Clinical Decision Support to Increase Emergency Department Naloxone Coprescribing: Implementation Report

Area of Science:

• Public Health
• Clinical Informatics
• Emergency Medicine

Background:

• Coprescribing naloxone with opioid analgesics is a CDC best practice to prevent fatal opioid overdose.
• Naloxone coprescription by emergency medicine clinicians remains rare, occurring in less than 5% of indicated cases.
• Previous studies lacked detailed reporting on clinical decision support (CDS) design and pragmatic outcomes for naloxone prescribing.

Purpose of the Study:

• To rigorously evaluate and quantify the impact of CDS on improving naloxone coprescribing in emergency departments (EDs).
• To assess the increase in naloxone prescriptions filled by patients discharged from EDs following CDS implementation.
• To test the hypothesis that CDS would increase naloxone coprescribing rates.

Main Methods:

• Designed and implemented an automated, interruptive, electronic health record-based CDS using user-centered principles.
• Defined high-risk opioid prescriptions based on morphine milligram equivalents or patient history.
• Evaluated outcomes using the RE-AIM framework, including effectiveness assessed via Bayesian structural time-series models and prescription fill rates.

Main Results:

• CDS reached 15.99% of ED visits with opioid discharge prescriptions, with clinicians adopting it in 34.36% of alerts.
• Naloxone coprescribing increased by 18.1 weekly instances (2,327%), demonstrating significant effectiveness.
• Patients filled 43.80% of naloxone coprescriptions; CDS adoption and effect were maintained and increased over time.

Conclusions:

• Electronic health record-based CDS effectively increases naloxone coprescriptions and improves naloxone distribution.
• Minimally interruptive CDS significantly improves process outcomes, controlling for secular trends.
• The study provides strong evidence for the replicability and effectiveness of CDS in promoting naloxone coprescribing.