Scaling E.Q.U.I.P.P.E.D. Clinical Decision Support (Georgia)

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Creating Age-Friendly Health Systems: Implementing Decision Support in the ED to Improve Geriatric Prescribing Practices

SIGNIFICANCE AND POTENTIAL IMPACT

Scaling and disseminating a CDS system that provides physicians with targeted medication information may enhance safe prescribing practices for geriatric patients in the ED.

Suboptimal prescribing can result in repeated ED visits, hospitalizations, or other adverse events

Older adults, particularly those prescribed new medications upon discharge from an ED visit, are at an increased risk of adverse drug events (ADEs). Preventable suboptimal prescribing can result in repeated ED visits, hospitalizations, or other adverse events. Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is a previously validated CDS tool developed to reduce PIMs prescribed in the ED for adults aged 65 years and older. While it is currently in use at 20 Veterans Administration Hospitals and three community hospitals, Dr. Ann Vandenberg of Emory University wants to scale and disseminate EQUIPPED to three additional EDs and a new EHR platform not previously used with the EQUIPPED tool.

Using CDS to improve quality of prescribing in the ED

Dr. Vandenberg describes the ED environment as “busy, with a lot of interruptions and transitions,” while ED physicians have limited training in geriatric medicine. To help facilitate safe prescribing practices for clinicians, EQUIPPED offers education sessions on geriatric clinical prescribing guidelines, customizable pharmacy order sets, and monthly performance evaluation tools that are refined based on clinical and local data. Data from previous EQUIPPED implementations show a significant and sustained reduction in the average monthly PIMs prescribed at the time of discharge. Dr. Vandenberg is confident the EDs implementing EQUIPPED in this project will have similar results.

“Some drugs are not as effective or have adverse risks for older adults, but some providers do not know that. This project will really raise awareness of this issue.”
– Dr. Vandenberg

A multi-disciplinary approach to ED safety

Dr. Vandenberg feels the most significant aspect of this research is how it will spread the principles of geriatric medicine into spaces where they might not be as common. “EQUIPPED is part of a movement to create age-friendly health systems,” Dr. Vandenberg explains. With a rapidly aging population, she wants older adults in the United States to know that researchers and clinicians are “looking after them and equipping the ED to protect them.”

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Scaling and disseminating a CDS system that provides physicians with targeted medication information may enhance safe prescribing practices for geriatric patients in the ED.

Project Details - Ongoing

Summary:

The prescription of potentially inappropriate medications (PIMs) to older adults upon discharge from the emergency department (ED) is a common yet preventable event. Episodes of suboptimal prescribing in the ED have increased as more older adults are discharged to home rather than admitted to an inpatient unit. These increases have been attributed to lack of emergency medicine geriatric training, insufficient knowledge of age-related changes in how the body responds to and metabolizes medications, and time constraints in treating older adults with multiple morbidities in this setting. Consequences of suboptimal prescribing include an increased risk of repeat ED visits, hospitalizations, and death.

Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is a well-established quality improvement initiative designed to decrease the number of PIMs prescribed to adults aged 65 and older upon discharge from the ED. EQUIPPED Clinical Decision Support (CDS), includes education sessions on clinical guidelines for geriatric prescribing, point-of-care prescribing order sets implemented 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 Veteran Health Administration’s EHR at 11 sites and into a commercial EHR at 3 academic hospitals, EQUIPPED CDS resulted in a significant and sustained reduction in average monthly PIMs prescribed to older adults at ED discharge. Most recently, the initiative increased the percentage of prescribers who prescribed zero PIMs from 27 to 71. These results indicate that EQUIPPED CDS is ready to be scaled and spread beyond these two EHRs.

The specific aims of the research are as follows:

  • Scale EQUIPPED CDS in two ways: 1) to three additional ED satellites of an existing EQUIPPED site that use the Epic EHR, and 2) into a new EHR, Cerner/PowerChart, at a new academic site ED. 
  • Evaluate scale-up using Reach-Effectiveness-Adoption-Implementation-Maintenance framework. 

By scaling to EHRs that are well established and widely used, EQUIPPED has the potential to reach approximately 45 percent of the civilian EDs in the United States, in addition to 100 percent of the VA EDs. The implementation will also extend EQUIPPED to a community hospital setting. In doing so, it will increase the diversity of providers and patients potentially impacted by EQUIPPED.