ACP Status Collection: Difference between revisions

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{{Project
{{Project
|ProjectActive=in planning
|ProjectActive=planned
|ProjectProgram=CC
|ProjectProgram=CC and Med
|ProjectRequestor=Dr. Roberts
|ProjectRequestor=Dr. Roberts
|ProjectCollectionStartDate=2026-06-??
|ProjectCollectionStartDate=2026-06-??
|ProjectCollectionStopDate=
|Project=ACP Status Collection
|Project=ACP Status Collection
}}
}}
This article is about collecting the "ACP Status" (Advanced Care Planning) temp entry. See [[ACP Status Collection over time]] for related collections.
This article is about collecting the "ACP Status" (Advanced Care Planning) temp entry. See [[ACP Status Collection over time]] for related collections.
{{DL|
This is a starting point, all below needs to be updated.
}}


== Purpose ==
== 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.
We collect ACP status as a quality indicator that reflects discussion of goals of care for all patients admitted to ICU or medicine. The primary intent is the collection of the actual status, not the quality of the documentation. We may do a different collection project at a later time to address the quality of documentation.  


== Collection Instructions ==
== Collection Instructions ==
For each record, use the last documented ACP status in the chart ''prior to '' admission date. After admission, collect the first ACP status documented by a physician
* For each new record, use the last documented ACP status in the chart ''prior to '' admission date, a date and time is NOT required
*ACP forms from prior hospitalizations, PCH, health directives can be used to determine the ACP status prior to admission
* On admission, collect the first ACP status documented by a physician only
* At discharge, collect the last ACP status documented by a physician only
An initial '''ACP Status''' entry will be automatically added.  
 
=== Time entries in this project ===
* The ACP form does not have a field for time entry, so if there is documentation in the orders or notes with a time entry, use the earliest related date and time documented elsewhere in the chart.
* If a '''time is not available''', use the best estimate for the time. If there is no estimate at all, use noon, or the closest to noon that the [[#Data Integrity Checks (automatic list)|Data Integrity Checks]] will allow.


* for '''each''' ACP documentation, change
===Level of documentation required===
** Project '''ACP Status'''
* Code based on whether there is evidence in the chart that a deliberate conversation about goals of care happened.
*** Item one of the following
* If status is documented as "presumed ACP R" and there is no evidence that a conversation happened, enter "not documented".
**** '''ACP R''' - full resuscitation
* If the form is not signed, but there is other charting that indicates a physician had a conversation with the patient, code as per the form, ie we don't care that the form was not signed but that a conversation happened.  
**** '''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  ===
=== "True ACP" vs terminal comfort care ===
Moved here from [[ACP Status Collection for LAU]]
* For the [[#Purpose]] of this project, we are not considering scenarios where a decision is made to provide terminal comfort care. Collect/code those as if they had not been documented.
{{DT|  
{{ex|
* many patients are deemed comfort care, with no official change in their status except in the notes and orders, can we use the dttm in orders or notes to reflect ACP last status? I would think yes based on [[ACP-C]] and [[Palliative care]] criteria?  [[User:Lkaita|Lisa Kaita]] 09:53, 11 June 2025 (CDT)
* Ex: patient deteriorates and the ACP status is established as [[ACP-C]], this could be on admission or anytime after admission.
** Interesting. It would depend on the purpose of this field, to some degree. Also, we discussed today that there has been category creep in those over time:
* Ex: On day one an ACP R is established and on day 20 they deteriorate and are deemed ACP C, disregard this and do not change the original ACP R status.  
*** [[ACP-C]] content I think was really only ever intended as page intro for what is essentially an index page to make sure we keep in mind all places where the concept is used.
* Ex: an ACP status has not yet been established, patient deteriorates and is deemed ACP C, disregard this and enter the first ACP status as not documented
*** APC-C setting qualifies for [[Transfer Ready DtTm tmp entry]]
* Ex: patient is in ICU and they withdraw care
*** Having ACP-C status qualifies for [[Palliative care]] dx, but other things do as well, so not interchangeable. The page explicitly says they are not the same.  
:: I think we are actually looking for properly completed and documented advanced care plans, specifically, but will confirm. [[User:Ttenbergen|Ttenbergen]] 16:30, 11 June 2025 (CDT)
* "note indicating that there was a discussion with patient or care team", a definition similar to that ...
}}
{{DL|
* if date/time is not documented, is a date/time required? would it be date of first service and 1200?
** that might put it before the first service start dttm, which (and needs to) trigger the cross check. The DtTm is important since we will look at this in the context of delays, so even a best guess would be better than a not-filled. So I would say enter best guess. If it is clear the discussion was on the unit and after admission, and there really is no way to figure out when, we could have some sort of standard, eg xhrs after admission. I will confirm. [[User:Ttenbergen|Ttenbergen]] 16:30, 11 June 2025 (CDT)
* How about something like this: Use the best estimate for the time. If there is no estimate at all, use noon (or the closest to noon that the requirement that it has to be within the admission will allow).
}}
}}
* If the patient lives longer than initially anticipated, then code continued status as usual. That is, if there is evidence of a deliberate conversation about goals of care, this can be coded. There is no specific timeline of how long the patient has to live for this to apply.


