Targeted intervention improves ED prescribing for elderly


A targeted intervention at an urban Veterans Affairs Medical Center helped to improve the prescribing practices for elderly veterans discharged from the emergency department

A targeted intervention at an urban Veterans Affairs Medical Center helped to improve the prescribing practices for elderly veterans discharged from the emergency department (ED), according to a recent study published in the Journal of the American Geriatrics Society.

In the initial phase of the study, a team of ED doctors, geriatricians, clinical pharmacists, nurses, and clinical applications coordinators developed a process improvement model with an aim of reducing the prescribing of potentially inappropriate medications (PIMs) for patients who were 65 years and older. The list of PIMs included those medications taken from the American Geriatrics Society 2012 Beers Criteria Update.

The targeted intervention involved provider education, electronic medical record (EMR) clinical decision support, provider feedback, and program evaluation. ED staff providers were encouraged to attend a geriatric pharmacology lecture during November 2012. Two months later, they reviewed the 2012 Beers Criteria Update, and reminder cards detailing the top five most-frequently prescribed PIMs were placed at computer stations in the ED in May 2013.

The team worked on geriatric outpatient pharmacy order sets that were categorized by common discharge diagnoses with preferred medications for the elderly. These order sets were placed next to the original order sets in the EMR.

“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,” Melissa B. Stevens, MD, and her colleagues wrote. “The order entry process was streamlined with prepopulated fields including: ‘days supply,’ ‘number of pills,’ and method for prescription pick-up.”

The team of pharmacists, ED providers, and pharmacy and therapeutics committee reviewed the order sets and logic before implementation in December 2012.

All 16 ED providers received feedback individually through an audit and peer benchmarking from February 2013 through April 2013. Then they also were evaluated monthly with a total of medications prescribed and total number that were PIMs.


Study results

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 wrote.

The “Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department” initiative demonstrated that the prescribing practices in the ED could be improved with provider education, clinical decision support in the EMR, and peer feedback.

Of the five most commonly prescribed PIMs, the interventions helped reduce prescriptions in the elderly for skeletal muscle relaxants, chronic NSAIDs, and promethazine. The largest decrease was seen in the muscle relaxant category, the authors noted.

“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,” they wrote.

The EQUiPPED intervention is continuing at seven other VA facilities. Funding for the study was provided by a grant from Emory University Department of Medicine.

Also, see: Greatest impact of pharmacist transition care seen in the elderly

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