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the CDS did not recommend the scan, providers could override the alert by entering a brief justification. Evaluation of this effort was conducted using a mixed methods design. Results: Overall, after deploying the CDS tool, there was a significantly lower utilization of CT brain (10%, 95% CI 7-13%); p< 0.001) and CT c-spine (6%, 95% CI 0-11%; p < ¼0.0546) while utilization of CT PE did not change significantly (p¼0.50). As hypothesized, the change in CT usage depended on how high (or low) usage was at the start of the study (p<0.001; see Figures); For CT Brain, the high utilizers decreased usage by 13% (95% CI: 5%, 23%; p<0.001), while the average and low utilizers did not change their usage (p>0.35). For CT PE, the high utilizers decreased their usage by 13% (95% CI: 5%, 21%; p<.001), average users did not change their usage (p¼0.80), and the low users increased usage by 40% (95% CI: 17%, 66%; p<0.001). A similar pattern was observed for CT c-spine. Conclusion: Clinical decision support that is embedded directly into the provider workflow decreased the overall utilization and physician variability of high cost imaging, especially among higher utilizers. Key lessons learned should be headed in further translating these evaluation findings into practice.

IntroductionEmergency medicine (EM) pharmacy practice has experienced significant growth in the past decade, but the scope of services provided for freestanding emergency departments (FSEDs) has not been previously described.ObjectivesThe primary objective was to describe EM pharmacist interventions provided through telepharmacy services for three FSEDs.MethodsThis was a retrospective chart review conducted in three FSEDs that are part of a large health system. EM pharmacists provide remote clinical coverage for the FSEDs. Pharmacist interventions for FSED patients between 1 January 2017 and 31 December 2018 were eligible for inclusion. Documentation related to non‐direct patient care activities was excluded. Drug therapy recommendations were categorized by therapeutic drug class and the proportion associated with Institute for Safe Medication Practices (ISMP) high‐alert medications was analyzed. The clinical significance of a random sample of drug therapy recommendations was rated using a validated scale. Data was analyzed descriptively and a weighted Kappa statistic was calculated to assess inter‐rater reliability.ResultsA total of 4313 interventions met inclusion criteria with drug therapy recommendations accounting for 38.4% of all interventions. Of 1664 drug therapy recommendations, there were 1424 linked to a medication with the most frequently implicated therapeutic classes being antimicrobial agents (n = 732; 51.4%), vaccines (n = 168; 11.8%), and cardiovascular agents (n = 90; 6.3%). ISMP high‐alert medications accounted for 11% (n = 157) of these recommendations with antithrombotic agents (n = 51; 32.5%), insulin (n = 34; 21.7%), and opioids (n = 20; 12.7%) most frequently implicated. In a random sample of drug therapy recommendations, 19.2% were rated as significant errors by both reviewers with moderate inter‐rater reliability (κ = 0.55; SE 0.09). When assessing the value of service, 59% of interventions were rated as significant by both reviewers with fair inter‐rater reliability (κ = 0.22; SE 0.05).ConclusionEM pharmacists provided clinically significant drug therapy recommendations through telepharmacy services which may represent a novel approach to optimize patient care in FSEDs.

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