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

TMP file: For each ICU patient, use the last documentation of ACP status that you find in the chart that is closest to 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 discharge. If there is no changes during ICU admission from initial ACP status and source you have recorded then no need to enter anymore.

Always pair the status & source of this documentation in chart in Tmp using an integer in column N.

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
  • 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.
  • for both Source and Status:
    • 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.
  • Integer (column "N"): 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 a date.
• if no ACP decisions are documented at all then:
  • Project ACP Status - delete this line
  • Project ACP Source
    • Item not documented

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)

Some examples of pairing ACP status and Source in TMP: CLICK HERE

Template:Discussion I have a chart that I am working on that I would like feedback on. I have a patient from an outside of city hospital, with a physicians note that says "Full codes". The patient was transferred to VGH, and the first documented ACP status on my chart was an "R" written in the physician's IPN. Weeks later, after a formal discussion with the patient, the form was filled out with an ACP "R". This is how I recorded this information: My first set of entries was:ACP status-R (1), source-other (1)(IPN from different hospital), with a date of APR.22nd. My second set of entries was:ACP status-R (2), source-other (2) (IPN from VGH), with a date of Apr.23rd. My third set of entries was:ACP status-R (3), source-form (3), May 15th. Any thoughts on this would be appreciated!Mlagadi 12:45, 2016 May 19 (CDT)

• Correct. Look at example here: CLICK HERE-Trish Ostryzniuk 11:05, 2016 May 20 (CDT)

Mandatory after 2016-05-01

Entries for this will be mandatory for records with admit dates after 2016-May-01.

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-.

Question

• Just wondering if there is a reason that there are 2 pre-populated entries for ACP source in CCMDB?? Most patient will only have one entry for source and one for status so we frequently have to delete the second entry. I think it would be easier to just pre-populate one entry of each (status and source) and then if there are more than one, we can just add it. This is my opinion. --LKolesar 12:25, 2016 May 19 (CDT)

• Asking if data collectors would find it be beneficial/useful to have a "sort" button available for numerical ordering of ACP status entries similar to the "sort" button in place for admitting dx and acquired complications? Pamela Piche 09:50, 2016 May 20 (CDT)

• • I would find this very helpful - going back to review the ACP status is difficult when they are sorted based on the 1st entry. Mschaffer 09:04, 2016 May 31 (CDT)
• I agree that this would be helpful and had also thought about it.--Jpeterson 08:59, 2016 June 2 (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"

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

will need to make a check that looks for matching pairs of integers Ttenbergen 15:34, 2016 May 9 (CDT)

• right now when we enter anything into the tmp in the ICU program, the information jumps around and it makes entry into tmp very frustrating. This is likely from the attempt to pair ACP items. If possible, instead of "automatic" pairing, just put in the "magic wand" which we can click if we want to put them together. The "automatic" pairing is making entry slower and the information is jumping around. --LKolesar 08:58, 2016 June 8 (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
• 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