Decision Support in the Emergency Department to Improve Medication Safety for Older Adults

Inappropriate ED prescribing puts older adults at risk

Transitions in care, especially when patients are discharged from the emergency department (ED) back to home, can be a risky time for patients, particularly among older adults. More than half of older adults discharged from the ED leave with a new prescription medication. Often, the ED provider does not have full knowledge of a patient’s current medication regimen. Full medication review and reconciliation may not occur for several reasons, including the challenge of treating complex patients such as older adults with multiple chronic conditions in a busy ED or clinical decision support (CDS) that is not designed for the ED setting. For older patients, new medications prescribed outside of the primary care setting increases the chance of adverse drug events (ADEs), which can lead to repeat ED visits, hospitalization, or even death. The risk of receiving a new, potentially inappropriate medication (PIM) upon discharge from the ED ranges from approximately 5 percent to 13 percent.

Scaling an effective clinical decision support tool can improve medication safety

Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is a validated CDS tool developed to reduce PIMs prescribed in the ED for adults aged 65 years and older. EQUIPPED CDS includes educational material on clinical guidelines for geriatric prescribing, point-of-care prescribing order sets in the existing electronic health record (EHR), and behavioral reinforcement in the form of monthly audits and feedback with peer benchmarking. Successfully implemented into the Veterans Health Administration’s EHR at 20 sites and into a commercial EHR at three community hospitals, EQUIPPED CDS resulted in a significant and sustained reduction in PIMs prescribed to older adults at ED discharge. Dr. Ann Vandenberg and her team at Emory University implemented EQUIPPED into a new EHR, using the traditional EQUIPPED implementation model, and at three additional sites using a new hub-and-spoke implementation model. By using differing EHRs and implementation models, they sought to further demonstrate EQUIPPED’s agility and effectiveness in reducing PIMs across different settings.

“One of the interesting things we learned was how high some of these potentially inappropriate medication prescribing rates are and uncovered the need to [implement] a tool like EQUIPPED. Across all sites, prescriptions of potentially inappropriate medications reduced after EQUIPPED was implemented, regardless of implementation model.” – Dr. Ann Vandenberg

EQUIPPED improves safety of prescribing

For the “traditional” site, modeled after previous EQUIPPED implementation efforts, the site adapted and implemented all program components itself. In contrast, the spread sites can be conceived as spokes branching from a hub that had already implemented EQUIPPED. The central hub had the experience and infrastructure in place to deliver education, order sets, and provider feedback reports to a local known champion, who was tasked with delivering provider feedback reports, participating in regular ED meetings, and answering questions. Regardless of the model used or the EHR in place, EQUIPPED proved successful at all sites in significantly reducing prescriptions of PIMs, including two medication classes most problematic for older adults: skeletal muscle relaxants and benzodiazepines. The research showed that EQUIPPED CDS can be successfully and effectively implemented using different implementation models and EHR platforms. If scaled more broadly, it could have profound patient safety impacts by improving medication management and reducing ADEs.