Scaling E.Q.U.I.P.P.E.D. Clinical Decision Support Older adults are a vulnerable population at high risk for medication adverse drug events (ADEs), especially when they are discharged from the Emergency Department (ED). More than half of older adults discharged from the ED leave with a new prescription medication.1,2 The risk of receiving a new potentially inappropriate medication (PIM) upon discharge from the ED ranges from 5.6%-13%.2-7 Prescribing new medications for older patients outside the primary care setting increases chances for suboptimal prescribing as well as ADEs, both major reasons for repeat ED visits, hospitalization or death.1-8 EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) is an innovative quality improvement initiative designed to reduce PIM prescribing for adults aged 65 years and older.9 EQUIPPED?s three interventions together address the 5 Rights Framework promoted by AHRQ: 1) provider education via didactic education; 2) electronic clinical decision support via specialized geriatric pharmacy order sets and links to online educational content at point of prescribing; and 3) academic detailing including audit and feedback and peer benchmarking. EQUIPPED is informed by the Beers Criteria,10 widely used by government agencies and supported by research in various settings1,5,6 as a marker of prescribing quality. EQUIPPED has been successfully implemented in 11 urban and rural Veterans Affairs (VA) Medical Centers using the Computerized Patient Record System electronic health record (EHR), with the first 4 sites reducing PIMs from 7.4%-11.9% of all medications at pre-implementation baseline to 4.5%-6.1% one year post-implementation.11 It has further been implemented in 2 academic hospitals using the Epic EHR, with the first site reducing the percentage of providers who prescribed zero (0) PIMs from 25/89 (28%) pre- implementation to 61/89 (68%) 6 months post-implementation. With demonstrated effectiveness in 2 widely used EHRs, we now propose to scale up EQUIPPED CDS in 2 ways. First, we will extend implementation of EQUIPPED CDS to a new EHR, Cerner/Powerchart, thereby widening the scope of applicability to at least 45% of the hospital EHR market outside the VA system.12 Second, we will effect local scale-up by widening implementation from 1 academic hospital to 4 additional hospitals (including 2 community sites) within a single health system.
Specific Aim 1 : Scale EQUIPPED CDS in two settings, Cerner/Powerchart EHR at Emory University Hospital and three addition sites in the Mount Sinai ED system.
Specific Aim 2 : Evaluate implementation scale-up using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework.
As of 2014, adults aged 65 years and older accounted for about 25 million Emergency Department (ED) visits in the US. Older adults are more vulnerable to medication adverse effects, yet they are frequently prescribed at least one new medication upon ED discharge, which adds complexity for patients and increases the risk of drug-drug interactions, adverse drug events, or dosing errors. E.Q.U.I.P.P.E.D. (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) is a multi-component quality improvement initiative that uses clinical decision support (CDS) to reduce potentially inappropriate medication prescriptions written by ED providers for older adults at time of ED discharge. Already successfully implemented in 11 VA using Computerized Patient Record System and 2 academic hospitals using Epic, EQUIPPED CDS is being scaled to encompass a new site using Cerner and an Epic-based health system.
