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ED Prescribing for Elderly Improved in Team-Based VA Program

ATLANTA – In a crowded and fast-paced emergency department, who has time to look up which medications are optimal for elderly patients?

That was one of the assumptions in a new study conducted by Department of Veterans Affairs (VA) researchers. Yet, a study team lead by researchers from Emory University and the Atlanta VA Medical Center found that 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 goal is to decrease the use of potentially inappropriate medications (PIMs), defined by the American Geriatrics Society Beers criteria, in veterans aged 65 and older.

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 all were used to remedy the problem.

ED clinical staff attended a November 2012 geriatric pharmacology lecture, then reviewed the 2012 Beers Criteria Update two months later. Reminder cards listing the top five most-frequently prescribed PIMs were placed at ED computer stations in May 2013.

Perhaps most importantly, 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 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.

The largest decrease was documented with muscle relaxants but there also were declines in prescriptions for chronic NSAIDs, and promethazine, according to the study results. The authors note the PIMs reduction was sustained for 12 months, “suggesting a culture change with respect to prescribing patterns for older adults discharged from the ED.”