Locating Advance Care Planning Documents in the Electronic Health Record during Emergency Care

Abstract

Context: Emergency Departments (EDs) care for people at critical junctures in their illness trajectories, but Advanced Care Planning (ACP) seldom happens during ED visits. One barrier to incorporating patient goals into ED care may be locating ACP documents in the electronic health record (EHR).

Objectives: To determine the ease and accuracy of locating ACP documentation in the EHR during an ED visit.

Methods: Academic ED with 82,000 visits per year. The EHR system includes a Storyboard with the patient's code status and a link to ACP documents. A real-time chart audit study was performed of ED patients who were either ≥65 years old or had a cancer diagnosis. Data elements included age, Emergency Severity Index, ACP document location(s) in the EHR, Storyboard accuracy, ED code status orders, and discussions of ACP or code status.

Results: Of the 160 audited charts, 51 (32%) were for adults <65 years old with a cancer diagnosis. Code status was discussed and updated during the ED visit in 68% (n=108). ACP documents were found in 3 different EHR places. Only 30% (n=48) had ACP documents in the EHR, and of these (22%, n=13) were found in only one of the three EHR locations. The Storyboard was inaccurate for 5% (n=8). ED case managers frequently discussed APC documentation (78%, 43/55 charts).

Conclusions: Even under optimal conditions with social work availability, ACP documents are lacking for ED patients. Multiple potential locations of ACP documents and inaccurate linkage to the Storyboard are potentially addressable barriers to ACP conversations.

Keywords: Advance care planning; electronic health records; emergency department; healthcare power of attorney; palliative medicine; quality improvement.