In a single-center study reported at the ASCO Quality Care Symposium and simultaneously published in the Journal of Oncology Practice, Switzer et al found that an intervention consisting of a resident training module and use of a best practice alert (BPA) in electronic medical records (EMRs) improved the rates of resident advanced care planning documentation, although such rates remained suboptimal. 

“Resident advanced care planning documentation remains suboptimal in the high-risk cohort of hospitalized patients with advanced cancer. However, rates seem to be positively influenced by online modules and EMR-based interventions.”

— Switzer et al

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Study Details

The retrospective analysis involved observation of resident code status documentation through admission notes and direct EMR orders before and after implementation of a training module and code status BPA intervention among patients admitted to the Cleveland Clinic oncology service. The analysis covered an 8-week preintervention and 8-week postintervention period.

The mandatory online educational training module consisted of a 1-hour program for all internal medicine residents, including information on institutional and state law on advanced care planning practices and multiple interactive videos and scenarios intended to ensure understanding of types of code status and promote skills in discussing advanced care planning. The BPA provided a small pop-up window that appears upon opening of patient charts and notifies providers to update patient code status. The online module and BPA were implemented in July 2018, with a 2-week mandatory module completion deadline.

Change in Code Status Documentation

During the period of analysis, there were 535 unique admissions to the oncology service, consisting of 244 before BPA and 291 after BPA. Compared with the preintervention period, in the postintervention period, residents increased the rate of admission note code status documentation from 47.1% to 61.5% and increased the rate of code status orders at time of discharge from 12.7% to 30.9%.

Among the 50% of residents who responded to an online survey regarding the intervention, the most commonly reported barrier to advanced care planning documentation was forgetting to discuss it, reported by 31.4%, 25.8%, and 21.6% of first-, second-, and third-year residents. Time constraints of admission as a barrier was reported by 15.7%, 25.8%, and 27.0% of residents, respectively. Feeling uncomfortable in orchestration of advanced care planning conversations was reported by 58%, 6%, and 5% of residents, respectively.

The investigators concluded, “Resident advanced care planning documentation remains suboptimal in the high-risk cohort of hospitalized patients with advanced cancer. However, rates seem to be positively influenced by online modules and EMR-based interventions. Additional efforts to improve the current practice and culture of advanced care planning remain a crucial aspect in the quality and safety of our approach to patient care.”

Benjamin Switzer, DO, MHSA, MS, of the Internal Medicine Department, Cleveland Clinic, is the corresponding author for the Journal of Oncology Practice article.