University of Minnesota Medical School, Minneapolis, Minnesota, USA.
Department of Medicine, Hebrew SeniorLife, Boston, Massachusetts, USA.
J Am Geriatr Soc. 2021 Apr;69(4):861-867. doi: 10.1111/jgs.17051. Epub 2021 Mar 6.
Describe a systematic approach to address advance care planning (ACP) during a COVID-19 outbreak and its impact on the incidence of new do-not-hospitalize (DNH) directives among long-term care (LTC) residents.
Prospective quality improvement initiative.
Two long-term chronic care campuses within a large academic healthcare organization.
LTC residents with activated healthcare proxies who lacked DNH directives based on documentation in the electronic medical record (EMR) as of April 13, 2020.
Using a structured discussion guide, trained healthcare staff from various disciplines contacted the residents' proxies to conduct COVID-19 focused ACP discussions. Residents without DNH directives with COVID-19 were prioritized. Preferences ascertained in the discussion were communicated to the residents' primary care teams and directives were updated in the EMR accordingly.
Residents who acquired a new DNH directive during the study initiative were determined using the EMR. Subsequent changes in DNH orders, hospitalizations, and deaths were ascertained by retrospective chart review from the date of new DNH through August 5, 2020.
At baseline, 315/581 (54%) of LTC residents did not have a DNH directive. Their mean age was 87 (±9) years and 70% were female. Following ACP discussions, 124/315 (39%) of residents acquired a new DNH directive. Among residents with new DNH directives, 65/124 (52%) were diagnosed with COVID-19 from April 2, 2020 to May 21, 2020. During follow-up, only 6/124 (4.8%) residents had their DNH order reversed, 2/124 (1.6%) residents were hospitalized with illnesses unrelated to COVID-19, and 29/124 (23%) died.
There was substantial opportunity to increase the proportion of LTC residents with DNH orders during the COVID-19 pandemic through a systematic ACP initiative which utilized real-time EMR data. New directives to avoid hospitalizations were sustained among the majority of residents beyond the peak of the pandemic.
描述一种在 COVID-19 爆发期间解决预先医疗护理计划（ACP）的系统方法，以及它对长期护理（LTC）居民中新的不入院（DNH）指令发生率的影响。
前瞻性质量改进倡议。
大型学术医疗保健组织内的两个长期慢性护理校园。
截至 2020 年 4 月 13 日，电子病历（EMR）中没有 DNH 指令的、医疗代理人已激活且缺乏 DNH 指令的 LTC 居民。
使用结构化讨论指南，来自各个学科的经过培训的医疗保健人员联系居民的代理人进行以 COVID-19 为重点的 ACP 讨论。有 COVID-19 的没有 DNH 指令的居民被优先考虑。讨论中确定的偏好传达给居民的初级保健团队，并相应地在 EMR 中更新指令。
通过 EMR 确定在研究倡议期间获得新 DNH 指令的居民。通过回顾性图表审查，从新 DNH 日期到 2020 年 8 月 5 日，确定 DNH 订单、住院和死亡的后续变化。
在基线时，581 名 LTC 居民中有 315 名（54%）没有 DNH 指令。他们的平均年龄为 87（±9）岁，其中 70%为女性。进行 ACP 讨论后，315 名居民中有 124 名（39%）获得了新的 DNH 指令。在有新 DNH 指令的居民中，有 65 名（52%）从 2020 年 4 月 2 日至 5 月 21 日被诊断患有 COVID-19。在随访期间，只有 6 名（4.8%）居民的 DNH 指令被推翻，2 名（1.6%）居民因与 COVID-19 无关的疾病住院，29 名（23%）居民死亡。
通过一项利用实时 EMR 数据的系统 ACP 倡议，在 COVID-19 大流行期间，有很大机会增加有 DNH 指令的 LTC 居民的比例。在大流行高峰期过后，大多数居民的新避免住院指令得以维持。
