AN INTERDISCIPLINARY APPROACH TO IMPROVING ADVANCE CARE PLANNING IN INTERNAL MEDICINE

Background: While Medicare data demonstrates that healthcare spending is up to four times higher in yearly decedents than survivors, studies demonstrate that early advance care planning (ACP) leads to improved clinical outcomes and reduces cost without increase in patient anxiety or depression. Nationwide the creation of the Physician Order for Life Sustaining Treatment (POLST), a traveling do not resuscitate (DNR) medical order that is applicable in any care setting (including at home), has improved ACP as patients with POLSTs are more likely to have their treatment preferences known and honored than patients without this document.

Purpose: Our goal was to increase the number of ACP conversations with completion of electronic Medical Orders for Life Sustaining Treatment (eMOLST), the New York State electronic equivalent of a POLST, for patients who are DNR during their inpatient Internal Medicine admission.

Description: Completion rates of the eMOLST on all patients with a DNR order admitted to the Internal Medicine service were examined from September 2017 through August 2018. Two interventions were performed:

1. In January 2018 the hospital linked the electronic medical record (EMR) directly to the eMOLST via single sign-on.

2. From January 2018 through March 2018 all Internal Medicine hospitalists, residents, social workers, and case managers underwent an in-person, one-hour training on eMOLST completion led by an Internal Medicine hospitalist and a social worker. Training included emphasis on breaking down traditional hospital hierarchies and encouraging any team member to champion the importance of ACP for any individual patient. From April 2018 through the end of the study period providers received weekly email reminders to complete eMOLSTs and the topic was added to the daily interdisciplinary rounds. One additional education session was held in July 2018 for new residents.

The completion rate of the eMOLST for patients with a DNR order within the Department of Medicine was then compared before (9/2017-3/2018) and after the intervention period (4/2018-8/2018).

Prior to the intervention period the average monthly completion rate was 12.5% (range 8.1-20.7%) with an increase to 54.5% (range 24-75.8%) after the intervention period. Completion rates remained above 50% from June 2018 throughout the rest of the study period.

Conclusions: By linking the eMOLST to our EMR, engaging in a brief educational intervention, and providing weekly email reminders we were able to demonstrate a 4.5 fold, sustainable increase in eMOLST completion rates within the Department of Medicine on all patients with a DNR order. To the best of our knowledge this is the first demonstration of the efficacy of a direct link from a state-wide eMOLST registry to an EMR. It also demonstrates that sustainable change in provider ACP practices can be achieved with an interdisciplinary intervention. Given prior studies showing a reduction in healthcare expenditure, improved patient experience, and higher fulfillment of patients’ wishes with ACP discussions/eMOLST completion we hypothesize that over time our increase in eMOLST completion will lead to improved end of life care and a sustainable decrease in cost at our hospital.