July 8, 2015
ED Team Effort Reduces Potentially Inappropriate
Prescribing for Elderly

Atlanta—In the rush to provide care and move patients through quickly, emergency departments (EDs) sometimes prescribe less-than-optimal medications for older patients.

According to preliminary results from a new study conducted by Department of Veterans Affairs (VA) researchers, ED prescribing practices can be improved by use of a team including clinical pharmacists, emergency physicians, geriatricians, nurses, and clinical applications coordinators. The report was published recently in the Journal of the American Geriatrics Society.

The study, Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the ED (EQUiPPED), is an ongoing multicomponent, interdisciplinary quality improvement initiative in eight VA EDs. The study team, led by researchers from Emory University and the Atlanta VA Medical Center, sought to decrease the use of potentially inappropriate medications (PIMs)—as identified by the American Geriatrics Society Beers Criteria—prescribed to veterans aged 65 and older at ED discharge.

To reach that goal, they used informatics-based clinical decision support with electronic medical record–embedded geriatric pharmacy order sets and links to online geriatric content as well as provider education, including academic detailing, audit and feedback, and peer benchmarking.

For example, 2 months after a November 2012 geriatric pharmacology lecture, healthcare providers reviewed the 2012 Beers Criteria Update. Reminder cards listing the top five most-frequently prescribed PIMs then were placed at computer stations in the ED in May 2013.

In addition, the study team put together outpatient pharmacy order sets with preferred medications for the elderly, categorized by common discharge diagnoses. ED prescribers were able to see the specialized sets, which were approved by the clinical pharmacist and others, when they viewed the original order sets in the electronic medical record.

“Dose adjustments for renal impairment, point-of-prescribing education regarding medications to avoid, and links to synthesized geriatric content were embedded within the order sets,” study authors explain. “The order entry process was streamlined with prepopulated fields including: ‘days supply,’ ‘number of pills,’ and “method for prescription pick-up.”

Before the targeted intervention, “the average monthly proportion of PIMs prescribed was 9.4 ± 1.5%. This declined to 4.6 ± 1.0% after the initiation of the EQUiPPED interventions,” the authors note.

Prescriptions were reduced for skeletal muscle relaxants, chronic NSAIDs, and promethazine, with the largest decrease documented among muscle relaxants, according to study results.

“The reduction in PIMs was sustained for 12 months, suggesting a culture change with respect to prescribing patterns for older adults discharged from the ED,” the authors point out.

“Preliminary evaluation demonstrated a significant and sustained reduction of ED-prescribed PIMs in older veterans after implementation of EQUiPPED,” the report concludes. “Longer follow-up and replication at collaborating sites would allow for an assessment of the effect on health outcomes and costs.”

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