Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens

Abstract

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 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.

Keywords: acute care; clinical informatics; geriatrics; medication safety; pharmacy intervention; vulnerable elderly.

Figure 1. Screenshot of electronic PIM dashboard directing pharmacists to patients at highest risk of adverse drug events (ADEs)

Figure 1

Flow diagram depicting screening by Potentially Inappropriate Medications (PIMs) tool and by pharmacist. After electronic criteria were applied, the pharmacist determined whether proactive consultation was indicated based on diagnoses, duration of PIM use, dose, renal function, and concomitant medications.