ACP Status collection in ICU: Difference between revisions

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''see [[Comfort Care]] for collection of similar info in Medicine''
{{Project
|ProjectActive=legacy
|ProjectProgram=CC
|ProjectRequestor=Critical Care QI Team
|ProjectCollectionStartDate=2015-08-10
|ProjectCollectionStopDate=2016-12-31
|Project=ACP Status collection in ICU
}}
{{LegacyContent
|explanation=Collection for this project stopped 2016-12-31
|successor=xxx
|content=
 
This article is about collecting the "ACP Status" (Advanced Care Planning) temp entry.
 
== Start and stop date ==
* First ACP Collection Start Date: 2015-08-10
* Date with complete data across all sites: 2015-09-01
* Date that ACP status documented in chart closest to ICU ADMIT and ICU END.  Start to collect dates on: 2016-04-8
* Revised ACP Collection Start Date: 2016-05-01
* '''Stop Date: 2016-12-31'''
**For patients who have been admitted before or on Dec 31, 2016 and are still in the unit by Jan 2017 and have ACP status data, just email Pagasa the ACP status, ACP source and dates - she will add it in the TMPV2 table of the master database.
 
== Purpose ==
We collect ACP status as a quality indicator that reflects documentation (e.g. completed ACP form or Admitting Orders) and discussion of goals of care for all patients  admitted to ICU.
 
== Collection Instructions ==
For each ICU patient, use the last documented ACP status in the chart ''prior to ICU'' admission date. After ICU admission, collect any ACP status changes and source of this documentation until the patient is discharged from the ICU.
If there are no changes during ICU admission from initial ACP status and source you have recorded then no need to enter more. Only use ACP forms made during '''same hospitalization''' (e.g. ACP status documented by ER, or ward or in prior ICU for transferred patients); ACP forms from prior hospitalizations are not to be collected (not included) in this project.
An initial '''ACP Status''' and '''ACP Source''' entry will be automatically added.
Add additional pairs of entries for each additional ACP documentation since the beginning of this hospitalization.
 
* for '''each''' ACP documentation, change
** Project '''ACP Status'''
*** Item one of the following
**** '''ACP R''' - full resuscitation
**** '''ACP M+''' - all medical care given except cardiac resuscitation; intubation either happened or allowed
**** '''ACP M-''' - all medical care given except cardiac resuscitation and intubation; also if ACP M is written without +/-
**** '''[[ACP C]]''' - comfort care
**** '''not documented''' - should be paired with same in ACP Status
** Project '''ACP Source'''
*** Item one of the following:
**** '''Form '''
**** '''Orders '''
**** '''Form and Orders '''
*****choose this item if the ACP status and Date are the '''same''' on both the ACP Form and the ICU Admitting Orders (see below for sample forms). Otherwise, enter a new ACP documentation with different ACP status or date.
**** '''Other''' - with this option only, put in tmp comment what other place you obtain ACP status and date
**** '''not documented''' - should be paired with same in ACP Source
** for both Source and Status:
*** Date: '''Same date''' filled out for both Project '''ACP''' and '''ACP Source'''
**** '''No Date''': check the checkbox for source and status if there is no date
*** '''Integer (column "N"): used to ''pair'' status and source entries; put a number; use the same number for the status and source entry for the same form. e.g. put a "1" for the status and source for the first tmp entry pair, then put a "2" for each of the second. This allows us to pair up entries even if there are more than one for the same date.


''' not active yet, we are still working on this!Ttenbergen 15:41, 2015 August 6 (CDT)'''
===Question - Source Others ===


This article is about collecting the "ACP Status" temp entry.
=== Examples ===
Some EXAMPLES of pairing ACP status and Source in CCMDB_TMP: [[Media:ACP status collection examples status and source.pdf|CLICK HERE]] to see table of examples.


