# Minimizing PIMs in the Geriatric ED

Every emergency department that is looking to provide better care for its older patients can introduce a care process for triggering a medication reconciliation and subsequently identifying potentially inappropriate medications (PIMs) - ideally with pharmacist involvement.

As you consider incorporating a care process to reduce potentially inappropriate medications (PIMs) note that it is recommended that all geriatric patients presenting to the ED, regardless of chief complaint, have a medication list obtained and reconciled. This can be accomplished either using pharmacy involvement, multidisciplinary team, or computer‐based resources. 

Below, we provide a high-level framework for developing a care-improvement process with a focus on medication reconciliation. Truly, if you are doing medication reconciliation, you will also be looking for PIMs, which we also touch on below.

These care processes are aligned with the 4M's of age-friendly care and can help hospitals meet domain 2 of the new CMS Age-Friendly Hospital Measure.

For sites interested in GEDA Accreditation, the information below can help with meeting care processes B1 and B2.

B1. Care process for medication reconciliation to be performed by a pharmacist of pharmacy technician.

B2. Guidelines to minimize potentially inappropriate medication use through an ED-based pharmacist or through a hospital-specific or other list of potentially inappropriate medications. 

The benefits of pharmacist involvement

Due to the chronic and complex nature of geriatric syndromes in older adults, a multidisciplinary team approach is pivotal to providing tailored, high‐quality patient care that can reduce ED revisits, mortality, and functional decline of older adults.

Prior ED Studies have shown that having pharmacists and technicians perform medication reconciliations reduced medication history errors and resultant medication order errors by over 80%. Early pharmacist-led medication review in the ED can decrease odds of admission, hospital length of stay, and unplanned hospitalizations.

If ED-based Pharmacy resources are available, your workflows can be customized for an integrated interprofessional team model that will benefit older patients in the ED. 

Developing a policy for medication reconciliation and minimizing PIMs

An effective care process for medication reconciliation will clearly define the criteria for when a pharmacy technician or pharmacist will conduct a best possible medication history (BPMH) and risk assessment for potentially inappropriate medications and in what timeframe - both in terms of when BPMH happens and what hours and days of week it is available.

Meeting the B1 and B2. care processes for GEDA Accreditation requires med reconciliation and reduction of PIMs for patients being discharged from the emergency department, not just those being admitted.

Ideally, consideration for high-risk encounters during off hours is an additional strategy to meet the need of vulnerable older adults.   

Triage triggers for pharmacist consult

Given that most emergency departments don’t have the resources for a pharmacist to perform medication review for each geriatric patient, developing specific prioritization criteria for medication review is an effective means to target specific risk group and aligning volumes with resources. 

Triage trigger examples

You could choose one or several of the following trigger examples depending on your team, resources, and patient population. Some example triggers for flagging to the ED Pharmacist are (but are not limited to): 

ISAR positive, 70+ years old, and 10+ meds

Chief complaint related to fall or syncopal episode

Recent ED visit or discharge from hospital (within 30 days)

Presence of 2 or more high-risk medications:

Anticoagulants

Hypoglycemic agents (oral, insulin)

Psychoactive meds (antipsychotics, sedative hypnotics, antiepileptics, mood stabilizers, antidepressants)

Opioids

Muscle relaxants

Highly anticholinergic medications (e.g., diphenhydramine, dumenhydrinate)

Referral/request by treating physician or Nurse Practitioner or Physician's Assistant

Suspect medication-related adverse effect as reason for ED visit

Once there's a policy in place for triggering a pharmacist consult or medication reconciliation, the next logical step would be to identify PIMs based on an established tool. Some established tools are:

 GEMS-Rx

STOPP/START

Beers Criteria

Developing a procedure

This is a suggestion intended to help ED teams develop their own process that works for their department's needs and abilities. 

Once a patient fitting your defined criteria is identified (screens positive triggering a medication reconciliation) a pharmacist consult is ordered. This example workflow can be adapted based on your resources or needs. 

Computer generated alert sent to Pharmacist within the EHR 

Pharmacist does Best Possible Medication History and conducts medication reconciliation and medication review within 24 hours of BPMH.  

Identify PIMs based on Validated Tool (GEMS-Rx, STOPP/START, Beers) and using clinical judgement. 

For every medication reconciliation performed, the ED pharmacist assesses each medication for appropriateness based on clinical indication, dose (considering age, renal function, and hepatic function), adverse drug reactions, therapeutic duplication, drug interactions, and specific patient characteristics and comorbidities. 

Although automated EHR alerts are a great solution, is not a necessity for accreditation. A manual process is sufficient for sites just starting or waiting until an EHR alert to be built. As with any process either on paper or in the EHR, it needs to be well described in terms of when in the ED encounter it happens, who is performing the actions, specific criteria for the action, what happens when screening/assessment is positive, and how the process is monitored. 

The diagram below illustrates a workflow that might be adapted to your emergency department. It illustrates the team-based approach required for great geriatric emergency care. In addition to what is shown here, you could add a step that involves communication with primary care physician on discharge about any medication recommendations the medication reconciliation resulted in.  

Adapted from: Lee S, Skains RM, Magidson PD, Qadoura N, Liu SW, Southerland LT. Enhancing healthcare access for an older population: The age-friendly emergency department. J Am Coll Emerg Physicians Open. 2024 May 8;5(3):e13182. 

An effective process will clearly define the criteria for when a pharmacy technician or pharmacist will conduct a medication review history, ideally utilizing the best possible medication history (BPMH) during the B1 process. The timeframe, both in terms of when BPMH happens and what hours and days of week it is available is essential.