Photo by Marcelo Leal | Unsplash
The winter of 2015 was a cold one in Portland, Oregon. Around the holidays, a 90-year-old retired pastor known as Father Bill slipped and fell on an icy sidewalk. He had a small area of bleeding (a subdural hematoma), and he was admitted to the hospital at Oregon Health and Science University (OHSU).
On the second night of his stay, he developed delirium with restlessness and fidgetiness. “This happened in the evening as it so often does,” said Katie Drago, a geriatrician at OHSU. “Geriatricians are not there.” Nurses called the intern who was working that night and asked him to order a medication to calm Father Bill.
The intern went into the electronic health record (EHR), and ordered intravenous (IV) haloperidol and quetiapine, two antipsychotic medications. The EHR system offers options for different doses for every medication. Of the four options on display, the intern chose the “moderate” doses of each medication. Father Bill received two doses of 5 mg IV haloperidol and 25 mg of quetiapine.
In the morning, he was having obvious respiratory difficulty and was in distress. His daughters were by his side, and they decided it was time for hospice care. On the fifth day of his stay in the hospital, Father Bill died.
When the team at the hospital reviewed his case, they found that a 5-mg dose of haloperidol is ten times the recommended dose for his age. The administration of this dose may have contributed to his death. They did not blame the intern, who was overwhelmed and reliant on the information available in the EHR. But they realized they needed to change the system to avoid such errors.
One possibility would have been to provide an alert to warn providers of inappropriate doses. However, this approach has its downsides: alert fatigue is common. Instead, the team turned to another model for providing age-specific dosing information: pediatric prescribing contexts. With this tool, if a patient is under 18, the EHR automatically offers alternative, age-appropriate dose options. “Every EHR in the country has pediatric prescribing context,” said Drago. “We used that same logic.”
The team started by adding alternative doses for haloperidol. The inpatient physician informaticist said, Drago recalls, “Don’t stop at just haloperidol. Do everything.” They called this new system a “geriatric prescribing context” (GPC). As opposed to an EHR alert, the GPC does not require any additional attention or decisions; it is embedded unobtrusively into the provider’s workflow.
They decided to apply the GPC to all hospitalized patients 75 years and older. This threshold was based on their appraisal that everyone in their 80s and 90s needs these guidelines, whereas people in their 70s tend to be more heterogeneous.
Drago sat down with a geriatrics physician assistant and a clinical pharmacist, and together they built the master list of medications across eight different drug classes. They consulted various well-established guidelines: the AGS Beers Criteria, the STOPP/START criteria, and a comprehensive pharmaceutical reference. Ultimately, they devised alternative dose recommendations for a total of 51 medications. Then their pharmacy informatics partner built out all the background in the EHR over the course of just a few days. The GPC went live in July of 2017.
“We didn’t do any rollout, there was no advertisement, no announcement,” said Drago, although they did write up a very brief description for the pharmacy handbook. “We consciously didn’t include a lot of fanfare. We built it so it would be seamless for the end user.”
They were eager to see what effect the new system would have on provider workflows and prescribing practices. Over the following year, the team looked back at doses received, and compared them to the doses prescribed before the GPC was implemented. In this way, they examined more than 3,500 patients.
What they found was that after the GPC was implemented, nine of the ten most commonly prescribed medications showed a closer alignment with the doses recommended for geriatric patients. For most of these medications, that meant a trend toward lower doses. But for one, acetaminophen, it was the opposite: the recommended dose is higher for older patients. Accordingly, following the introduction of the GPC, doses for acetaminophen increased (albeit without exceeding recommended daily doses), which may have in turn led to a reduction in opioid prescriptions.
The adherence to the new recommendations was not 100 percent. But that does not necessarily indicate a problem. After all, providers still need to be able to use their discretion and take into account differences among individuals.
The results of this study were published in an article in the Journal of the American Geriatrics Society. One limitation the authors acknowledged is that their data did not show an actual decrease in adverse drug events. It is reasonable to expect that the new system would lead to such a reduction, and future research might demonstrate that. In fact, the same team is currently working to answer that question.
This system could be a model for other hospitals throughout the country. “What we saw were modest but real alignment with standardized recommendations,” said Drago. The system is “pretty simple and elegant in its logic.” And it could mean averting more deaths like that of Father Bill.
Editor’s note: Join the next Age-Friendly Health Systems Action Community. Join the next info call on Tuesday, February 23 at 1:00 – 2:00 pm ET. Read the Invitation to Join the 2021 IHI Age-Friendly Action Community for details.
You may also be interested in:
What to Say During Telehealth Visits with Older Adults