*if status is documented as "presumed", is this what we should use?
===Sources===
** then you enter "not documented" (but maybe we need to fine-tune the wording)
*'''ACP Prior to admission (PTA)'''
**ACP forms from previous hospitalizations, PCH, health directives can be used to determine the ACP status prior to admission. If the last ACP status prior to admission cannot be readily found within the current chart, enter not documented. The PTA ACP does not need to be established or signed by a physician.
*'''ACP first'''; in this context consider the first done by a provider for the current [[Definition of a Critical Care Program Admission]]/[[Definition of a Medicine Program Admission]], not the first during this hospitalization
**ACP form, orders, notes, use ACP forms made during same hospitalization (e.g. ACP status documented by ER, or ward or on prior ICU/ward for transferred patients)
**SBGH EPR- 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. 
*'''ACP Last'''
**ACP form, order, notes use ACP forms made during same hospitalization (e.g. ACP status documented by ER, or ward or on prior ICU/ward for transferred patients)
**SBGH EPR as per above instruction


{{DT| meeting with Dr R today where we changed the approach, he would like the ACP status PTA (prior to admission) if documented anywhere, and the first ACP status established by a physician only, this could be found in the orders, the ACP sheet or the progress notes. It was pointed out the actual ACP form does not have a time entry field it only has a date, he instructed to use our best guess/judgment for the time. He no longer wants the ACP last status
=== Data Entry Instructions === 
* he also described the situation where a pt is deteriorating quickly and the patient is changed to ACP C or in ICU and they withdraw care, he does not want this captured a a true ACP status.
For every new record,  an entry of "not entered" will be automatically generated.   
* on the medicine admission order forms there is a checkbox for "previously established ACP" These patient's sometimes have an ACP status form completed so we are uncertain if the previously established ACP is referring to the form or a PTA ACP status, should we use this as an established first ACP status?  
* I have suspended collection until T & L discuss this further [[User:Lkaita|Lisa Kaita]] 14:07, 16 June 2025 (CDT)
* How about the changes I made above, do they capture the new rules? We can discuss today Wednesday if I can catch you while there. [[User:Ttenbergen|Ttenbergen]] 01:09, 24 June 2025 (CDT)}}


*but if there is no documented ACP status?
Update that line to one of the following:
** then you enter "not documented"
* '''Project:''' ACP PTA
*** yes, but using date & time of first service, date & time of current boarding location service or one of these dates & 12:00?
** '''Items''':
**** I have removed the date requirement from the initial listing, and updated what to use for the "change" listing. If clear now, pls delete the question. If still not clear, pls explain.
*** ''not yet entered'' (automatic entry)
*** [[ACP-C]]
*** ACP-M
*** ACP-R
*** not documented
** Date/Time, Checkbox, Integer, Real: not used


