The impact of an electronic medical record alert on code status documentation for hospitalized patients with advanced cancer.

Abstract

319 Background: Cardiopulmonary resuscitation in hospitalized patients with advanced cancer is associated with high rates of morbidity and mortality. Advanced care planning (ACP) in this population has exhibited improvements in quality, patient satisfaction, hospice utilization, rates of harm, and healthcare costs. We have sought to observe the changes in ACP documentation by Internal Medicine residents within a tertiary hospital’s inpatient oncology service following a mandatory caregiver training module and enterprise-wide modification in Epic, as well as identify self-reported barriers in code status documentation. Methods: Patients admitted to the Cleveland Clinic’s oncology service were retrospectively reviewed for 8 weeks before and after the implementation of an ACP caregiver training module and code-status best-practice-alert (BPA) into Epic. ACP documentation was assessed in admission notes and direct orders into Epic. In addition, Internal Medicine residents were surveyed on behaviors and perceived barriers contributing to code status documentation. Results: A total of 551 patients (181 pre and 370 post-BPA) were reviewed, exhibiting a 17.2% (44.2 to 61.4) increase of code status documentation in resident admission notes and a 17.6% (10.5 to 28.1) increase in code status orders by residents into patient Epic charts by the time of discharge. Observed 30, 60, and 90-day mortality rates from the day of admission were 18.2, 24.9, and 32%, respectively. The most common self-reported barrier to resident ACP documentation was “forgetting to discuss during the admission process”, and 58% of first-year residents admitted to feeling “uncomfortable” in orchestrating goals-of-care conversations. Conclusions: Resident ACP documentation continues to be suboptimal in the high-risk cohort of hospitalized advanced cancer patients. However, documentation rates appear to be positively influenced by large-scale and multimodal approaches. Further efforts to improve the current practice and culture of advanced directives and code status for the inpatient oncology patient population remains a crucial aspect in the quality and safety of our approach to patient care.