# Clinical Decision Support for Safe Prescribing in the Geriatric ED Learning from EQUiPPED EQUiPPED is a medication safety improvement program that was initially developed in the Veterans Affairs (VA) health system as a quality improvement (QI) project. EQUiPPED stands for enhancing quality of prescribing practices for older adults discharge from the ED. The QI goal was to decrease the proportion of potentially inappropriate medications (PIMs) prescribed to veterans aged 65 years of age and older at the time of discharge from the ED to 5% or less. It has been shown to be effective, feasible and sustainable at reducing potentially inappropriate prescriptions from the ED across multiple settings, including being academic and the VA systems.  Early results after exporting EQUIPPED from the VA to 3 academic health systems demonstrated significant reduction in PIM prescribing at one of the sites and a trend towards reduced prescribing of specific high-risk medication classes at all sites. Achieving significant reduction in specific high-risk drug classes may be a more appropriate target for sites that have relatively low baseline PIM prescribing rates.  (this dovetails nicely to work done by Rachel Skains and Michelle Lin on the GEMS Rx expert consensus-based list of high-risk prescriptions for older ED patients). EQUiPPED has 3 components:  Provider education –didactic education and academic detailing focused on reducing potentially inappropriate medications (PIMs)  Clinical Decision Support (CDS)– Discharge medication order sets designed to promote safer prescribing and provide alternatives to PIMs. Avoid alerts that require acknowledgement and interrupt workflow when possible.  Provider feedback – Clinicians receive monthly prescribing feedback reports that include individual prescribing habits, peer benchmarking, and alternate prescribing recommendations.  Clinicians meet with site champion at least once for one to one academic detailing.  Read the Articles: Stevens MB, Hastings SN, Powers J, et al. 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;63(5):1025-9. doi: 10.1111/jgs.13404.  Vaughan CP, Hwang U, Vandenberg AE, et al. Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme. BMJ Open Quality 2021;10:e001369. doi:10.1136/ bmjoq-2021-001369  The authors found that their existing computerized provider order entry (CPOE) process could increase prescribing of PIMs in older adults at the time of ED discharge. Existing discharge order sets consisted of an alphabetized list of commonly used medications without consideration of dosage adjustments for age or renal function. By engaging ED providers, they determined clinicians preferentially used the existing list for prescribing because it streamlined order entry and not because they necessarily felt the listed medications were superior choices. Subsequently, the EQUiPPED authors developed geriatric medication order sets grouped according to common discharge diagnoses with medication options preferred for use in older adults. These templates were placed alongside existing order sets in the electronic medical record order menu for all patients checked into the ED. Dose adjustments for renal impairment, point-of-prescribing education regarding medications to avoid, and links to synthesized geriatric content were embedded within the order sets. When providers prescribed medications using the order sets, the order entry process was streamlined with prepopulated fields including: “days supply,” “number of pills,” and method for prescription pick-up. Pharmacists, ED providers, and the local VA pharmacy and therapeutics committee reviewed template logic that the group developed before implementation. In addition to expediting the order entry process, the order sets simultaneously encouraged providers to choose safer medications.  Designing Decision Support for the EMR As you look to incorporate passive decision support into your electronic medical record (EMR) you should work with your Pharmacy Department and Information Systems to establish a list of essential categories of drugs commonly prescribed in the ED. This is true for both potentially inappropriate medications (PIMs) and drug interaction alerts. Use brief but practical precautions with education on pharmacology and pharmacokinetic considerations for older adults. Physicians may be able to prescribe drugs, but prompts along the way indicate why they may not be first line for certain patients. Add point of prescribing education with links to geriatric-specific education content where relevant. Avoid drug alert messages that require provider