Lessons Learned From Implementation of a “Geriatric-Friendly” Admission Order Set

Falls are a significant source of injury for elderly patients.¹ Reducing fall risk requires a multifaceted clinical approach and medication management is a key tactic.² Advancements in electronic medical records (EMRs) and computerized physician order entry with clinical decision support (CDS) creates new opportunities to prevent adverse events.³ Literature often focuses on CDS to guide prescribing; therefore, we wanted to report on efforts to implement a “geriatric-friendly” admission order set as a complementary strategy.

Salem Health is a 454-bed nonprofit medical center located in Salem, Oregon. Twice annually, Salem Health conducts the Physician Leadership Institute (PLI) as a venue for interdisciplinary team-based quality improvement projects. During the spring of 2015, a PLI team focused on fall prevention by reducing prescribing of drugs classified as potentially inappropriate medications (PIMs; also known as the Beers list) in patients aged 65 and older through targeted education of physicians, nurses, and pharmacists. The Beers list serves as a reference for health care professionals to improve safe medication use in older adults by reducing polypharmacy, drug interactions, and adverse drug events.⁴ This project focused on medications associated with an increased risk of falling including sedative-hypnotics, anxiolytics, antipsychotics, antihistamines, and muscle relaxants. The project documented a decrease in falls; however, there was no corresponding reduction in PIMs prescribing. Instead, results were likely secondary to increased attention on falls as survey data indicated greater discourse between prescribers, nursing staff, and patients/family members on the risks associated with these medications. It was anecdotally observed that prescribing increased during high admission periods. Since PIMs are located on the general admission order set, it was speculated that some PIMs may have been unintentionally ordered. Removing PIMs from the general admission order set would not have widespread approval so the PLI team recommended development of an alternative “geriatric-friendly” admission order set as a future direction to improve patient safety.

The order set that removed these PIMs (ie, alprazolam, lorazepam, promethazine, and prochlorperazine) was approved in December 2016. It was used on 43 patients in the first 3 months. Patients were aged 82 ± 8 years, evenly divided between males (44%) and females (56%), and primarily admitted for pulmonary (33%), central nervous system (28%), or cardiac (23%) issues. Seven patients received a PIM during their hospital stay—3 received an anxiolytic (clonazepam, lorazepam) as a continuation of a home medication while 4 received a new anxiolytic (lorazepam) or antipsychotic (prochlorperazine, promethazine). A more formal analysis will need to be conducted to assess impact. However, despite the small sample, this process provided valuable insight into the challenges of altering how providers interact with the EMR. Physicians were notified of the new order set through a variety of mechanisms (eg, physician newsletter, face-to-face meetings with hospitalist groups), but uptake was slow and required consistent marketing efforts. However, seemingly conflicting with usage, providers verbally agreed that reducing PIMs prescribing is important and requested a review of the general admission order set to assess appropriateness in elderly patients across all disciplines. Similarly, it has stimulated discussion about EMR functionality to default to a different admission order set based on age or other patient-specific factors.

Decision support can decrease prescribing of inappropriate medications, increase use of recommended dosing, and lower rates of falls.⁵ However, use of CDS for geriatric patients is relatively low. In a survey of 15 academic hospital, only 8 reported use of CDS for high-risk medications in the elderly, and of those, 7 reported using CDS for less than 30 medications.⁶ Suggested barriers include insufficient expertise of an institution’s information technology system, unawareness of inappropriate prescribing in geriatric patients as a problem, and lack of provider acceptance.^3,6 These challenges are consistent with our experiences. The initial project was education-focused, which then served as the springboard for broader discussion with more stakeholders and a greater diversity of strategies. We hope that our experience will encourage other facilities to leverage their EMR to improve prescribing in elderly patients.