Electronic Surveillance and Pharmacist Intervention for Vulnerable Older Inpatients on High-Risk Medication Regimens Josh F. Peterson, MD, MPH,*† Sunil Kripalani, MD, MS,† Ioana Danciu, MS,* Debbie Harrell, MS, DPh,‡ Marketa Marvanova, PharmD, PhD,§ Amanda S. Mixon, MD, MS, MSPH,†¶ Carmen Rodriguez, BS,† and James S. Powers, MD†¶
OBJECTIVES: To develop and evaluate an electronic tool to assist clinical pharmacists with reviewing potentially inappropriate medications (PIMs) in hospitalized elderly adults. DESIGN: Pilot intervention. SETTING: Academic tertiary care hospital. PARTICIPANTS: Hospitalized adults aged 65 and older admitted to the general medicine, orthopedics, and urology services during a 3-week period in 2011 who were administered at least one medication from a list of 240 PIMs. INTERVENTION: A computerized PIMS dashboard flagged individuals with at least one administered PIM or a high calculated anticholinergic score. The dashboard also displayed 48-hour cumulative narcotic and benzodiazepine administration. Participants were ranked to reflect the estimated risk of an adverse event using logical combinations of data (e.g., use of multiple sedatives in a nonmonitored location). In a pilot implementation, a clinical pharmacist reviewed the flagged records and delivered an immediate point-of-care intervention for the treating physician. MEASUREMENTS: Clinician response to pharmacist intervention. RESULTS: The PIMS dashboard flagged 179 of 797 individuals (22%) admitted over a 3-week period and 485 participant-medication pairs for review by the clinical pharmacist. Seventy-one participant records with 139 participant–medication pairs required additional manual review of the electronic medical record. Twenty-two participants receiving 40 inappropriate medication orders were judged to warrant an intervention, which was delivered by personal communication over the telephone or text From the *Departments of Biomedical Informatics; †Medicine; Pharmaceutical Services, School of Medicine, Vanderbilt University, Nashville, Tennessee; §School of Pharmacy, College of Pharmacy, Chicago State University, Chicago, Illinois; and ¶Tennessee Valley Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. ‡
Address correspondence to Josh Peterson, 2525 West End Ave—Suite 1050, Nashville, TN 37203. E-mail: [email protected] DOI: 10.1111/jgs.13057
JAGS 62:2148–2152, 2014 © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society
message. Clinicians enacted 31 of 40 (78%) pharmacist recommendations. CONCLUSION: An electronic PIM dashboard provided an efficient mechanism for clinical pharmacists to rapidly screen the medication regimens of hospitalized elderly adults and deliver a timely point-of-care intervention when indicated. J Am Geriatr Soc 62:2148–2152, 2014.
Key words: medication safety; vulnerable elderly; pharmacy intervention; clinical informatics; acute care; geriatrics
I
ndividuals aged 65 and older are at higher risk of experiencing an adverse drug event (ADE) than younger individuals, particularly if they are prescribed medications associated with risk of delirium, falls, cognitive decline, sedation, and other adverse reactions.1–7 Potentially inappropriate medications (PIMs) in elderly adults are identified on multiple published lists, including the highly cited Beers criteria, Screening Tool of Older Persons’ Prescriptions (STOPP), and scales of anticholinergic load.8–15 These publications are developed based on evidence review and expert guidance and list medications, medication doses or frequencies, or drug combinations that are thought to cause more harm than benefit in vulnerable elderly adults. Examples of drug classes are benzodiazepines, centrally and peripherally acting anticholinergics, antipsychotics, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensive medications, and other cardiac medications. Despite guidelines cautioning against their use, prescribing of PIMs is common in the hospital setting.16–20 Automated interventions to reduce the use of PIMs are variably effective.3,21–23 Evaluations of clinical decision-support systems to encourage substitution or discontinuation of PIMs demonstrate that physicians often ignore or override automated alerts because of perceived lack of clinical relevance (if the alert does not incorporate clinical context) or “alert fatigue.”3,21–23 Some authors have pointed out that geriatric medication decisions are difficult
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and not always amenable to resolution using a computerized prompt.24–26 The revised 2007 Assessing Care of Vulnerable Elders indicators from the American Geriatrics Society emphasizes patient education, drug regimen review, prescribing indicated medications, and medication monitoring.27 Active review by a clinical pharmacist has been shown to lead to significant improvement in the appropriateness of prescribing, as well as trends toward greater satisfaction and fewer emergency department visits and deaths at 1 year,28 but untargeted approaches that rely entirely on clinical pharmacists have high labor costs and may be difficult to sustain.29 Tools and procedures to conduct real-time geriatric medication risk (GMR) surveillance as a complement to clinical pharmacy review and decision support targeting the ordering provider were developed. This approach extends a model for pharmacy services successfully applied to the prescription of aminoglycosides, vancomycin, insulin, and medication management during acute kidney injury.30 A hospital clinical information system was used to perform an automated review of medication orders, flag cases, and synthesize the relevant information about those cases into a clinical dashboard that a clinical pharmacist could review. This pilot study is designed to test the feasibility, clinician responsiveness, and acceptability of a PIM dashboard, coupled with an intervention by a clinical pharmacist, in reducing the use of PIMs in hospitalized elderly adults.
