ACP Status collection in ICU

see Comfort Care for collection of similar info in Medicine

This article is about collecting the "ACP Status" temp entry.

Purpose

The purpose of collecting ACP status is to provide a quality indicator that would reflect documentation (e.g. completed ACP form or Admitting Orders) and discussion of goals of care for all patients admitted to ICU.

Coding Instructions

• NOTE: 2016-APR-08-Record the DATE in TMP when ACP status was documented on patients chart.

When you enter a new ICU patient two records will be automatically generated in the tmp table:

1. ACP Status at admit
   • Record the closest date when ACP status was documented in the chart at time of ICU admission. Date can be before of after ICU admission.
2. ACP Status at end (end of ICU: at discharge, transfer or death).
   • Record the closest date that ACP status was documented in the chart at time of ICU discharge, transfer or death.
     • NOTE: *If the pt has care as been discontinued, do not automatically change the ACP to C. Use the last documented ACP status documented on chart for the end of ICU stay.

• Question: If the ACP order is written on admission and the status stays the same without any new order, do we just put the same date as the original acp order date on discharge?--LKolesar 12:39, 2016 April 11 (CDT)
  • Yes, use same date if no change. No longer applies in the new collection below - will only collect once if there is no new order at discharge.JMojica 13:19, 2016 April 29 (CDT)

• Question 2: To obtain the date when ACP was written prior to ICU (if no date is immediately evident), are we required to go back in the chart to find the order or documentation prior? and... if so...how far back? This could be a lot of work. --LKolesar 12:39, 2016 April 11 (CDT)
  • Go back only within the same hospitalization. No longer in prior hospitalization. If still has no date, make an entry on the Comment 'No date found'. JMojica 13:19, 2016 April 29 (CDT)

• Question 3: Is there an option to put the ACP status without a date if it is difficult to find? The kardex may have the status for example, but looking for when it was first written in the notes or the orders could be time consuming. --LKolesar 12:39, 2016 April 11 (CDT)
  • see reply in question2. JMojica 13:19, 2016 April 29 (CDT)

Change the ITEM for each of them to the ACP status at that time.

Options are as follows

• ACP C - comfort care
• 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 resuscitation and intubation
• ACP n/a - no documented ACP on the chart
  • If you cannot find any mention of ACP on the chart, do not default to ACP-R, put ACP n/a as per above instructions indicate.
  • Also, if the documented ACP is not present on the chart, use ACP n/a.
    • If the ACP status is clearly mentioned in the MD's IPN note, then I will use this as the ACP status, even if it is not written in the orders or checked off on the Level of Care document at the front of the patient's chart. Are other people collecting this way as well?Mlagadi 07:27, 2016 April 11 (CDT)
• Do not fill Checkbox, numbers, not used for this project

What if ACP-M is documented without +/-?

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

New Instructions

For a week or so, collect old and new way, starting 2016-May-01, once this is settled the old way will go away.

For each ICU patient,

• for each ACP documentation, enter
  • Project ACP
  • 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
  • Project ACP Source
  • Item one of the following
    • 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.
    • Form
    • Orders
    • other - with this option only, put in tmp comment where
  • Date: date filled out, or check checkbox if no date
    • Same date filled out for both Project ACP and ACP Source
    • Date is used as the identifier for each ACP documentation.
    • Date prior to ICU admission must be during the same hospitalization (e.g. ACP status documented by ER, or ward or in prior ICU for transferred patients).
    • Date and ACP status for prior hospitalizations are not to be collected (not included) in this project.
• if there is no ACP documentation, enter
  • Project ACP Source
  • Item not documented

WRHA guidelines / forms

• WRHA ACP Guidelines/workbook
• WRHA Advance Care Policy
• Example of WRHA ACP FORM
• Example of Admitting Orders for ICU

Start and stop date

• First ACP Collection Start Date: 2015-AUG-10
  • Date with complete data across all sites: 2015-SEP-1
    • Date that ACP status documented in chart closest to ICU ADMIT and ICU END. Start to collect dates on: 2016-APR-8
• Revised ACP Collection Start Date: 2016-May-01
• Stop Date: none

Template:CCMDB Data Integrity Checks

Before being able to check tmp complete each critical care patient will have to have two entries:

• (1) ACP Status at admit
• (1) ACP Status at end

The check will be run at completion time, i.e. this is not one of the tmp checks that get run before each send.

Implemented as query s_tmp_ACP in CCMDB.mdb_Change_Log_2016#2016-Mar-16

This will change in the new collection.

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
  • The 3 variables collected at 3 time periods
    • Prior to ICU during the same hospitalization. This would pertain to ACP status documented by emergency or ward or in prior ICU for transferred patients. Would not included prior ACP status for prior hospitalizations.
    • At time of ICU admission (first documentation with new order or ACP form after or at ICU admission)
    • At time of ICU discharge (last documentation with new order or ACP form prior to ICU d/c)

• The expected outcome:
  • % of patient with and without documented ACP during ICU
  • 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 project "ACP at admit / ACP at end" 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 - RE Patients admitted prior to August 10

I spoke with Julie about this and she said to put in the ACP status on all your patients if it is not too much trouble when you have the charts. If you have finished reviewing charts and they are complete, don’t bother going back to look for the ACP status. There will probably be a week transition period given before she starts gleaning this data to give us time to get used to collecting this information. Hope this helps. Laura