通过基于惊喜问题的电子病历工作流程，在儿童重症监护病房（CICU）中促进早期护理目标对话。
Promoting early goals of care conversations in the CICU with a surprise question-based EHR workflow.
作者信息
Ushpol Adam, Parsons Colby, Golec Sophia, Frousios Ritsa, Tsega Surafel, Linker Anne S, Ronquillo Maria, Gidwani Umesh
机构信息
Icahn School of Medicine at Mount Sinai, 50 E 98th St, Apt 10J-3, 10029, New York, NY, USA.
Department of Medicine, NYC Health + Hospitals/Kings County, 451 Clarkson Avenue, 11203, Brooklyn, NY, USA.
出版信息
BMC Palliat Care. 2024 Dec 20;23(1):288. doi: 10.1186/s12904-024-01602-4.
BACKGROUND
The Surprise Question (SQ) - Would you be surprised if this patient died within the next 6 months? - is a validated tool for mortality prediction. The Mount Sinai Cardiac Intensive Care Unit (CICU) incorporated the SQ into a novel EHR workflow to identify patients who would benefit from early initiation of Palliative Care (PC).
METHODS
Implementation of the SQ proceeded in two steps. During the feasibility pilot (December 2021-March 2022), providers answered the SQ using an EXCEL spreadsheet for all CICU patients, without changing other workflows. In April 2022, the CICU launched a new workflow-column built into the Epic patient-list dashboard with the SQ as the backbone. For patients with SQ answers of "NO," providers were prompted to facilitate and document a goals of care (GOC) conversation. We conducted a retrospective, observational, quasi-experimental study of all admissions to the CICU with SQ = NO between December 2021-September 2022. Clinical data was obtained via EHR query and chart review. We compared the frequency and timing of GOC conversations and the likelihood of redirected GOC (defined as code status change and/or hospice discharge) during the 3-month pilot versus the 6-month implementation period.
RESULTS
195 admissions were included: median [IQR] age 72.0 [61.0, 84.0] years; LOS > 5 days 43.6%; CICU mortality 17.9%. These clinical characteristics were comparable between the pilot (N = 57) and implementation (N = 138) periods. However, ICU interventions (i.e. mechanical ventilation, renal replacement therapy) were more common among the pilot cohort (52.6% vs. 33.3%, p = .015). For the primary outcomes, compared to the pilot period, there was a significantly higher frequency of GOC conversations (61.4% vs. 81.2%, p = .004) and GOC conversations < 2 days from CICU admission (40.4% vs. 61.6%, p = .007) in the intervention period. There was no difference in the likelihood of redirected GOC towards comfort or no escalation (28.1% vs. 21.0%, p = .288).
CONCLUSION
We facilitated earlier GOC conversations directed to critically ill patients with high mortality risk by integrating the SQ into the EHR.
背景
意外问题（SQ）——如果该患者在接下来的6个月内死亡，你会感到意外吗？——是一种经过验证的死亡率预测工具。西奈山心脏重症监护病房（CICU）将SQ纳入了一种新的电子健康记录工作流程，以识别那些将从早期启动姑息治疗（PC）中受益的患者。
方法
SQ的实施分两步进行。在可行性试点阶段（2021年12月至2022年3月），医护人员使用EXCEL电子表格为所有CICU患者回答SQ，而不改变其他工作流程。2022年4月，CICU在Epic患者列表仪表板中启动了一个新的工作流程列，以SQ为核心。对于SQ回答为“否”的患者，医护人员会被提示促进并记录护理目标（GOC）对话。我们对2021年12月至2022年9月期间所有SQ为“否”的CICU入院患者进行了一项回顾性、观察性、准实验研究。临床数据通过电子健康记录查询和病历审查获得。我们比较了3个月试点期与6个月实施期内GOC对话的频率和时间，以及重新定向GOC（定义为代码状态改变和/或临终关怀出院）的可能性。
结果
纳入了195例入院患者：年龄中位数[四分位间距]为72.0[61.0, 84.0]岁；住院时间>5天的患者占43.6%；CICU死亡率为17.9%。这些临床特征在试点期（N = 57）和实施期（N = 138）之间具有可比性。然而，ICU干预措施（即机械通气、肾脏替代治疗）在试点队列中更为常见（52.6%对33.3%，p = 0.015）。对于主要结局，与试点期相比，干预期内GOC对话的频率显著更高（61.4%对81.2%，p = 0.004），且从CICU入院起<2天内进行GOC对话的比例更高（40.4%对61.6%，p = 0.007）。重新定向GOC至舒适或不升级的可能性没有差异（28.1%对21.0%，p = 0.288）。
结论
我们通过将SQ整合到电子健康记录中，促进了针对高死亡风险重症患者的更早的GOC对话。
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