== Coding Instructions ==
=== If care has been discontinued ===
When you enter a new ICU patient two records will be automatically generated in the tmp table:
If the pt has care as been discontinued, do not automatically change the ACP to C. Only add a new pair of records if there is a new '''documented ACP status''' on chart.  
* ACP Status at admit (ie within 6 hours of admission)
* ACP Status at end (ie at end of stay resp. at death)


Change the ITEM for each of them to the ACP status at that time. Options are as follows
=== If ACP-M is documented without +/- ===
* [[ACP C]]
If ACP M is just written with no qualifiers then one would classify as ACP M-.
* ACP R - {{discussion}} what means this one?
* ACP M+ - (no cardiac resuscitation with intubation either happened or allowed)
* ACP M- - (no resuscitation / no intubation)
* ACP n/a - (no documented ACP on the chart)
Don't fill Checkbox, dates, numbers, not used for this project


=== What if ACP-M is documented without +/-? ===
===ACP from EPR (STB only at this time)===
If ACP M is just written with no qualifiers then one would classify as ACP M-.  Since a significant proportion of patient do want intubation but do not want CPR, I do think it is useful to distinguish)''. Kendiss
*To collect the ACP status go to EPR orders.  Under "transfers and care directives" there should be an order that states, "advanced care planning goals of care"  with the ACP status listed (this also displays in the top of the EPR individual patient demographic information).  If you double click on the order, the ACP electronic form displays (it is exactly the same as the paper form which was previously used).
{{discussion}}
*When the physician writes the order, the form automatically is populated with the doctor name and the ACP status also.  However, if there are special conditions or comments, the doctor may fill out parts of the form itself separately from the displayed order. 
*"-" means no intubation, so how does that work with "Since a significant proportion of patient do want intubation but do not want CPR"? Ttenbergen 15:41, 2015 August 6 (CDT)
*When putting in the source of ACP, if the order for ACP is written and the form has no additonal information (other than status and dr name) just put source as "order".  If the electronic form is filled out with additional information then put "order and form".  --[[User:LKolesar|LKolesar]] 11:37, 2016 May 26 (CDT)


==Start and stop date==
== WRHA guidelines / forms ==
* Start Date: 2015-08-??
*[[Media:WRHA ACP form Nov 2013.pdf | Example of WRHA ACP FORM]]
* Stop Date: none
*[[Media:AdmittingOrdersforICU.pdf | Example of Admitting Orders for ICU]]


== {{CCMDB Data Integrity Checks}} ==
== Cross Checks ==
* [[Query s tmp ACP]]


== Data use / Reporting and Analysis ==
== Data use / Reporting and Analysis ==
* would allow QI team to follow:
* The Critical Care QI team expects the following data from this project
** % of patient with documented ACP during ICU
** Variables: ACP Status, Date of ACP form/Order and Source of ACP documentation
* Changes in these over the course of the admission.
* The expected outcome:
** % of patient with and without documented ACP during ICU stay
** Type of timing of ACP documentation
** The sources of ACP documentation
** Level of care at both admission and discharge
** Level of care at both admission and discharge
***% having ACP R on admission and discharge
** % of patients with no change in level of care during ICU
** % of patients with change in level of care during ICU
** % of patients with change in level of care during ICU
***% having ACP status determined during ICU stay
***% having ACP change with decreased intensity
***% having ACP change with increased intensity
** Level of care at the time of ICU death
** Level of care at the time of ICU death
** Level of care at the time of discharge for survived patients