{{DT| if we follow the instructions above would this not be a previously established ACP status and not a new one? so we would enter this as PTA and capture the first ACP status established by a medicine doc? [[User:Lkaita|Lisa Kaita]] 14:07, 16 June 2025 (CDT)  
* '''Project:''' ACP first
* Agreed; in any case, I think this info would belong above with the other when-to-enter-what content rather than here. [[User:Ttenbergen|Ttenbergen]] 09:08, 24 June 2025 (CDT) }}
** '''Items''':
*** ''not yet entered'' (automatic entry)
*** [[ACP-C]]
*** ACP-M
*** ACP-R
*** not documented
* Date/Time, Checkbox: using instructions in [[#Date/Time in this project]], enter the dttm of the status decision
** if ACP status is established during this hospitalization, but by a different service/ward prior to the medicine/ICU admission, use the first service [[Admit DtTm]]
{{Discuss| Task
* I had understood that DR wanted to know if the doctors on the ''current'' service are processing this. That might be a misunderstanding, though.  DR if a patient is admitted to our service from another service or ward (icu to medicine, ER to medicine/ICU, surgical ward to ICU/medicine) and has an ACP already established by the previous service, can we use this as the first documented ACP? or do you want to know when the new service establishes an ACP status?
** Ah... I don't think I got clarification on that one. I have added it to my list for my next meeting with Dr. Roberts (Thu Jul 3). Also added to Task in case that happens sooner. [[User:Ttenbergen|Ttenbergen]] 22:57, 29 June 2025 (CDT)
}}
*** consider [[#"True ACP" vs terminal comfort care]]


=== Examples ===
** Integer, Real, Comment: not used
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.


=== If care has been discontinued ===
* '''Project:''' ACP last
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.
** '''Items''':
*** ''not yet entered'' (automatic entry)
*** [[ACP-C]]
*** ACP-M
*** ACP-R
*** not documented
** '''Date/Time''': using instructions in [[#Date/Time in this project]], dttm of the status decision
** '''Checkbox''': check if "no dttm" for "same" below
** which item/Dttm to code:
*** if the ACP last status is the '''same''' as the ACP first status, enter the same ACP status as the first, and check the '''checkbox''' for "no dttm" as it is not applicable
*** if the ACP last status is '''different''' than ACP first status, enter the dttm of the last documented change in ACP Status and the dttm as per [[#Date/Time in this project]]
*** consider [[#"True ACP" vs terminal comfort care]]


=== If ACP-M is documented without +/- ===
* Comment (optional): If there are multiple ACP status changes/family discussions that are affecting the LOS or seem unusual, leave this as a comment in the "Q" column, NOT the [[Notes field]]
If ACP M is just written with no qualifiers then one would classify as ACP M-.
**  Integer, Real: not used


===ACP from EPR (STB only at this time)===
===Questions?  ===
*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".  --[[User:LKolesar|LKolesar]] 11:37, 2016 May 26 (CDT)


== WRHA guidelines / forms ==
== WRHA/SH guidelines / forms ==
*[[Media:WRHA ACP form Nov 2013.pdf | Example of WRHA ACP FORM]]
*[[Media:WRHA ACP form Nov 2013.pdf | Example of WRHA ACP FORM]]
*[[Media:AdmittingOrdersforICU.pdf | Example of Admitting Orders for ICU]]


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


== Data use / Reporting and Analysis ==
== 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
== Reporting and Analysis Files ==
* the SAS program that reads the data can be found in {{S:\MED\CCMED}}Julie\SAS_CFE\CFE_macros\CFE_CC_ACP.sas
* the file for the analysis and report can be found in {{S:\MED\MED_CCMED}}<to be determined>


== Log ==
== Log ==

Latest revision as of 21:42, 21 August 2025

Projects
Active?: planned
Program: CC and Med
Requestor: Dr. Roberts
Collection start: 2026-06-??
Collection end:

This article is about collecting the "ACP Status" (Advanced Care Planning) temp entry. See ACP Status Collection over time for related collections.

Purpose

We collect ACP status as a quality indicator that reflects discussion of goals of care for all patients admitted to ICU or medicine. The primary intent is the collection of the actual status, not the quality of the documentation. We may do a different collection project at a later time to address the quality of documentation.

Collection Instructions

  • For each new record, use the last documented ACP status in the chart prior to admission date, a date and time is NOT required
  • On admission, collect the first ACP status documented by a physician only
  • At discharge, collect the last ACP status documented by a physician only

Time entries in this project

  • The ACP form does not have a field for time entry, so if there is documentation in the orders or notes with a time entry, use the earliest related date and time documented elsewhere in the chart.
  • If a time is not available, use the best estimate for the time. If there is no estimate at all, use noon, or the closest to noon that the Data Integrity Checks will allow.

Level of documentation required

  • Code based on whether there is evidence in the chart that a deliberate conversation about goals of care happened.
  • If status is documented as "presumed ACP R" and there is no evidence that a conversation happened, enter "not documented".
  • If the form is not signed, but there is other charting that indicates a physician had a conversation with the patient, code as per the form, ie we don't care that the form was not signed but that a conversation happened.

