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, 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
    • 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.
  • Project ACP Source
    • Item one of the following
      • Form
      • Orders
      • Other - with this option only, put in tmp comment what other place you obtain ACP status and date from is none of the above.
        • I just wanted to check and see what other people are using the "other" option for. If a patient has an ACP status on either the form or the orders, than I do not include an "other" option unless the "other" option occurred prior in the patient's ICU stay. For example: a patient arrived in the ICU, with no other ACP documentation other than a physicians note in the IPN stating "ACP-R", until three days later when the form was filled out. In this case, my first entry would be "ACP-R other", while my second entry would be "ACP-R form". If however, the physicians note and ACP form were filled out on the same day, then I would only have one entry, which would be "ACP-R form". The list of provided examples on WIKI would appear to contradict the way I am collecting, but I feel like it is redundant to enter "other" if the ACP status has been addressed in the orders, or on the ACP form. Any thoughts? Mlagadi 14:46, 2016 September 6 (CDT)
      • not documented - should be paired with same in ACP Source
  • for both Source and Status:
    • Date: date filled out, or check checkbox (column B) if NO DATE
      • Same date filled out for both Project ACP and ACP Source
    • 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.

Examples

(needs update, removed link to pdf that is no longer correct)

Problem: date required to send, not accepting checkbox instead

Template:Discussion Please update to include the example of how to enter ACP-no documentation for status or source to reflect recent changes to collection.

• it appears if no status or source date AND Column B (no date)is checked off, CCMDB won't send.
  • Julie had mention to Lori P today that should find a date and document best guess closet to ICU admission or if it appears the ACP status was determined closer to end of ICU admission. No blanks dates allowed, is that the rule????Trish Ostryzniuk 11:59, 2016 September 6 (CDT)

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

• 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

Error triggers 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"
  • no date or no integer

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

If a record does not have a paired partner with same tmp integer there will be an error. Query s_tmp_ACP_unpaired.

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
• 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