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A5087 - Implementation of a Goals of Care Documentation Template for Code Status Discussions in the Medical Intensive Care Unit
Author Block: A. Doyle1, A. B. Kaye1, E. Chen2; 1Pulmonary Critical Care, Rush University Medical Center, Chicago, IL, United States, 2Pulmonary and Critical Care, Rush University Medical Center, Chicago, IL, United States.
Rationale: Documentation of goals of care (GOC) and code status discussions (CSD) is an important aspect of inpatient medical care, especially in the medical intensive care unit (MICU) where many hospital deaths occur and handoffs are frequent. We sought to determine if implementation of a documentation template improved efficiency and quality of documentation of CSD. Methods: Using the electronic medical record (EMR), we performed a two-phase retrospective chart review of MICU patients who died or were transferred to hospice care after a change in code status at a tertiary care hospital. Data from phase 1 (June 2016 - January 2017) was used to create the documentation template, which was implemented in January 2017. Charts from phase 2 (January - June 2017) were then analyzed and compared to phase 1 charts using Chi-Squares. Results: In phase 1, 107 charts were analyzed. CSD documentation was not present in 4.7%. A separate note was utilized 60.7% of the time. MICU residents authored 44.9% of documentation, followed by MICU attendings at 19.6%. 67.6% of documentation was submitted within 1 hour of DNR order placement, 47% was submitted >24 hours prior to death, and 10% was submitted following death. In phase 2, 114 charts were analyzed. CSD documentation was not present in 4.4%. A separate note was utilized 71.9% of the time, with 50% using the GOC documentation template and 21.9% using a separate (non-template) note. MICU residents authored 48.2% of documentation, followed by MICU fellows at 21.9%. Rate of documentation submitted within 1 hour of DNR order placement rose to 68.4%, and documentation submitted after death fell to 5.3%. 53.5% of documentation was submitted >24 hours prior to time of death. There was no statistically significant difference in documentation rate, author, time from DNR order placement to note submission, or time from note submission to death. However, phase 2 saw a trend toward increased utilization of a separate note for CSD documentation (p=0.07), as well as more frequent documentation by MICU residents and fellows. Additionally, there was improvements in the rate of documentation occurring within 1 hour of DNR order placement and >24 hours before time of death. Conclusions: Implementation of a documentation template for GOC and CSD increased the rate of documentation utilizing a separate note and may increase documentation by housestaff. This may lead to higher quality documentation, making it easier for care teams to access information regarding GOC and CSD.