Electronic Tool for Older Inpatients on High-Risk Medication
Electronic Tool for Older Inpatients on High-Risk Medication
An electronic PIM dashboard identified a large population of elderly inpatients prescribed PIMs and facilitated a focused pharmacy review and subsequent proactive intervention for individuals susceptible to an adverse drug event. With the dashboard, the pharmacist could quickly find individual or drug characteristics that increased risk, including overlapping sedating medications, cumulative dosing of opiates, and interacting medications. A fully manual approach would have required abstracting or reviewing data from a much larger set of charts. Alternatively, the pharmacist would need to be physically present on every rounding team. The majority of individuals that the dashboard flagged did not require a proactive intervention after the pharmacist reviewed dashboard or chart data. If efficacy is validated in controlled studies, this approach could save considerable time and leverage the limited numbers of clinical pharmacy staff with geriatric expertise.
Many prescribing guidelines and principles for the care of vulnerable older adults have been published, yet there is little guidance on how to translate these recommendations efficiently to clinical practice. Extensive clinical knowledge is required to effectively screen medication regimens for highest-risk PIMs, and this skill is concentrated in clinicians and pharmacists who have expertise in caring for older adults. The use of automated methods to leverage the efforts of skilled clinicians or ancillary services to improve care is a promising approach to bridge this implementation gap.
Other rigorously evaluated pharmacy interventions to reduce errors or inappropriate prescribing have not proven to be effective at improving outcomes. Although clinical outcomes were not assessed in this pilot study, the technical feasibility, implementation logistics, and intermediate effect on prescribing of the technology were successfully established. More-efficient and -targeted use of clinical pharmacy services to assist with hospital care of vulnerable elderly adults could affect outcomes associated with PIM use, including delirium, physical activity, falls, and restraint use. Additional studies could also be conducted to adapt this intervention model to healthcare settings with less-robust EHRs.
The reliance on a single pharmacist with a strong clinical background to apply implicit criteria for selecting people for an intervention limited the study. With training, any clinical pharmacist could use the dashboard tool, although clinical judgment and final recommendations may vary between pharmacists. Acceptance of a clinical pharmacist's recommendation by physicians in private practice or different subspecialties might vary substantially from what was presented in this report and presents an additional research and implementation challenge for further dissemination of this approach, although it is likely that this intervention model will be accepted to complement rounding pharmacists and therapeutic drug monitoring team.
In 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.
Discussion
An electronic PIM dashboard identified a large population of elderly inpatients prescribed PIMs and facilitated a focused pharmacy review and subsequent proactive intervention for individuals susceptible to an adverse drug event. With the dashboard, the pharmacist could quickly find individual or drug characteristics that increased risk, including overlapping sedating medications, cumulative dosing of opiates, and interacting medications. A fully manual approach would have required abstracting or reviewing data from a much larger set of charts. Alternatively, the pharmacist would need to be physically present on every rounding team. The majority of individuals that the dashboard flagged did not require a proactive intervention after the pharmacist reviewed dashboard or chart data. If efficacy is validated in controlled studies, this approach could save considerable time and leverage the limited numbers of clinical pharmacy staff with geriatric expertise.
Many prescribing guidelines and principles for the care of vulnerable older adults have been published, yet there is little guidance on how to translate these recommendations efficiently to clinical practice. Extensive clinical knowledge is required to effectively screen medication regimens for highest-risk PIMs, and this skill is concentrated in clinicians and pharmacists who have expertise in caring for older adults. The use of automated methods to leverage the efforts of skilled clinicians or ancillary services to improve care is a promising approach to bridge this implementation gap.
Other rigorously evaluated pharmacy interventions to reduce errors or inappropriate prescribing have not proven to be effective at improving outcomes. Although clinical outcomes were not assessed in this pilot study, the technical feasibility, implementation logistics, and intermediate effect on prescribing of the technology were successfully established. More-efficient and -targeted use of clinical pharmacy services to assist with hospital care of vulnerable elderly adults could affect outcomes associated with PIM use, including delirium, physical activity, falls, and restraint use. Additional studies could also be conducted to adapt this intervention model to healthcare settings with less-robust EHRs.
The reliance on a single pharmacist with a strong clinical background to apply implicit criteria for selecting people for an intervention limited the study. With training, any clinical pharmacist could use the dashboard tool, although clinical judgment and final recommendations may vary between pharmacists. Acceptance of a clinical pharmacist's recommendation by physicians in private practice or different subspecialties might vary substantially from what was presented in this report and presents an additional research and implementation challenge for further dissemination of this approach, although it is likely that this intervention model will be accepted to complement rounding pharmacists and therapeutic drug monitoring team.
In 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.
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