By Annette M. Boyle


A recent quality improvement project conducted at the VA found that a team approach and some simple tools can substantially improve prescribing practices for elderly patients released from emergency care. In this VA photo, a nurse gives medication to a patient.

ATLANTA — In the bustle of a hectic VAMC emergency department, do healthcare providers always remember which common medications are often problematic for older veterans? Usually not.

But a little help and some teamwork can make avoiding potentially inappropriate medications (PIMs) much easier.

Knowing the right drug and the right dose for an older patient is important in any emergency department (ED). It’s especially critical for the VHA, with 45% of patients receiving care being age 65 or older, according to VA researchers.

A recent quality-improvement project conducted at the VA found that a team approach and some simple tools can substantially improve prescribing practices. The Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the ED (EQUiPPED) quality initiative implemented in eight VA EDs aimed to reduce the number of prescriptions for PIMS written at discharge for elderly patients. The researchers defined PIMs as the American Geriatrics Society 2012 Beers Criteria Update Category 1 medications to avoid for all older adults.

Results of the program were recently published in the Journal of the American Geriatrics Society.1

“A number of studies have shown that older patients are frequently prescribed potentially inappropriate medications, which can lead to adverse drug events such as falls, drug-drug interactions or hospitalization. Our study demonstrated that a team approach, combined with education and order sets, can significantly reduce the use of these medications,” said lead author Melissa B. Stevens, MD, of the Atlanta VAMC and assistant professor of medicine at Emory University School of Medicine.

In the eight months preceding the intervention, the monthly proportion of PIMs at the first site, Atlanta, averaged 9.4%. The rate dropped to an average of 4.6% within six months of the start of the quality initiative. The low rate was sustained for more than 12 months, “suggesting a culture change with respect to prescribing patterns for older adults discharged from the ED,” noted the authors.

The Intervention

In Atlanta, an interdisciplinary team that included ED physicians, geriatricians, gerontologists, clinical pharmacists, quality-improvement nurses and clinical-applications coordinators employed the VA’s Vision-Analysis-Team-Aim-Map-Measure-Change-Sustain model to develop the EQUiPPED initiative. The team set a goal of less than 5% for PIMs.

The initiative kicked off in November 2012 with provider education on geriatric pharmacology, delivered as a lecture, during three shifts over the course of a month to maximize access for all ED providers. Of the 16 full-time staff providers, 12 attended a session. Some received additional information during a quarterly journal club in January 2013. The team also developed reminder cards that identified the five most frequently prescribed PIMs, based on prescribing trends at the Atlanta VAMC and placed those at ED computer stations.

Next, the team developed geriatric outpatient pharmacy order sets that provided medication options appropriate for older patients for common discharge diagnoses and embedded dose adjustments for renal impairment and other information. These appeared next to existing order sets in the electronic medical record (EMR) order menu. Activated in February 2013, the order sets streamlined the prescribing process for providers by prepopulating fields with appropriate number of days of supply, number of pills and method for prescription pickup.

“Providers had used the previous discharge order sets, which listed common medications without consideration for age or conditions, such as kidney function, because they simplified the order-entry process,” Stevens told U.S. Medicine. “The geriatric order set made it easier to choose safer drugs and dosages for older patients.”

All ED staff providers also received over a three-month period at least one face-to-face feedback session, which discussed their individual prescribing patterns and compared their performance to that of other ED providers at their site. The team distributed standardized monthly reports to each provider on the number of veterans over age 64 each provider saw and discharged, total number of prescriptions written, the proportion of PIMs, the classes of PIMs and peer-benchmarking data.

In Atlanta, the five most frequently prescribed PIMs or categories of PIMs were diphenhydramine, hydroxyzine, skeletal muscle relaxants, chronic NSAIDs (more than 30 days) and promethazine. Muscle relaxants saw the biggest drop following the intervention, with a 60% reduction. Hydroxyzine and diphenhydramine were the only two that did not decrease.

A Flexible Bundle

The other sites saw similar drops in PIMs, said Stevens, despite some differences in the specifics of the intervention’s implementation.

“Because we introduced the changes as a bundle, we can’t say which elements are most important,” Stevens noted, but flexibility in the structure of the team, the education and feedback process, and introduction of the order sets did not significantly affect results.

“As a quality-improvement initiative rather than a research study, we had more flexibility and could adapt the interventions to reflect the resources available at each of the eight sites,” she explained. In some sites, emergency physicians provided the one-on-one feedback, while in others, a clinical pharmacist or geriatrician led those discussions.

“In Atlanta, we introduced all the order sets at once, while in Durham, we needed to introduce them sequentially. Both approaches worked.”

  1. Stevens MB, Hastings SN, Powers J, Vandenberg AE, Echt KV, Bryan WE 3rd, Peggs K, Markland AD, Hwang U, Hung WW, Schmidt AJ, McGwin G, Ikpe-Ekpo E, Clevenger C, Johnson TM 2nd, Vaughan CP. Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED): Preliminary Results from Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department, a Novel Multicomponent Interdisciplinary Quality Improvement Initiative. J Am Geriatr Soc. 2015 May;63(5):1025-9. doi: 10.1111/jgs.13404. Epub 2015 May 6. PubMed PMID: 25945692.