==Collectability==
* the data are saved in table L_TmpV2 under projects "ACP at admit / ACP at end / ACP Status / ACP Source" of the centralized_data.mdb
''just leaving this here, it was discussed during implementation''
* the SAS program that reads the data can be found in X:\Julie\SAS_CFE\CFE_macros\CFE_CC_ACP.sas
is this easy info to get at admission?--[[User:TOstryzniuk|Trish Ostryzniuk]] 17:12, 2015 May 29 (CDT)
*Yes, it easy to obtain this information  at the time of admission, it is 9/10 that ACP  is established in ER.  Do you want us to collect when a change occurs (often pt come in as a M and 24-72 hrs later, it is changed to APC -C ,or this occurs much later in the admission as well)--[[User:PStein|PStein]] 08:23, 2015 June 1 (CDT)
**I agree with Pat. Is this for ICU and Medicine?--[[User:CMarks|CMarks]] 13:50, 2015 June 1 (CDT)
***I agree with Pat's comment. The pt would come in as ACP R & the status would be changed once discussion with family or pt took place.  This usually happens 24-48 hours after admission or much later in the admission if pt status changes or the family cannot agree on the treatment plan.-- Judy K, Jun 4, 2015
****At GGH ICU this is easy to obtain, I agree with Pat the ACP status often changes several times during an admission, do you want to capture these changes? or just ACP at admission and discharge?  {{Discussion}}
*****Is this ICU only? or medicine as well?{{Discussion}}
******ICU QI team has requested to collect this info.  We will discuss at TASK team meeting and discuss asking Dr. Roberts for medicine. 
*******Would this include up to the first 24 or 48 hours, or would this need to be in place before arrival? - Judy Kublick Jun 4.15.
********At STB obtaining ACP is done from EPR and the changes are in the orders. It is easy to obtain.--[[User:LKolesar|LKolesar]] 11:22, 2015 June 1 (CDT)
*********STB CICU - Yes it is usually on the chart. Is this going to be just for ICUs.-- Lois
**********VIC ICU - Med: I agree that is is usually easy to obtain. I find that it is often an "R" as a default until the MD has a chance to speak more in depth with family or the patient. So yes, it does often change throughout the stay, and my concern would be that the initial ACP status is not always the most "accurate" representation. So if it changes within the first 24 to 48 hours, which one would we enter? [[User:Mlagadi|Mlagadi]] 09:05, 2015 June 2 (CDT) {{Discussion}}
***********GRA-MED: not always available on admission to Medicine but is always discussed at some point in the admission; often changes during stay  [[User:SCortilet|SCortilet]] 15:13, 2015 June 2 (CDT)
************HSC _B3_D5: Same as Lois-usually on chart or the request is made for confirmation if not: or if the medical status on presentation is suggestive of a need for clarification or adjustment but that would require a time frame to arrange with client/family.--[[User:Llemoine|Llemoine]] 07:46, 2015 June 3 (CDT)
 


== Legacy ==
We used to collect this with different instructions, see article version of 15:34, 2016 May 9 (CDT) for details.


== See also ==
''see [[Comfort Care]] for collection of similar info in Medicine''


[[Category: OverstayProject]]
}}
[[Category: Critical Care Elements]]
[[Category:End-of-life related data]]
[[Category: All Projects Critical Care Only]]
[[Category:ACP]]
[[Category: End-of-life related data]]

Latest revision as of 17:13, 22 December 2021

Projects
Active?: legacy
Program: CC
Requestor: Critical Care QI Team
Collection start: 2015-08-10
Collection end: 2016-12-31

Legacy Content

This page contains Legacy Content.
  • Explanation: Collection for this project stopped 2016-12-31
  • Successor: xxx

Click Expand to show legacy content.

This article is about collecting the "ACP Status" (Advanced Care Planning) temp entry.

Start and stop date

  • First ACP Collection Start Date: 2015-08-10
  • Date with complete data across all sites: 2015-09-01
  • Date that ACP status documented in chart closest to ICU ADMIT and ICU END. Start to collect dates on: 2016-04-8
  • Revised ACP Collection Start Date: 2016-05-01
  • Stop Date: 2016-12-31
    • For patients who have been admitted before or on Dec 31, 2016 and are still in the unit by Jan 2017 and have ACP status data, just email Pagasa the ACP status, ACP source and dates - she will add it in the TMPV2 table of the master database.

Purpose

We collect ACP status as a quality indicator that reflects documentation (e.g. completed ACP form or Admitting Orders) and discussion of goals of care for all patients admitted to ICU.