acknowledgement as these are often ignored. Drug Interaction Alerts for the Geriatric ED Three commonly prescribed medication classes in the ED are antimicrobial drugs, NSAIDs, and Cardiovascular drugs. These may be potentially inappropriate or lead to drug-drug interactions, especially for our older ED patients. Antimicrobial drug interactions Trimethoprim-Sulfamethoxazole (TMP-SMX) and spironolactone taken together increase the risk for hyperkalemia with a clear association between trimethoprim and sudden cardiac death. There is a 12 fold increased risk in hospital admission for hyperkalemia in elderly patients taking TMP-SMX in combination with spironolactone compared to amoxicillin in combination with spironolactone. There is a 7 fold increased risk in hospital admission for hyperkalemia in elderly patients taking TMP in combination with ACEIs or ARBs. Set Alerts: Trimethoprim-Sulfamethoxazole (TMP-SMX)– Alert fires if this antibiotic is ordered and  the patient is on an ACEI, ARB, mineralocorticoid, or ARNI.   Other examples of TMP-SMX interactions where alert fires on medication ordering:   Sulfonylurea + TMP-SMX à hypoglycemia   Warfarin + TMP-SMX à supratherapeutic INR and bleeding  Macrolides interact with statins, calcium channel blockers  Clarithromycin or erythromycin (but not azithromycin) + lipophilic statins (Atorvastatin, Lovastatin, Simvastatin) -> 10-16-fold increase in the blood concentrations of these statins, increasing the risk for rhabdomyolysis.  Clarithromycin or erythromycin (but not azithromycin) + amlodipine ->  hypotension  Clinical Pearl that you can add to antimicrobial ordering panel: of the macrolides, azithromycin is the safest when it comes to drug interactions as it does not inhibit the CYP 3A4 and has the least impact on the QTc. NSAID drug interactions  Celecoxib inhibits the CYP 2D6 enzyme. Metoprolol is a substrate of CYP2D6. Coadministration of metoprolol with celecoxib may increase the plasma concentrations of metoprolol. The mechanism is celecoxib inhibition of metoprolol metabolism via CYP 2D6. Prodrugs codeine and tramadol are metabolized through 2D6 into their active metabolites. This drug interaction can lead to inadequate analgesia. NSAIDs should not be given to patients who are taking ASA for coronary artery disease – especially if they have a recent coronary stent are thought to be at increased risk for coronary occlusion if NSAIDs are combined with ASA. Context: ASA’s mechanism of action is platelet inhibition through the irreversible inhibition of the synthesis of platelet thromboxane A2 by blocking the activity of platelet cyclooxygenase (COX)-1. In addition, NSAIDs are reversible inhibitors of platelet COX-1 Set Alerts: Celecoxib + metoprolol -> bradycardia  Celecoxib + codeine or tramadol -> decreased analgesic effect  NSAIDs + ASA -> thrombosis  Clinical Pearl that you can add to antimicrobial ordering panel: Be wary of prescribing NSAIDs in patients who are already taking aspirin and in patients who have coronary artery disease, especially with a recent stent. If a patient taking low-dose ASA for vascular protection requires an anti-inflammatory agent, COX-2 inhibitors should be chosen over traditional NSAIDs. Cardiovascular drug interactions When starting a patient on a direct oral anticoagulant (DOAC) in the ED for stroke prevention with atrial fibrillation, strongly consider stopping the ASA if the patient is taking it only for primary prevention. In warfarin-treated patients who will use acetaminophen chronically, the INR should be tested 3 to 5 days after the first acetaminophen dose. In warfarin-treated patients with otherwise unexplained INR variability, acetaminophen use should be considered as a possible contributing factor. Set Alerts: Anticoagulants (DOAC/Warfarin) + antiplatelet drugs (ASA/clopidogrel) -> bleeding  Warfarin + Acetaminophen -> increased INR/bleeding  Beta Blockers/Calcium Channel Blockers + Cholinesterase inhibitors  -> bradycardia  Pain Management Alerts for the Geriatric ED Examples of analgesics to use with caution or to avoid in older adults. The rationale and warnings could be added to the EMR for clinical decision support. Morphine All metabolites are excreted by the kidneys and accumulate in renal failure. M6G (a morphine metabolite) is an analgesic, and its accumulation can contribute to respiratory depression; M3G has no analgesic activity and is associated with hyperalgesia and allodynia as well as neuro-excitatory effects such as myoclonus, agitation, and delirium.  