GEMS RX

A Randomized Trial to Reduce Inappropriate Prescribing to Older Adults Visiting the Emergency Department

GEMS-Rx Guidelines: 2024 Geriatric Emergency Medication Safety Recommendations (GEMS-Rx) identify 8 medication classes that are high risk (i.e., not recommended) for older adult (65+) patients.

Barbiturates

For epilepsy, use other anticonvulsants (e.g., lamotrigine, levetiracetam). For agitation, treat pain first with acetaminophen then low-dose opioid. For severe agitation, use low dose second-generation antipsychotic (e.g., olanzapine, risperidone, quetiapine [Lewy body dementia]).

For seizures disorders, benzodiazepine or ethanol withdrawal, barbiturates are acceptable to use.

Benzodiazepines

For epilepsy, use other anticonvulsants (e.g., lamotrigine, levetiracetam). For agitation, treat pain first with acetaminophen then low-dose opioid. For severe agitation, use nonpharmacologic approach then low dose second-generation antipsychotic (e.g., olanzapine, risperidone, quetiapine [Lewy body dementia]).

For seizure disorders, benzodiazepine or ethanol withdrawal, severe GAD, and end-of-life, benzodiazepines are acceptable to use.

First-Generation Antihistamines

For allergies, use intranasal saline or steroid (e.g., fluticasone, beclomethasone), topical antihistamines (e.g., azelastine), or second-generation antihistamines (e.g., fexofenadine, loratadine). For vertigo, use short-term steroids and canalith repositioning maneuvers.

For allergic reactions, first-generation antihistamines are acceptable to use.

Metoclopramide

For nausea, use ondansetron.

For gastroparesis, metoclopramide is acceptable to use.

First-Generation Antipsychotics

Second-Generation Antipsychotics (e.g., olanzapine, risperidone, quetiapine, aripiprazole, ziprasidone).

Nonbenzodiazepine, Benzodiazepine Receptor Agonist Hypnotics (Z-drugs)

For insomnia: melatonin, ramelteon, doxepin (≤ 3 mg). For anxiety: mirtazapine, buspirone, serotonin–norepinephrine reuptake inhibitor (SNRI, e.g., duloxetine, venlafaxine, desvenlafaxine).

Skeletal Muscle Relaxants

Treat musculoskeletal pain first with nonpharmacologic agents (e.g., heat, ice, massage) then with Tylenol, short-course NSAID, lidocaine patch, diclofenac gel.

Sulfonylureas

Metformin, Long-acting Insulin (e.g., glargine).

Skains, Rachel M., et al. "Geriatric emergency medication safety recommendations (GEMS-Rx): modified Delphi development of a high-risk prescription list for older emergency department patients." Annals of Emergency Medicine 84.3 (2024): 274-284.0

Frequently Asked Questions (FAQs)

Which medications are considered potentially inappropriate?

The 2024 GEMS-Rx recommendations identify eight high-risk medication classes for older adults (65+): barbiturates, benzodiazepines, first-generation antihistamines, metoclopramide, first-generation antipsychotics, nonbenzodiazepine hypnotics (Z-drugs), skeletal muscle relaxants, and sulfonylureas. These are considered potentially inappropriate when safer alternatives exist.

How soon will I see a change in my performance report after adjusting my prescribing?

Reports are generated from the most recent 90 days of prescribing data, so sustained changes may take a few weeks to appear. Continued adherence to GEMS-Rx recommendations will be reflected in subsequent feedback cycles. Rx recommendations will be reflected in subsequent feedback cycles.

How are prescriptions attributed?

The attending clinician listed on the patient’s discharge is recorded as the prescriber. When trainees write or enter orders, the supervising attending on record is considered the responsible prescriber for reporting purposes.

Medication orders may be entered by trainees or supervised APPs during the visit; however, prescribing outcomes are attributed to the attending physician responsible for the patient at discharge, consistent with standard ED quality reporting practices.

For encounters in which an APP cares for a patient independently (i.e., without an attending physician assigned), the prescription will be assigned to the APP.

How are prescriptions assigned to a prescriber?

For encounters in which an APP cares for a patient independently (i.e., without an attending physician assigned), the prescription will be assigned to the APP.

How are clinicians assigned to facility groups?

Please follow these steps to view your GEMS‑Rx performance report:

Log in to Epic
Click “My Reports” in the toolbar at the top. Alternatively, you can use the universal search and type “My Reports”:
In the Analytics Catalog search bar (in the ribbon below the first one), search for “GEMS” and press enter:
Find the report titled “Y GEMSRX Performance Report (Cogito SQL)”, double click the report or click the green play to the right to run the report.

Note:If you are the clinical champion, select the report titled “Y GEMSRX Champions Report (COG SQL)”; you must have privileges to run this specific report.

How do I opt out of receiving messages?

Participation is voluntary. If you choose not to participate or later wish to withdraw, you will not receive any further messages. If you wish to stop receiving messages, please contact Jennifer.arango@yale.edu to unsubscribe. Once withdrawn, you will not be able to rejoin the study later.