Background: Despite benefits of early Serious Illness Conversations (SICs), including increased satisfaction and earlier hospice referral, rates of SICs remain low. The primary aim of this study is to assess if standardized documentation of SICs increase following implementation of interventions for providers to have more of these conversations with patients admitted to a general medicine service during the COVID-19 pandemic.

Methods: In this interrupted time series analysis, encounters ≥18 years old with an elevated Epic (Verona, WI) Readmission Risk Score (RRS) of >28% admitted to a general medicine service at an academic medical center from January 2019 to December 2020 (pre-implementation), January 2021 (wash-in) or February 2021 to October 2021 (post-implementation) were included. The Expert Recommendations for Implementing Change (ERIC) framework guided development of interventions to encourage SICs and standardized documentation within a structured electronic health record module and complemented pre-existing faculty training in SICs. A multivariable segmented logistic regression model, appropriate for an interrupted time series design, was used to evaluate the immediate effect of our interventions (β2 or y-intercept change) and the difference in temporal trends (β3 or slope change) of the odds of standardized documentation of an SIC per month prior to and after our interventions.

Results: Major interventions (Table 1) included use of the Consolidated Framework for Implementation Research (CFIR) to assess barriers and facilitators, weekly emails sent to providers with admitted patients who may benefit from an SIC, encouraging use of a Quality and Safety Dashboard to facilitate identification of patients with elevated RRS and SIC needs, identification of clinical champions, and educational sessions among others. Major barriers included COVID-19 related challenges such as extreme census and burn out, while major facilitators included email reminders and standardized documentation. An interrupted time series model did not show a statistically significant change in the odds of standardized documentation of an SIC following implementation of our interventions (Figure 1) though the trend was slightly positive (β3 odds ratio (OR) 1.16, 95% Confidence Interval (CI) 0.98-1.39). An observed peak in standardized documentation of SICs during the pre-implementation period corresponds to a focus on conducting and documenting SICs in patients with COVID-19 related admissions at our institution during the first COVID-19 wave.

Conclusions: Implementation of context-specific interventions did not yield statistically significant changes in standardized documentation of SICs among encounters with elevated comorbidity burden. Possible reasons for the lack of effect include insufficient and or ineffective interventions and COVID-19 related challenges such as extreme census and clinician burn-out as well as other barriers. Continued support for providers in conducting these conversations is needed to protect patient autonomy and provide patient-centered advance care planning.

IMAGE 1: Table 1: ERIC Strategies Used with Description of Local Interventions

IMAGE 2: Figure 1: Observed Percent Encounters with Standardized Documentation of a Serious Illness Conversation with Corresponding Interrupted Times Series Analysis