; Hobson et al. 2019; Lance et al. 2021; Nance et al. 2020) These projects also found PD patients are often admitted across the hospital to various services due to the varied reasons for admission, which contributes to a lack of focused specialised care and gaps in services (Azmi et al. 2020, 2019; Carroll et al. 2020; Hobson et al. 2019; Nance et al. 2020; Corrado et al. 2020) which was again consistent with our findings. It has also been noted that a first admission to hospital is an indicator of future admissions (Hobson et al. 2019; Corrado et al. 2020). Analysis of organisational data did not reveal any specific factors accounting for the 44% longer LOS observed in the General Medical ward (Dinh et al. 2025). To contextualise this finding, focus group discussions provided valuable insights into the processes and culture within the Aged Care and Neurology wards. Participants identified poor communication between medical and allied health teams, the absence of clearly defined care pathways and limited access to resources as key contributors to delayed discharge and hospital‐acquired complications. These findings have informed the subsequent solutions phase, including the development of care pathways designed to improve interdisciplinary communication, care coordination and timely referral to allied health services.

Previous research suggests that healthcare redesign is likely to improve service delivery, reducing LOS and readmission rates and improving outcomes for PD patients with severe and complex symptoms admitted to hospital (Williams and Prior 2024; Lovegrove and Marsden 2020; Azmi et al. 2020; Hobson et al. 2019). The results of this study will be used by the project team to design solutions to improve the patient experience and hospital service delivery with the aim of reducing LOS and preventing readmissions. Reducing LOS for this cohort is expected to improve health outcomes for the PD patient and patient flow within the hospital. The issues we identify for the PD patient cohort may also be relevant to other patient cohorts.

4.1. Implications for the Profession and Patient Care

This study identified modifiable system‐level factors contributing to prolonged length of stay and hospital readmissions among people with Parkinson's disease. Improving clinician access to Parkinson's disease‐specific education and resources, supporting timely medication management, implementing standardised care pathways and strengthening interdisciplinary communication and discharge planning may improve patient outcomes and reduce avoidable complications. The findings may also have broader relevance for the management of other complex chronic disease populations requiring coordinated multidisciplinary care.

4.2. Limitations

A major limitation of this study is that primary qualitative data were not collected directly from patients or family members. The diagnostic phase focused on organisational data and frontline staff perspectives to identify system‐level factors influencing care delivery and patient flow. The absence of patient and carer perspectives may have influenced the issues identified and prioritised during the diagnostic phase. As this study was undertaken within a metropolitan health service with access to specialist neurology services, the identified root causes may not be representative of those experienced in other healthcare settings. Selection bias may also have influenced the qualitative findings. Focus group participants were recruited from clinical areas that had leadership approval and operational capacity to participate in the healthcare redesign process. As such, the views captured may not fully represent the experiences and perspectives of staff working in other clinical settings within the organisation. Future studies should seek broader organisational representation to ensure a more comprehensive understanding of barriers and enablers to optimal care.

Rural and regional hospitals may face additional challenges related to workforce availability, specialist access and service delivery models. Further diagnostic studies across a variety of healthcare settings are required to determine whether similar barriers exist and to identify context‐specific priorities for service improvement. Variables such as the time of admission, specifically distinguishing between after hours and business hours, were not analysed as potential contributors to the severe medication charting delays because this level of detail was not available but warrant further investigation.

5. Conclusion

This healthcare redesign project has highlighted many complex and multifactorial challenges faced by patients with PD during hospital admission, discharge and readmission. Our findings demonstrate that prolonged length of stay is driven by a combination of system inefficiencies, including fragmented service delivery, poor interdisciplinary communication, inadequate medication management and limited discharge planning. These issues are compounded by the vulnerability of the PD cohort, characterised by multiple comorbidities, hospital‐acquired complications and the burden of disease progression on patients and carers. Furthermore, clinicians who are not specialised in PD are often poorly resourced to make clinical decisions regarding medication adjustments. Identifying and implementing solutions to address the identified gaps has the potential not only to improve outcomes for PD patients but also to inform broader strategies for managing complex, chronic conditions within acute care systems.

Author Contributions

Susan Williams: conceptualization, investigation, funding acquisition, writing – original draft, methodology, validation, visualization, writing – review and editing, formal analysis, project administration, data curation, supervision. Hoang‐Mai Dinh: investigation, methodology, validation, formal analysis, data curation, writing – original draft. Vivian Imbriotis: data curation. Charlie Sargeant: data curation. Michal Lubomski: writing – original draft, supervision, conceptualization. Paul Silberstein: conceptualization, writing – original draft, supervision. Sarah J. Prior: writing – original draft, writing – review and editing, supervision, formal analysis.

Funding

This project received funding from NSLHD—North Foundation 2023 Grants Round: Patient Services.

Ethics Statement

The Northern Sydney Local Health District Human Research Ethics Committee provided ethics approved 10th November 2023 for data collection: HREA 2023/ETH02162. Royal North Shore Hospital approved Site Specific Assessment 203/STE03438: SSA 14th December 2023.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.