Codeine Codeine is a prodrug that needs to be converted to morphine, with only 10-15% being converted; CYP2D6 genetic polymorphism results in significant variation between individuals in the metabolism of codeine to morphine. Metabolites can accumulate in renal dysfunction. Tramadol Tramadol is metabolized primarily by CYP2D6, as such genetic polymorphisms may affect the metabolism of tramadol. Notable side effects of tramadol include hyponatremia (SIADH), serotonin syndrome, seizures (including lowered seizure threshold), respiratory depression, and increased intracranial pressure. Frequent drug–drug interactions and needs to be dose reduced in pts with renal impairment (eCrCl <30 ml/min in Beers Criteria).  Meperidine Meperidine had a neurotoxic metabolite that can accumulate with chronic administration, especially in those with renal dysfunction. Known to precipitate or worsen delirium (Beers Criteria). Skeletal muscle relaxants (e.g. cyclobenzaprine, orphenadrine, methocarbamol) Common side effects include dizziness, drowsiness, and hypotension. Some have strong anticholinergic activity. (Beers Criteria and on GEMS-Rx).  One study showed that older patients who took muscle relaxants were 2.25 times more likely to visit the emergency department for a fall or fracture and 1.56 times more likely to be hospitalized for a fall or fracture than patients who did not take these medications. Set Alerts: On a pain management ordering panel for patients over 65 years you could include: AVOID Avoid Toradol (Ketorolac) Use Avoid Muscle Relaxants: Poorly tolerated, anticholinergic, sedation, increase risk of fractures and of questionable efficacy. Avoid high-dose NSAIDs OPIATES ***The American College of Rheumatology recommends caution with the use of narcotics for OA. Please follow the hospitals opiate policy for the use of narcotics for acute and chronic pain ***Opiates can cause constipation, seizures, confusion, sedation, cardiorespiratory depression ***Codeine, meperidine, and butorphanol are POOR CHOICES Acetaminophen/hydrocodone 5/325mg tab Q8H PRN for 3 days Tramadol 50g tab PO Q6H PRN for 3 days For patients on OPIATES consider drugs for constipation Senna 2 tab PO daily PRN Bisacodyl 10mg suppository BID PRN for 5 days Polyethylene glycol PO daily for 7 days Acetaminophen 650mg PO Q6H PRN for 10 Days: DO NOT EXCEED 3000mg in a 24 hour period. Also check OTC drugs to be sure they don't contain Acetaminophen or Tylenol NSAID ***INDOMETHACIN is more likely than other NSAIDs to have adverse CNS effects, GI bleeding, acute kidney disease ***May cause fluid retention and exacerbate heart failure Ibuprofen 200mg tab PO Q6H PRN for 5 days Ibuprofen 400mg tab PO Q6H PRN for 5 days This provides a starting point for incorporating better clinical decision support into the ordering panels in your hospital. It's important at you continue this work to ensure prescribing panels don't get overloaded with pop-ups that create fatigue and interrupt clinician workflows, but rather create opportunity for education and critical thinking. The examples here can be incorporated into ordering panels at all prescribing points. Many of the examples are from the EQUiPPED discharge order sets, but are relevant throughout patient care. EQUiPPED Provider Feedback The EQUiPPED team created a dashboard to track prescription of PIMs by providers and benchmark providers against their peers. The dashboard includes the percentage of PIMs prescribed in the last 30 days, and key performance indicators of whether the rate has increased or decreased comparted to previous 30 days. In also shows monthly prescribing trends and a distribution of PIMs prescribed by drug class over the last year. From Stevens MB, et. al. J Am Geriatr Soc. 2015;63(5):1025-1029 Contributors References Antoniou T, Gomes T, Juurlink DN, Loutfy MR, Glazier RH, Mamdani MM. Trimethoprim-sulfamethoxazole-induced hyperkalemia in patients receiving inhibitors of the renin-angiotensin system: a population-based study. Arch Intern Med. 2010 Jun 28;170(12):1045-9. EQUIPPED, Enhancing Quality of Prescribing Practices for Older AdultsDischarged from the Emergency Department.​ Juurlink DN, Mamdani MM, Lee DS, Kopp A, Austin PC, Laupacis A, Redelmeier DA. 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Kirschner R, Donovan JW. Serotonin syndrome precipitated by fentanyl during procedural sedation. J Emerg Med. 2010 May;38(4):477-80. Koury KM, Tsui B, Gulur P. Incidence of serotonin syndrome in patients treated with fentanyl on serotonergic agents. Pain Physician. 2015 Jan-Feb;18(1):E27-30. Stevens MB, et al. J Am Geriatr Soc. 2015;63(5):1025–1029. Stevens M, etal. J Am Geriatr Soc. 2017;65(7):1609–1614.