To carry out the intervention, each EQUiPPED site used a letter from the VA Office of Geriatrics and Extended Care designating the analysis of outcomes data related to the intervention as an operational activity rather than as research. The EQUiPPED team developed pharmacy quick-order sets in dialogue with ED providers and clinical pharmacists. Clinical applications coordinators facilitated local integration of order sets into the Computerized Patient Record System (CPRS). Local clinical experts reviewed the order sets (eg, the Pharmacy & Therapeutics Committee, the Antimicrobial Stewardship Committee, and the Chief of Pharmacy Service) before implementation.
Once the order sets were implemented, the sites began educating providers about the order sets along with the information about Beers List medications. As soon as possible, usually 1 month after the educational sessions, the sites began evaluating data from the local corporate data warehouse regarding medications prescribed in order to calculate monthly PIM rates. Each provider received a report that showed their PIM rate and overall prescribing in the previous month and benchmarked this performance in relation to anonymized peers. The first feedback session was given in person by a physician or a physician-pharmacist team. All sites followed these standard EQUiPPED procedures.
Site Innovations and Adaptations
The Durham site developed a Beers List look-up tool to streamline the calculation of PIMs per provider every month and ensure the systematization of procedures. Although each site introduced education, order sets, and feedback in the same order, launch times differed. Varying levels of staff availability and expertise resulted in order-set rollout times that ranged from 3 weeks to 12 months. Some sites launched additional tools. For example, Durham, Atlanta, and Bronx added blue line alerts, a noninterruptive informational message in CPRS for every Beers List drug prescribed at their VA that warned prescribers to “use with caution in patients 65+.”
Some sites physically placed caution cards on the edge of ED computer screens listing the top 5 PIMS drugs at that site. Nashville, Birmingham, and Durham’s order sets included links to external sites, such as the World Health Organization analgesic ladder and to narcotics equivalency tables to simplify pain management. Nashville ED providers requested e-mail attachments of Beers List drugs, Beers alternatives, and reminders with monthly feedback reports.
Other differences depended on the makeup of the EQUiPPED intervention team and the patient population at each site. A physician champion within the ED, a geriatrician, and a geriatric pharmacist directed the lead Atlanta site. In contrast, a geriatrician led the Durham project and used incentives to help encourage ED provider participation. All Durham ED providers who participated in the program received laminated Beers pocket cards, a printed guide to download the Geriatrics at Your Fingertips app, and a gift card to purchase the app. Other sites distributed some of these materials but did not include the gift card.
Durham-trained resident physicians rotated through the ED each month, as did Atlanta’s. Durham also introduced pre- and posttraining quizzes for resident physicians to test knowledge gained.13 No other site followed this pattern. Differences in local formularies, priorities, patient groups, and preferences led sites to select different order sets for presentation and to adapt them if needed.
Tennessee Valley posted the largest array of order sets in the CPRS with 42 different medication order sets, Atlanta and Birmingham had 12 order sets, and Bronx used the fewest at 3. Durham chose to implement its order sets progressively, with an initial 3, then an additional 2, and then an additional 2. Durham sought feedback from providers during this staged rollout and incorporated changes into the development of the next set. Birmingham and Bronx began tracking use of order sets electronically. The Atlanta site conducted qualitative interviews with a subset of providers (both untrained and trained) to evaluate usage patterns. Nashville used the geriatric order sets as a template to develop order sets for other emergency conditions.
Implementation Model
By understanding practice variations and similarities at a heterogeneous group of VA hospitals, tracking prescribing data, and conducting a thematic content analysis of field reports from EQUiPPED sites, the investigators were able to develop a relatively standardized process model to improve ED prescribing practices for clinicians caring for older adults. The implementation model captures factors at the level of context (alignment with priorities of care), inputs (resources available), outputs (activities and participation), and outcomes (short, medium, and long-term). In addition to the process model, EQUiPPED has developed an implementation tool kit, which includes order set logic, the Beers look-up tool developed by Durham, education materials, and provider feedback templates.
