Initiating advance care planning at admission: a brief intervention to increase goals of care discussions in geriatric trauma patients in an urban level I trauma center

Franchesca Hwang; Joohee Son; Kelsey Ensor; Nicole Goulet; Allison Brown; Jesse Victory; Leslie Tyrie

doi:10.1136/tsaco-2022-001058

Initiating advance care planning at admission: a brief intervention to increase goals of care discussions in geriatric trauma patients in an urban level I trauma center

Trauma Surg Acute Care Open. 2023 Nov 20;8(1):e001058. doi: 10.1136/tsaco-2022-001058. eCollection 2023.

Authors

Franchesca Hwang¹, Joohee Son¹, Kelsey Ensor², Nicole Goulet³, Allison Brown¹, Jesse Victory¹, Leslie Tyrie⁴

Affiliations

¹ Surgery, NYU Langone Health - Brooklyn, Brooklyn, New York, USA.
² Surgery, NYC Health + Hospitals, Brooklyn, New York, USA.
³ Surgery, Weill Cornell Medicine, New York, New York, USA.
⁴ Surgery, Hackensack University Medical Center, Hackensack, NJ, USA.

Abstract

Objectives: The burden of geriatric trauma continues to rise. Older trauma patients experience higher morbidity and mortality and thus benefit from early goals of care (GOC) discussions and advance care planning (ACP). The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) recommends holding a family meeting within 72 hours of admission when treating geriatric trauma patients. At our level I trauma center, we sought to increase early GOC discussions by implementing a new history and physical (H&P) note template for geriatric trauma patients.

Methods: Patients (aged >65 years) admitted to the trauma surgery service (≥24 hours) were included in the study. The intervention was a change in the H&P note template to include confirmation of code status or previous ACP and identification of a healthcare proxy. Primary outcomes were the rates of recognizing a pre-existing Do-Not-Resuscitate (DNR) status/advanced directives at admission and of documentation of a GOC discussion within 72 hours. Outcomes from a 3-month period (March-May) during the pre-intervention (2021) and post-intervention (2022) periods were compared.

Results: The pre-intervention and post-intervention groups had 107 and 150 patients, respectively. We observed an increase in recognition of pre-existing DNR code status at time of admission from 50% to 95% (p=0.003) and documentation of a GOC discussion within 72 hours from 17% to 83% (p<0.0001). We also observed a trend showing that new DNR orders were placed more frequently in the post-intervention period (9% vs 17%, p=0.098). The in-hospital mortality was not significantly different.

Conclusions: The importance of GOC discussions and ACP documentation for geriatric trauma patients is evident, but its completion can be challenging. Our intervention of a new H&P note template increased GOC discussions, and this implementation may be feasible in other trauma centers to comply with the ACS-TQIP Geriatric Trauma Management Guidelines.

Level of evidence: Level III.

Keywords: advance directives; geriatrics; patient outcome assessment.