"True ACP" vs terminal comfort care

  • For the #Purpose of this project, we are not considering scenarios where a decision is made to provide terminal comfort care. Collect/code those as if they had not been documented.
Example:   
  • Ex: patient deteriorates and the ACP status is established as ACP-C, this could be on admission or anytime after admission.
  • Ex: On day one an ACP R is established and on day 20 they deteriorate and are deemed ACP C, disregard this and do not change the original ACP R status.
  • Ex: an ACP status has not yet been established, patient deteriorates and is deemed ACP C, disregard this and enter the first ACP status as not documented
  • Ex: patient is in ICU and they withdraw care
  • If the patient lives longer than initially anticipated, then code continued status as usual. That is, if there is evidence of a deliberate conversation about goals of care, this can be coded. There is no specific timeline of how long the patient has to live for this to apply.

Sources

  • ACP Prior to admission (PTA)
    • ACP forms from previous hospitalizations, PCH, health directives can be used to determine the ACP status prior to admission. If the last ACP status prior to admission cannot be readily found within the current chart, enter not documented. The PTA ACP does not need to be established or signed by a physician.
  • ACP first; in this context consider the first done by a provider for the current Definition of a Critical Care Program Admission/Definition of a Medicine Program Admission, not the first during this hospitalization
    • ACP form, orders, notes, use ACP forms made during same hospitalization (e.g. ACP status documented by ER, or ward or on prior ICU/ward for transferred patients)
    • SBGH EPR- 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.
  • ACP Last
    • ACP form, order, notes use ACP forms made during same hospitalization (e.g. ACP status documented by ER, or ward or on prior ICU/ward for transferred patients)
    • SBGH EPR as per above instruction

Data Entry Instructions

For every new record, an entry of "not entered" will be automatically generated.

Update that line to one of the following:

  • Project: ACP PTA
    • Items:
      • not yet entered (automatic entry)
      • ACP-C
      • ACP-M
      • ACP-R
      • not documented
    • Date/Time, Checkbox, Integer, Real: not used
  • Project: ACP first
    • Items:
      • not yet entered (automatic entry)
      • ACP-C
      • ACP-M
      • ACP-R
      • not documented
  • Date/Time, Checkbox: using instructions in #Date/Time in this project, enter the dttm of the status decision
    • if ACP status is established during this hospitalization, but by a different service/ward prior to the medicine/ICU admission, use the first service Admit DtTm
Task
  • I had understood that DR wanted to know if the doctors on the current service are processing this. That might be a misunderstanding, though. DR if a patient is admitted to our service from another service or ward (icu to medicine, ER to medicine/ICU, surgical ward to ICU/medicine) and has an ACP already established by the previous service, can we use this as the first documented ACP? or do you want to know when the new service establishes an ACP status?
    • Ah... I don't think I got clarification on that one. I have added it to my list for my next meeting with Dr. Roberts (Thu Jul 3). Also added to Task in case that happens sooner. Ttenbergen 22:57, 29 June 2025 (CDT)
  • SMW


  • Cargo


  • Categories
    • Integer, Real, Comment: not used
  • Project: ACP last
    • Items:
      • not yet entered (automatic entry)
      • ACP-C
      • ACP-M
      • ACP-R
      • not documented
    • Date/Time: using instructions in #Date/Time in this project, dttm of the status decision
    • Checkbox: check if "no dttm" for "same" below
    • which item/Dttm to code:
      • if the ACP last status is the same as the ACP first status, enter the same ACP status as the first, and check the checkbox for "no dttm" as it is not applicable
      • if the ACP last status is different than ACP first status, enter the dttm of the last documented change in ACP Status and the dttm as per #Date/Time in this project
      • consider #"True ACP" vs terminal comfort care
  • Comment (optional): If there are multiple ACP status changes/family discussions that are affecting the LOS or seem unusual, leave this as a comment in the "Q" column, NOT the Notes field
    • Integer, Real: not used

Questions?

WRHA/SH guidelines / forms

Data Integrity Checks (automatic list)

none found

Cross Checks

Data use / Reporting and Analysis

Reporting and Analysis Files

  • the file for the analysis and report can be found in S:\MED\Med_CCMED\​S:\MED\Med_CCMED\<to be determined>

Log

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