Collection Instructions

For each ICU patient, use the last documented ACP status in the chart prior to ICU admission date. After ICU admission, collect any ACP status changes and source of this documentation until the patient is discharged from the ICU. If there are no changes during ICU admission from initial ACP status and source you have recorded then no need to enter more. Only use ACP forms made during same hospitalization (e.g. ACP status documented by ER, or ward or in prior ICU for transferred patients); ACP forms from prior hospitalizations are not to be collected (not included) in this project.

An initial ACP Status and ACP Source entry will be automatically added. Add additional pairs of entries for each additional ACP documentation since the beginning of this hospitalization.

  • for each ACP documentation, change
    • Project ACP Status
      • Item one of the following
        • ACP R - full resuscitation
        • ACP M+ - all medical care given except cardiac resuscitation; intubation either happened or allowed
        • ACP M- - all medical care given except cardiac resuscitation and intubation; also if ACP M is written without +/-
        • ACP C - comfort care
        • not documented - should be paired with same in ACP Status
    • Project ACP Source
      • Item one of the following:
        • Form
        • Orders
        • Form and Orders
          • choose this item if the ACP status and Date are the same on both the ACP Form and the ICU Admitting Orders (see below for sample forms). Otherwise, enter a new ACP documentation with different ACP status or date.
        • Other - with this option only, put in tmp comment what other place you obtain ACP status and date
        • not documented - should be paired with same in ACP Source
    • for both Source and Status:
      • Date: Same date filled out for both Project ACP and ACP Source
        • No Date: check the checkbox for source and status if there is no date
      • Integer (column "N"): used to pair status and source entries; put a number; use the same number for the status and source entry for the same form. e.g. put a "1" for the status and source for the first tmp entry pair, then put a "2" for each of the second. This allows us to pair up entries even if there are more than one for the same date.

Question - Source Others

Examples

Some EXAMPLES of pairing ACP status and Source in CCMDB_TMP: CLICK HERE to see table of examples.

If care has been discontinued

If the pt has care as been discontinued, do not automatically change the ACP to C. Only add a new pair of records if there is a new documented ACP status on chart.

If ACP-M is documented without +/-

If ACP M is just written with no qualifiers then one would classify as ACP M-.

ACP from EPR (STB only at this time)

  • To collect the ACP status go to EPR orders. Under "transfers and care directives" there should be an order that states, "advanced care planning goals of care" with the ACP status listed (this also displays in the top of the EPR individual patient demographic information). If you double click on the order, the ACP electronic form displays (it is exactly the same as the paper form which was previously used).
  • When the physician writes the order, the form automatically is populated with the doctor name and the ACP status also. However, if there are special conditions or comments, the doctor may fill out parts of the form itself separately from the displayed order.
  • When putting in the source of ACP, if the order for ACP is written and the form has no additonal information (other than status and dr name) just put source as "order". If the electronic form is filled out with additional information then put "order and form". --LKolesar 11:37, 2016 May 26 (CDT)

WRHA guidelines / forms

Cross Checks

Data use / Reporting and Analysis

  • The Critical Care QI team expects the following data from this project
    • Variables: ACP Status, Date of ACP form/Order and Source of ACP documentation
  • Changes in these over the course of the admission.
  • The expected outcome:
    • % of patient with and without documented ACP during ICU stay
    • Type of timing of ACP documentation
    • The sources of ACP documentation
    • Level of care at both admission and discharge
      • % having ACP R on admission and discharge
    • % of patients with no change in level of care during ICU
    • % of patients with change in level of care during ICU
      • % having ACP status determined during ICU stay
      • % having ACP change with decreased intensity
      • % having ACP change with increased intensity
    • Level of care at the time of ICU death
    • Level of care at the time of discharge for survived patients
  • the data are saved in table L_TmpV2 under projects "ACP at admit / ACP at end / ACP Status / ACP Source" of the centralized_data.mdb
  • the SAS program that reads the data can be found in X:\Julie\SAS_CFE\CFE_macros\CFE_CC_ACP.sas

Legacy

We used to collect this with different instructions, see article version of 15:34, 2016 May 9 (CDT) for details.

See also

see Comfort Care for collection of similar info in Medicine

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