End-of-life care planning: improving documentation of advance directives in the outpatient clinic using electronic medical records.

BACKGROUND: The right to self-determination is fundamental in clinical ethics. End-of-life conversations and advance directives (ADs), in addition to preserving this right, have been shown to decrease the likelihood of in-hospital death, improve the quality of care, and lower health costs in the final week of life. Despite these benefits, the rates of AD documentation are poor. OBJECTIVE: Our aim was to assess the effectiveness of an electronic medical record (EMR)-based reminder in improving AD documentation rates. METHODS: We conducted a prospective quality improvement study in outpatients at the Grady Memorial Hospital Purple Pod Clinic in Atlanta, GA. Using the EMR system EPIC we set to implement a reminder system consisting of the addition of "Advanced Directives Counseling" to the problem list (ADPL) of 50% of outpatients meeting one of the following criteria: age >65 years, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), malignancy, cirrhosis, end-stage renal disease (ESRD), or stroke. Primary care physicians were encouraged to document ADs for all patients. The number of patients with documented ADs was assessed at 6 months post-test of change. RESULTS: A total of 588 patient charts were screened by seven providers, with 157 patients meeting the predefined criteria for AD documentation. During a 6-month period, 64 patients were seen in the clinic; 38 had AD on their problem list, and 26 did not. Seventy-six percent of charts with ADPL had documentation of an AD. Only 11.5% of those without ADPL had an AD documented. CONCLUSIONS: EMR-based reminders are effective in improving documentation rates of ADs. Further research is needed to establish whether improved documentation impacts inpatient management and costs of care.

Quality improvement of tuberculosis screening in foreign-born patients.

In the United States, a disproportionate percentage of tuberculosis (TB) cases occur in foreign-born persons. We implemented a performance improvement project to improve rates of screening for latent tuberculosis infection in a medical clinic. A questionnaire was developed to identify patients for tuberculosis screening, which was performed as a Tuberculin Skin Test (TST). Patients with positive skin tests underwent further testing. One hundred and sixty-five patients were screened, with 58 TSTs ordered and 36 placed. Twenty-seven patients returned to have the TST read with 12 positive. Eleven of these patients had chest X-rays, 2 revealing findings suggestive of active TB. This project identifies the importance of a standardized TB screening process for high-risk patients and identifies barriers to such a process.

Comparison of African-American patients with systolic heart failure versus preserved ejection fraction.

Evidence exists for race-specific differences in the cause and natural history of heart failure (HF). These differences may have important treatment implications, but relatively limited data on African-Americans exist. A cohort of 89 African-American patients admitted to an urban teaching hospital with diagnoses of HF was examined. Most patients had systolic HF (71%), and the remainder had HF with preserved ejection fractions (EFs). Patients with HF with preserved EFs tended to be generally older (67 vs 57 years, p = 0.01) and were more likely to be women (69% vs 42%, p = 0.02). There were no significant differences between patients with systolic HF and those with HF with preserved EFs in the prevalence of coronary artery disease (23%), diabetes mellitus (44%), or chronic obstructive pulmonary disease (38%). Gastrointestinal bleeding and anemia were significant contributors to admission in patients with preserved EFs, with baseline hematocrits being significantly lower (34.9 vs 38.3, p = 0.01). On discharge, patients with HF with preserved EFs were less likely to be prescribed angiotensin-converting enzyme inhibitors than patients with systolic HF (65% vs 83%, p = 0.08) or diuretics (58% vs 82.%, p = 0.03). In conclusion, differences exist in African-American patients who present with HF; optimal therapeutic approaches will require a better understanding of their underlying pathophysiology.

Quality of care in African-American patients admitted for congestive heart failure at a university teaching hospital.

Previous studies have shown that the quality of congestive heart failure (CHF) treatment for hospitalized patients varies. The goal of this study was to evaluate the compliance of physicians at a large, inner-city teaching hospital with current evidence-based guidelines. A retrospective review of the medical records of 104 patients admitted with CHF was conducted. Quality-of-care indicators were assessed, including the use of echocardiograms, the administration of angiotensin-converting enzyme (ACE) inhibitors and beta blockers to appropriate patients, and lifestyle and medication counseling at discharge. The assessment of left ventricular (LV) function was documented in 96.1% of patients (n = 100). A total of 65 patients (92.8%) with systolic dysfunction were considered to be ideal candidates for ACE inhibitor therapy. Of these 65 patients, 58 (89.2%) were discharged on ACE inhibitors. Of 41 patients with LV systolic dysfunction who were considered to be ideal candidates for beta-blocker therapy, only 10 (24.4%) were discharged on beta-blocker therapy. Of all patients with CHF, 50% received discharge counseling on medication compliance, 48% received counseling on a low-salt diet, and only 9% were told to monitor daily weight. This study shows that in a major academic teaching hospital, there is a need for improvement in the use of beta-blocker therapy as well as greater emphasis on patient education strategies regarding diet, medication adherence, and monitoring daily weight.