Increasing healthcare proxy documentation in an intensive care unit: a quality improvement initiative
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Abstract
In New York State, the Health Care Proxy Law allows patients to designate a person they trust to make medical decisions on their behalf should they lose the capacity to do so. In an Intensive Care Unit (ICU) setting, identification of a health care proxy (HCP) is especially important as patients are at heightened risk of losing decision-making capacity during their clinical course. While our hospital has guidelines to solicit and correctly document the patient’s HCP information, it is not routinely done. Missing or incomplete HCP documentation is a prevalent issue, with lack of patient education, physical document issues, and time and workflow constraints commonly cited as barriers. We describe the implementation of a small-scale quality improvement project to increase the percentage of completed HCP documentation in our ICU through multi-faceted interventions targeting education, workflow, access, and technology.
Background
In New York State, the Health Care Proxy Law allows patients to designate someone they trust to make medical decisions on their behalf should they lose the capacity to do so. Implicit are the prerequisites that the patient is aware of this opportunity (or is asked about it) and that the proper documentation is completed and stored in the electronic health record (EHR). In an intensive care unit (ICU) setting, identification of a healthcare proxy (HCP) is especially important as patients are at heightened risk of losing decision-making capacity during their clinical course.
In our 280-bed hospital within a larger health system, there are guidelines in place to ask patients about a HCP. However, it is not consistently done, or the documentation is either incomplete or incorrectly completed. Missing or incomplete HCP documentation is a prevalent issue, with patient education, workflow, physical document issues and time management cited as common barriers.1–4 Downstream consequences include delays in establishing goals of care and negative effects on patient experience, as identified through mortality peer reviews at our institution.
Therefore, we developed a focused quality improvement project aimed to increase the percentage of completed HCP forms by 15% for all ICU patients over the course of 3 months.
Methods
A 16-bed mixed adult medical and surgical ICU at a tertiary referral urban teaching hospital was the site for this quality improvement project. All patients admitted to the ICU were included. The EHR was reviewed to determine the percentage patients with completed HCP documentation. ‘Completed’ HCP documentation was defined as a scanned copy of the correctly completed paperwork into the advanced care planning (ACP) tab of the EHR. HCP paperwork was ‘correctly completed’ when it was dated and signed by the patient and a witness.
Baseline data was collected 1 month prior to our interventions. Data was collected at 1-week intervals to mitigate the risk of duplicate patients with long lengths of stay. Postintervention data collection continued for 3 months.
Process analysis of the current workflow identified the responsibility of HCP form completion to be shared between nursing and resident physicians (residents), defined as trainees in a graduate medical education programme. Nurses typically inquire about a patient’s HCP and residents complete the documentation and assist with upload to the EHR. An anonymous Google survey of residents revealed time constraints (87%), lack of physical forms (20%) and failing to remember (40%) as frequent barriers to HCP form completion among 15 respondents.
Based on these responses, interventions targeting education, workflow, access and technology were deployed in tandem. The internal medicine resident noon conference was used as a forum to highlight the importance of HCP documentation, including what it is, proper form completion and conversation script tips. All internal medicine residents working daytime assignments are required to attend this conference. With several faculty project champions, coaching and feedback on HCP completion continued as a part of daily rounds in the ICU. Discussing HCP with patients during the initial ICU consultation was a new expectation in the workflow. Physical HCP forms were placed in provider work areas in the ICU and emergency department for ease of access and visual prompting. Technology was leveraged in three ways: (1) the EHR note template for the initial ICU consultation was adapted to auto-populate the available HCP information from the ACP tab, which also served as a visual reminder for completion when information was missing, (2) providers were prompted to use the smart phone application of our EHR to directly upload the completed paperwork to the ACP tab and (3) providers were encouraged to enable an EHR tool that identified patients missing a completed HCP form.
Results
The preintervention baseline was derived from a random audit of an average of 10 charts weekly (totalling 40 charts). The weekly median percentage of sampled charts with completed HCP forms comprised the baseline rate of 40%. A random audit of an average of 11 charts weekly post intervention (totalling 133 charts) assessed the weekly median percentage of HCP completion to be 67%. Trends were analysed using GraphPad statistical software. Data was plotted using Microsoft Excel (figure 1). Comparing the data using a χ2 test yielded a value of 8.524 with 15 df. The two-tailed p value equals 0.9011.
Percentages of completed HCP forms, pre intervention and post intervention.
Discussion
While our multifaceted approach to address identified barriers to HCP completion did not yield a statistically significant improvement, we observed a postintervention increase from baseline of 40% to 67%, which was sustained at 12 weeks post intervention. These results are promising and may suggest the beginning of knowledge internalisation, competency in discussing and documenting HCP information and adoption of the new ICU workflow by residents. Having faculty project champions helped to reinforce the changes in expectations and workflow. Fixed changes to the EHR also continued to support completion of the HCP form.
Some limitations exist with our project. The preintervention baseline was derived from 1 month of data and may reflect a snapshot of patients and resident practice. Our results may be confounded with patients who lacked capacity at the time of admission. These patients would not be intervened on, but still counted as having incomplete HCP documentation. Small sample size may have affected our results. As our residents rotate through the ICU in 4-week blocks, the postintervention data only captured the practice of three cohorts of residents. Extending the duration of data collection could overcome this limitation. Since all interventions were deployed simultaneously, it was also difficult to determine which one was the most impactful. We believe the EHR enhancements and faculty champions were synergistic and promote sustainability of our interventions.
Conclusion
We describe a small-scale quality improvement project to increase the percentage of completed HCP documentation in an ICU by leveraging faculty and technology to effect changes in practice and culture. Although not statistically significant, we observed a postintervention increase from baseline of 40% to 67%, which was sustained at 12 weeks post intervention. Next steps include extended surveillance to assess implementation of changes and expansion of project scope to include other ICUs in our health system.
Contributors: SL spearheaded the QI initiative, conceived of the project and wrote key parts of the manuscript. AM provided initial data gathering and manuscript editing and writing. LM provided key quality improvement knowledge, was a liaison with the electronic medical record and edited the paper. PD provided initial guidance, structure to the QI initiative and mentorship along with key editing of the manuscript. JF provided structure, guidance, final editing and the overall plan to the manuscript and statistical guidance.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Ethics statements
Patient consent for publication:
Not applicable.
Ethics approval:
There are no ethical disclosures. The project was deemed a quality project by the quality improvement committee in the department of medicine at Mount Sinai Beth Israel Hospital.
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