ACP Status collection in ICU

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

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, an initial "ACP Status" and "ACP Source" entry will be automatically added. Add additional pairs of entries for additional ACP documentation.

• 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
  • Project ACP Source [for Location of ACP documentation]
  • 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 what other place you obtain ACP status date from is none of the above.
  • 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.

Question

• Once a pt arrives in the ICU who was previously an inpatient on the ward, do you want the previous ACP status before the ICU admission documented or do we just start with the first ACP status decided on admission to the ICU and then any documented changes thereafter? For example if a pt was "R" on the ward and on arrival to the ICU after discussion, it is changed to "M-": should I put the "R" and the "M-", or just start with the "M-" and document any changes after that? Because this project relates to the ICU admission, I just wanted this clarified. --LKolesar 13:40, 2016 May 4 (CDT)
  • All ACP documentations during the same hospitalization will now be collected if available. The QI Team would like the ACP status at 3 time periods namely, i) at PRE-ICU, ii) at admission and iii) at discharge. Since the date is being collected, I will assign the ACP status to each time period by programming. For this example, there are 2 entries of ACP documentation by data collector.
    • First:
      • Project='ACP status', Item='ACP R', Date_var= date1 before ICU admit date
      • Project='ACP Source', Item='Form', Date_var=date1 before ICU admit date
    • Second:
      • Project='ACP status', Item='ACP M-', Date_var= date2 (arrival date at ICU)
      • Project='ACP Source', Item='Form', Date_var=date2(arrival date at ICU)
    • The ACP Status assignment via program codes will be PRE-ICU='ACP_R', Admit_ACP='M-', Disch_ACP='M-'(if no more new form)

JMojica 17:06, 2016 May 4 (CDT)

Files before 2016-05-01

• I have a number of files that are ready to send, but it won't let me send them because I don't have the "source of ACP" filled in.

• Do I need to pull those charts again to find the source of ACP? There should be a way of grandfathering files completed before the roll out date for the ACP source item collection...The way I was able to send, was to put for for ACP source, ITEM: Orders.
  • No you should not have to pull the chart of already completed files you have to send this week, if you had not obtained the SOURCE of ACP status, prior to start date this week.Trish Ostryzniuk 17:29, 2016 May 6 (CDT)
  • Tina, this has caused sending problems this week, and work around some people had was to just put ACP source as orders.Trish Ostryzniuk 17:29, 2016 May 6 (CDT)
    • fixed in CCMDB.mdb_Change_Log_2016#2016-May-09; wil check only records with Arrive DtTm field >= 2016-05-01 Ttenbergen 10:51, 2016 May 9 (CDT)

If there is no ACP documentation

For patients who had no ACP documentation during their stay, enter as follows:

• Project ACP Status - delete this line
• Project ACP Source
  • Item not documented

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-.

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

Checks at sending time

If a patient exists who

• pt is ICU pt
• RecordStatus is complete
• one of the following is true
  • there is not at least one entry in tmp with project = "ACP Source"
  • project = "ACP Source" or "ACP Status" and item = "enter"

then won't be able to send anyone. In normal operation such a patient should not be possible to set to "complete", this is a double-check. Implemented as query s_tmp_ACP in CCMDB.mdb_Change_Log_2016#2016-May-04

pairs of records

Template:Discussion Should probably have a cross-check to ensure matched pairs of records, but not sure how that would work, since there might be several on one day. Julie was talking about using "almost" matches of entry date and time, but those might be almost the same if a collector is catching up after a weekend. Do we need to add the time field to to the collection to get a good match? Even if the time is estimated, as long as it's the same between each record pair it would address this.

• Is the adding of the time field done 'automated' or 'manual entry of time by the data collector'? If the latter, then it will just be the same as adding an integer for each pair (ie. maybe consecutive order or not as long as the same for each pair). Similar to how the Data collectors are doing with the admit/complication diagnoses - adding an integer for ranks. It seems that adding an integer will give a 'perfect' match and simple than the 'almost match' using the additional time field. JMojica 09:13, 2016 May 5 (CDT)
  • The time_value is entered manually. We could use an arbitrary integer (which would have little meaning) to match, or we could use the time_value field which will have meaning some of the time. Using it would be a problem when no info about the time is available. Do collectors have thoughts on this? Will also flag for Trish. Ttenbergen 10:40, 2016 May 5 (CDT)

Check at Complete-time

Can't check patient complete if the Item for an entry for this project is "enter" or "". Implemented in VBA in CCMDB.mdb_Change_Log_2016#2016-May-04

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)
• I see the request for three ACP documentation times: pre-ICU admit, at ICU admit and at the end of the ICU stay. But where is the option specifying the pre-ICU status or am I confused about this whole paragraph?--Jpeterson 13:40, 2016 May 9 (CDT)

• 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

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

Name of Tmp entry

The names were shortened for better usability:

• "ACP Status at admit" -> "ACP at admit"
• "ACP Status at end" -> "ACP at end"

Date collection

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

change to collect each ACP documentation form rather than beginning and ending status Ttenbergen

new started 2016-May-01, old discontinued 2016-May-04

old Coding Instructions

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

• for each of ACP 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.
• ACP 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.
  • if status has not changed, use same date as for status at admit

If a date can not be found in documents from this hospitalization, leave it blank but put a check in the checkbox.

For each of the two enter one of the following options:

• 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 (ie don't code as ACP-R) (leave date blank and check checkbox)

Do not fill numbers, not used for this project

If care has been discontinued

If the pt has care as been discontinued, do not automatically change the ACP to C. Use the last documented ACP status on chart for the end of ICU stay.

If documented elsewhere

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)

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

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

See also

see Comfort Care for collection of similar info in Medicine