Pediatrics
Corey Diamond, PharmD
A team at Vanderbilt University Medical Center launched a quality improvement project to increase the number of discharge prescriptions sent to their on-site outpatient pharmacy (OOP). As is often the case in pediatric emergency settings, many prescriptions go unfilled due to obstacles such as limited pharmacy access or lack of convenience.
Through a series of targeted changes, including modifications to the EHR system, provider education, and workflow adjustments, the team aimed to make the OOP the default option during open hours.
The initiative led to a significant and sustained rise in OOP prescription use, without increasing the rate of unfilled prescriptions. The findings were published in Hospital Pediatrics on January 15, 2025.
In discussing the broader meaning of their findings, the study authors said that simply increasing the number of prescriptions sent to OOP was not sufficient to improve patient access.
“The success of this initiative was in marrying the increasing number of prescriptions and their respective fill rates,” they wrote, pointing out that access alone does not guarantee patients will leave with medications in hand. They stressed that both quantity and follow-through needed to be addressed together to achieve meaningful improvement.
When the team analyzed patterns in the data, they found that prescriptions most likely to go unfilled were often medications that could also be obtained over the counter. They noted this is particularly relevant in pediatric care, where many such medications are covered by state Medicaid programs but still require a prescription to be filled at discharge. By identifying and addressing these gaps, the initiative was able to maintain a stable unfilled prescription rate of 15.8%, even as the number of prescriptions sent to the OOP grew significantly.
Design
The research team aimed to increase the percentage of prescriptions sent to the hospital’s OOP during its open hours. At baseline, most prescriptions were either printed or electronically sent to offsite pharmacies, contributing to a substantial number going unfilled. To address this, researchers sought to redirect prescription flow to the more accessible and supportive OOP.
The project began in July 2021, coinciding with a pilot expansion of the OOP’s operating hours. The team used a combination of retrospective and prospective data collection, with baseline data prior to the initiative being collected from January 2019 through June 2021. Weekly prescription data were collected thereafter using an electronic dashboard.
Several interventions were introduced in stages. These included setting the OOP as the default pharmacy in the electronic medical record system, adding reminders about OOP hours, educating staff and trainees, distributing multilingual pamphlets, and installing signage to guide families. Pediatric emergency medicine fellows served as project champions, reinforcing the initiative during clinical shifts. Additional changes included automatic printing of OOP directions in discharge paperwork and regular feedback to providers on performance.
The main outcome was the percentage of discharge prescriptions sent to the OOP during open hours. Secondary outcomes included the total number of prescriptions sent and the percentage that went unfilled within 24 hours. This approach allowed the team to assess both utilization and real-world effectiveness of the interventions.
Results
Following the implementation of the quality improvement interventions, the percentage of prescriptions sent from the pediatric emergency department to the OOP during open hours increased from a baseline of 8.9% to a peak of 70.9%. This peak was maintained for approximately 9 months before decreasing to 60%, where it remained stable for the subsequent 9 months.
The average number of prescriptions sent to the OOP each week rose from 17 prior to the initiative to 259 by the end of the study period. Despite this increase in volume, the rate of unfilled prescriptions at the OOP did not change, holding steady at 15.8% from August 2021 through June 2022.
Control charts demonstrated special cause variation corresponding to the timing of specific interventions, such as updating the electronic medical record to set the OOP as the default pharmacy and assigning pediatric emergency medicine fellows as project champions. The authors suggest that future efforts should continue to monitor both metrics together to ensure sustained success. ■