Using Cross-Checking Safety Tools, Decision Support, and Education Within the Electronic Medical Record to Increase Concordant Advance Care Planning Orders (QI728)

Objectives 1. Understand the importance and appreciate the achievability of improving code status ordering accuracy. 2. Gain initiative, insight and answers to specific questions on how to successfully replicate the project. Background Code status ordering lapses are a known cause of serious medical errors that are believed to be underreported, especially when unwanted resuscitation is performed. Aim Statement We describe a health system-wide iterative process of improving code status ordering in our EMR upon admission, to safely respect our patients' wishes. Methods At baseline, EMR code status ordering was mandatory upon admission (required field in the order sets and additional decision support alerts) and defined documentation processes existed including MOLST and eMOLST. The initiative had several phases: 1. We synchronized our system EMR code status order options in both inpatient and ambulatory settings with the options on NY MOLST. 2. We created enduring code status orders in the EMR that cross between settings and created an option of "affirming" the preexisting code status upon transitions of care rather than issuing a new order. 3. We created modal decision support that monitors for unexplained discrepancy between the present code status order, the previous code status, and the discretely documented code status decisions in the chart (both in the provider note and the nurse flowsheet). 4. We delivered a comprehensive educational program. Results Random chart reviews of 2-day span of admissions were conducted before the initiative and were repeated afterwards to measure the accuracy of admission code status orders by emergency and hospitalist providers for patients whose preexisting code status order or MOLST included DNR (27 of 229 patients). Post-intervention more patients had accurate continuation of DNR status (from 12.5% to 72.7%) and clearly preventable admission code status ordering errors were eliminated (from 75% to 0%). Some potentially preventable cases included missing order, external MOLST logged post-admission, or code status was erroneously changed prior to admission. Conclusions and Implications A multifaceted EMR-based intervention may drastically reduce the risk of code status ordering errors. Further study is required in this field.