METHODS Setting and Population Vanderbilt University Hospital is a 658-bed teaching hospital that serves as a principal referral center for physicians and people throughout the southeast United States. The pilot targeted individuals aged 65 and older admitted to the general medicine, orthopedics, and urology services. The institutional review board approved the study as a quality improvement intervention.
Description of Usual Care Patient information at Vanderbilt University Hospital is entered and stored in an electronic health record (EHR). All physician orders are entered electronically the hospital’s computerized order entry system, which provides decision support for the medication ordering process, suggesting for example, lower doses of certain medications when prescribed to elderly adults or individuals with impaired kidney function. In addition to providing on-screen text messages (which may be overlooked or ignored), the system relies on physicians to be personally attentive to the medication’s geriatric risk profile. There is no automated support to flag PIMs for further review or routine clinical pharmacist involvement on all medical units to assist physicians with more-appropriate prescribing.
Pilot Intervention and Study Procedures An electronic PIM dashboard (Figure 1) was developed that identifies, in real time, hospitalized individuals aged 65 and older who have been prescribed at least one PIM.
SURVEILLANCE FOR HIGH-RISK MEDICATIONS
2149
PIMs were defined as medications included on the Beers criteria, STOPP lists, or a published anticholinergic risk scale, cross-referenced with medications included on the pilot institution’s hospital formulary.8,10,11 The dashboard displays each individual’s age, sex, location, height, weight, estimated kidney function, flagged PIMs, anticholinergic score,10 total opioid equivalent use, benzodiazepine use, name of the inpatient service with origin of the order or order set, and a link to the summary view of the EHR. The dashboard also uses a higher number of PIMs and use of any benzodiazepine to sort the patient list by those potentially at highest risk and draw the pharmacist’s attention to those who may need an intervention more promptly. To briefly summarize the dashboard functions, an individual is added to the dashboard if any of the PIMs listed as “triggers” are prescribed, excluding medication orders that do not exceed a minimum daily dose requirement (Appendix S1). Regardless of the presence of PIMs, individuals are added if the calculated anticholinergic score for all administered medications is three or greater. The alerts column shows all ordered priority drugs that are still active or were discontinued
OBJECTIVES: To develop and evaluate an electronic tool to assist clinical pharmacists with reviewing potentially inappropriate medications (PIMs) in hospitalized elderly adults. DESIGN: Pilot intervention. SETTING: Academic tertiary care hospital. PARTICIPANTS: Hospitalized adults aged 65 and older admitted to the general medicine, orthopedics, and urology services during a 3-week period in 2011 who were administered at least one medication from a list of 240 PIMs. INTERVENTION: A computerized PIMS dashboard flagged individuals with at least one administered PIM or a high calculated anticholinergic score. The dashboard also displayed 48-hour cumulative narcotic and benzodiazepine administration. Participants were ranked to reflect the estimated risk of an adverse event using logical combinations of data (e.g., use of multiple sedatives in a nonmonitored location). In a pilot implementation, a clinical pharmacist reviewed the flagged records and delivered an immediate point-of-care intervention for the treating physician. MEASUREMENTS: Clinician response to pharmacist intervention. RESULTS: The PIMS dashboard flagged 179 of 797 individuals (22%) admitted over a 3-week period and 485 participant-medication pairs for review by the clinical pharmacist. Seventy-one participant records with 139 participant–medication pairs required additional manual review of the electronic medical record. Twenty-two participants receiving 40 inappropriate medication orders were judged to warrant an intervention, which was delivered by personal communication over the telephone or text From the *Departments of Biomedical Informatics; †Medicine; Pharmaceutical Services, School of Medicine, Vanderbilt University, Nashville, Tennessee; §School of Pharmacy, College of Pharmacy, Chicago State University, Chicago, Illinois; and ¶Tennessee Valley Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee. ‡
Address correspondence to Josh Peterson, 2525 West End Ave—Suite 1050, Nashville, TN 37203. E-mail: [email protected] DOI: 10.1111/jgs.13057
JAGS 62:2148–2152, 2014 © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society
message. Clinicians enacted 31 of 40 (78%) pharmacist recommendations. CONCLUSION: An electronic PIM dashboard provided an efficient mechanism for clinical pharmacists to rapidly screen the medication regimens of hospitalized elderly adults and deliver a timely point-of-care intervention when indicated. J Am Geriatr Soc 62:2148–2152, 2014.
