ACP Status Collection: Difference between revisions

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== 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 or medicine.
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 new record, use the last documented ACP status in the chart ''prior to '' admission date, a date and time is NOT required  
* 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
* On admission, collect the first ACP status documented by a physician only
*At discharge, collect the last ACP status documented by a physician only
* At discharge, collect the last ACP status documented by a physician only
*Only use ACP forms made during same hospitalization (e.g. ACP status documented by ER, or ward or on prior ICU/ward for transferred patients)
 
=== 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.
 
===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.  
{{ex|
* 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===
===Sources===
*ACP PTA
*'''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.
**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
*'''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
**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.   
**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 Last'''
**ACP form, order, notes
**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
**SBGH EPR as per above instruction


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*** not documented
*** not documented
** Date/Time, Checkbox, Integer, Real: not used
** Date/Time, Checkbox, Integer, Real: not used
{{DT| does the ACP Status PTA need to be documented by a physician or can it be documented by another discipline? [[User:Lkaita|Lisa Kaita]] 16:33, 24 June 2025 (CDT) }}
 
* '''Project:''' ACP first  
* '''Project:''' ACP first  
** '''Items''':  
** '''Items''':  
Line 47: Line 65:
*** ACP-R
*** ACP-R
*** not documented
*** not documented
* Date/Time: dttm of the status decision
* Date/Time, Checkbox: using instructions in [[#Date/Time in this project]], enter the dttm of the status decision
** if decision was made before admission, use the first service [[Admit DtTm]]
** 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]]
** 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. Note, the ACP form does not have a field for time entry, so if there is documentation on the orders or notes with a time entry, use the earliest date and time documented
{{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]]
 
** Integer, Real, Comment: not used


* '''Project:''' ACP last  
* '''Project:''' ACP last  
Line 58: Line 82:
*** ACP-R
*** ACP-R
*** not documented
*** not documented
* Date/Time: dttm of the status decision
** '''Date/Time''': using instructions in [[#Date/Time in this project]], dttm of the status decision
** 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.
** '''Checkbox''': check if "no dttm" for "same" below
** 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 dttm  
** which item/Dttm to code:
** if the ACP last status is different than ACP first status, enter the last documented ACP Status and the dttm that it was changed, if there is no time 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.
*** 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 a patient is deteriorating quickly and the ACP status is changed to ACP C,  or is in ICU and they withdraw care, do not document this as ACP last status for this project.  Use the ACP first status and check the checkbox for dttm. 
*** 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]]
{{Discuss| IF a patient in this situation continues to live for days, should the ACP status be changed at some point? and if so what timeframe should we use?
*** consider [[#"True ACP" vs terminal comfort care]]  
*If the ACP form does not have a signature, but an ACP status is checked off, should this be entered as not documented? [[User:Lkaita|Lisa Kaita]] 16:33, 24 June 2025 (CDT) }}
* 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 section
* Checkbox, Integer, Real: not used


===Question  ===
* 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 status is documented as "presumed ACP R" should we capture this as ACP R or not documented?
**  Integer, Real: not used
** then you enter "not documented" (but maybe we need to fine-tune the wording)
{{Discuss| Dan do you agree with this? [[User:Lkaita|Lisa Kaita]] 16:33, 24 June 2025 (CDT) }}


===Questions?  ===


== WRHA/SH 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]]


 
{{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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