Improving Communication About Resuscitation Preference for Patients Discharged from Hospital to Nursing Home: A Quality Improvement Project

Haynes, Christine; Dashiell-Earp, Cody; Wenger, Neil S.; Simon, Wendy; Skootsky, Samuel A.; Clarke, Robin; Watts, Frances; Walling, Anne M.

doi:10.1089/jpm.2018.0419

Cited by 2 publications

(4 citation statements)

References 9 publications

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“…Most of our patients (95.8%) who had resuscitation status changed to DNR during hospitalization survived to discharge, and without POLST orders were at risk for undesired attempts at resuscitation if they suffered cardiac arrest during transport or upon arrival at their discharge location. However, only 32.3% of these patients had completion of POLST orders at discharge, similar to a recently published incidence of 38% for patients with DNR status in a study by Haynes et al 6 ; of note, their study did not specify that patients were Full Code status on admission.…”

Section: Discussionsupporting

confidence: 75%

“…2,3 Therefore, completion of POLST orders at hospital discharge is recommended for patients who wish to forego resuscitation to extend this treatment plan during transport and beyond the hospitalization. 1,[4][5][6] Studies to date suggest that POLST orders, when available, are associated with patients receiving treatments they desire in hospitals and nursing facilities, and spending their end of life in their preferred location. 2,[7][8][9][10] However, there are little data regarding how often POLST orders are completed for hospitalized patients who have changed their treatment preferences from Full Code to Do Not Resuscitate (DNR) prior to discharge.…”

Section: Introductionmentioning

confidence: 99%

“…One recent study reported only 38% completion of POLST orders before hospital discharge for patients with DNR orders, but did not specify whether the DNR status was a change during that hospitalization. 6 Therefore, to add to understanding of this important transition of care, we studied how frequently providers completed POLST orders for hospitalized patients with change from Full Code to DNR status during hospitalization, and predictors of whether POLST orders were provided at discharge.…”

Section: Introductionmentioning

confidence: 99%

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Underutilization of Portable Orders for Life-Sustaining Treatment at Discharge from Hospital: Observational Study at US Academic Trauma Center

Rubins

2020

J GEN INTERN MED

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BACKGROUND: Decisions to limit use of life-sustaining treatment occur frequently during hospitalizations, and portable medical orders (also known as Portable Orders for Life-Sustaining Treatment (POLST)) can ensure that patient preferences regarding resuscitation are followed after discharge. OBJECTIVE: To determine the frequency and predictors of completion of POLST orders for adults with change during hospitalization in resuscitation status to Do Not Resuscitate. DESIGN: Retrospective observational study at level 1 trauma and academic hospital in Minneapolis, MN, USA PARTICIPANTS: All adults (18 years or older) hospitalized between June 2017 and June 2018, inclusive, with code status changed from Full Code to DNR. For patients with more than one hospitalization during this study interval, only the first hospitalization when DNR was ordered was included in this analysis. MAIN MEASURES: Completion of POLST orders by time of discharge. KEY RESULTS: From 2017 to 2018, 160 adults had a change from Full Code to DNR status during index hospitalization and survived to discharge, most (156 patients) to a nursing care facility. Of these, only 50 (31.2%) had POLST orders provided at discharge. Documentation of informed refusal of intubation in addition to DNR status was a significant predictor (OR 4.1, 99% CI 1.5-11.0) of POLST orders on discharge, as was admission to a medical service compared with non-medical service (OR 3.2, 99% CI 1.1-12.2). Palliative care consultants, rather than primary providers on the hospital services, completed most POLST orders. CONCLUSIONS: Despite primary hospital providers engaging in conversations regarding resuscitation and entering DNR orders during hospitalization, the majority of patients in our study discharged to other care facilities without POLST orders. POLST orders are a simple palliative care tool available to primary hospital providers to help ensure continuity of plan of care at discharge for patients who wish to avoid invasive life-sustaining treatments and/or cardiopulmonary resuscitation.

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Section: Discussionsupporting

confidence: 75%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Underutilization of Portable Orders for Life-Sustaining Treatment at Discharge from Hospital: Observational Study at US Academic Trauma Center

Rubins

2020

J GEN INTERN MED

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“…Audit with feedback has been tested through many randomized controlled trials and shown to have a generally positive, though modest, absolute effect of increasing the likelihood of achieving desired behavior change [ 42 , 43 ]. Audit with feedback also has been used to augment education to sustain high rates of completion of actionable medical orders in seriously ill populations [ 44 ]. Brehaut et al [ 45 ] reviewed the literature on audit with feedback and made 15 recommendations for optimizing its effectiveness.…”

Section: Design and Methodsmentioning

confidence: 99%

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

Ersek

Sales

Keddem

et al. 2022

Implement Sci Commun

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Background Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings. Methods PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations. Discussion The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

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Improving Communication About Resuscitation Preference for Patients Discharged from Hospital to Nursing Home: A Quality Improvement Project

Cited by 2 publications

References 9 publications

Underutilization of Portable Orders for Life-Sustaining Treatment at Discharge from Hospital: Observational Study at US Academic Trauma Center

Underutilization of Portable Orders for Life-Sustaining Treatment at Discharge from Hospital: Observational Study at US Academic Trauma Center

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

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