Key words: medication safety; vulnerable elderly; pharmacy intervention; clinical informatics; acute care; geriatrics
I
ndividuals aged 65 and older are at higher risk of experiencing an adverse drug event (ADE) than younger individuals, particularly if they are prescribed medications associated with risk of delirium, falls, cognitive decline, sedation, and other adverse reactions.1–7 Potentially inappropriate medications (PIMs) in elderly adults are identified on multiple published lists, including the highly cited Beers criteria, Screening Tool of Older Persons’ Prescriptions (STOPP), and scales of anticholinergic load.8–15 These publications are developed based on evidence review and expert guidance and list medications, medication doses or frequencies, or drug combinations that are thought to cause more harm than benefit in vulnerable elderly adults. Examples of drug classes are benzodiazepines, centrally and peripherally acting anticholinergics, antipsychotics, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensive medications, and other cardiac medications. Despite guidelines cautioning against their use, prescribing of PIMs is common in the hospital setting.16–20 Automated interventions to reduce the use of PIMs are variably effective.3,21–23 Evaluations of clinical decision-support systems to encourage substitution or discontinuation of PIMs demonstrate that physicians often ignore or override automated alerts because of perceived lack of clinical relevance (if the alert does not incorporate clinical context) or “alert fatigue.”3,21–23 Some authors have pointed out that geriatric medication decisions are difficult
0002-8614/14/$15.00
JAGS
NOVEMBER 2014–VOL. 62, NO. 11
and not always amenable to resolution using a computerized prompt.24–26 The revised 2007 Assessing Care of Vulnerable Elders indicators from the American Geriatrics Society emphasizes patient education, drug regimen review, prescribing indicated medications, and medication monitoring.27 Active review by a clinical pharmacist has been shown to lead to significant improvement in the appropriateness of prescribing, as well as trends toward greater satisfaction and fewer emergency department visits and deaths at 1 year,28 but untargeted approaches that rely entirely on clinical pharmacists have high labor costs and may be difficult to sustain.29 Tools and procedures to conduct real-time geriatric medication risk (GMR) surveillance as a complement to clinical pharmacy review and decision support targeting the ordering provider were developed. This approach extends a model for pharmacy services successfully applied to the prescription of aminoglycosides, vancomycin, insulin, and medication management during acute kidney injury.30 A hospital clinical information system was used to perform an automated review of medication orders, flag cases, and synthesize the relevant information about those cases into a clinical dashboard that a clinical pharmacist could review. This pilot study is designed to test the feasibility, clinician responsiveness, and acceptability of a PIM dashboard, coupled with an intervention by a clinical pharmacist, in reducing the use of PIMs in hospitalized elderly adults.
METHODS Setting and Population Vanderbilt University Hospital is a 658-bed teaching hospital that serves as a principal referral center for physicians and people throughout the southeast United States. The pilot targeted individuals aged 65 and older admitted to the general medicine, orthopedics, and urology services. The institutional review board approved the study as a quality improvement intervention.
Description of Usual Care Patient information at Vanderbilt University Hospital is entered and stored in an electronic health record (EHR). All physician orders are entered electronically the hospital’s computerized order entry system, which provides decision support for the medication ordering process, suggesting for example, lower doses of certain medications when prescribed to elderly adults or individuals with impaired kidney function. In addition to providing on-screen text messages (which may be overlooked or ignored), the system relies on physicians to be personally attentive to the medication’s geriatric risk profile. There is no automated support to flag PIMs for further review or routine clinical pharmacist involvement on all medical units to assist physicians with more-appropriate prescribing.
Pilot Intervention and Study Procedures An electronic PIM dashboard (Figure 1) was developed that identifies, in real time, hospitalized individuals aged 65 and older who have been prescribed at least one PIM.
SURVEILLANCE FOR HIGH-RISK MEDICATIONS
2149
PIMs were defined as medications included on the Beers criteria, STOPP lists, or a published anticholinergic risk scale, cross-referenced with medications included on the pilot institution’s hospital formulary.8,10,11 The dashboard displays each individual’s age, sex, location, height, weight, estimated kidney function, flagged PIMs, anticholinergic score,10 total opioid equivalent use, benzodiazepine use, name of the inpatient service with origin of the order or order set, and a link to the summary view of the EHR. The dashboard also uses a higher number of PIMs and use of any benzodiazepine to sort the patient list by those potentially at highest risk and draw the pharmacist’s attention to those who may need an intervention more promptly. To briefly summarize the dashboard functions, an individual is added to the dashboard if any of the PIMs listed as “triggers” are prescribed, excluding medication orders that do not exceed a minimum daily dose requirement (Appendix S1). Regardless of the presence of PIMs, individuals are added if the calculated anticholinergic score for all administered medications is three or greater. The alerts column shows all ordered priority drugs that are still active or were discontinued
