Implementation of geriatric clinical decision support in the emergency department for potentially inappropriate medications.

Abstract

The use of potentially inappropriate medications (PIMs) in older adults in the emergency department (ED) is associated with increased risk of readmissions and adverse drug reactions. We sought to assess the impact of electronic health record (EHR)-based geriatric clinical decision support (CDS) on adherence to geriatric recommendations for targeted PIMs prescribed to older adults while in the ED and at ED discharge. We performed a multicenter pre-post implementation cohort study comparing adherence to geriatric recommendations before and after implementation of ED geriatric CDS for patients 65 years or older for a targeted list of 12 PIMs. ED geriatric CDS consisted of custom order panels with clinical guidance for preferred alternative agents or preferred geriatric dosing if providers opted to proceed with ordering a targeted PIM; CDS was implemented for both medications ordered during the ED visit as well as outpatient prescriptions ordered at discharge. The primary outcomes were the proportions of ED orders and discharge prescriptions adherent to ED geriatric CDS recommendations. A total of 6745 ED orders and 1440 discharge prescriptions were eligible for study inclusion. The proportion of targeted PIMs consistent with geriatric CDS recommendations was higher in the postimplementation group compared to preimplementation group for both ED orders (52% vs. 71%; difference 19%, 95% confidence interval [CI] 16.8%-21.3%) and discharge prescriptions (0.5% vs. 31.7%; difference 31.1%, 95% CI 27.5%-34.7%). In the postimplementation period, geriatric CDS order panel utilization for targeted PIMs was 62.1% for ED orders and 36.7% for discharge prescriptions. Among orders placed through ED geriatric CDS order panels, 90% of ED orders and 80.4% of discharge prescriptions were adherent to geriatric CDS recommendations. EHR-based CDS for older adults in the ED increased the proportion of ED orders and discharge prescriptions adherent to geriatric drug therapy recommendations.