Best Practice Alerts for Advance Care Planning (ACP) in Patients with Hip Fracture
Nursing Research on the Green
Ricky Rivera MSN, FNP-C – Viterbo University
- Background: In order to reduce the occurrence of confusion regarding end-of-life care, it is important for health care providers to target patients facing mortality and engage in a discussion with these patients about preferences regarding advance directives. Patients with hip fractures should be included in this vulnerable group, because hip fractures are known to result in high mortality rates (approx. 36%) in the first year following the incident (Henderson & Ryan, 2015).
- Significance: As the population of the United States ages, providers can expect a corresponding aging of their patient population. According to the literature, factors such as age, gender, and certain comorbidities have been reported to negatively affect outcomes in patients with hip fractures. A systematic identification with the electronic medical record (EMR) to identify these patients could assist with appropriate planning for ACP.
- Purpose/objective: The purpose of this project was to establish a best practice alert (BPA) within the EMR to enable the systematic identification of vulnerable patients with hip fractures, aged 70 and older who also have other selected risk factors, based on the literature and institutional data. These patients will be identified so that qualified health professionals can engage them in a meaningful conversation regarding their final wishes, to be documented via POST form. Jean Watson's Theory of Caring was utilized as a theoretical framework for this project.
- Methods/project: Rosswurm and Larrabee's model for change to evidence-based practice, a six-stage process that details the steps for implementing a measured change in an established system, provided the methodology for this project (Rosswurm & Larrabee, 1999).
- Results: The project was implemented in three stages. The first stage was a closed trial utilizing 10 deceased patients' records (N=10). The alert as initially designed, based on risk factors, would have triggered 80% (n=8) of these patients. The second stage was a live, blind trial, meaning the alert was integrated into the currently operating electronic system (EPIC), but without provider notifications. After minor alert adjustments, the BPA system triggered appropriate patients at a rate of 89%. Three months later, the third stage â€œlive recordâ€ took place. Approximately 64 patients appropriate for meaningful conversations regarding their POST forms were identified, and processes have been implemented to continue to use this BPA.
- Clinical implications: By implementing this electronic alert, the ACP needs of a vulnerable patient population can be met. While this project utilized patients with hip fracture, targeting patients who may be high risk has widespread implications across multiple specialty areas. Engaging in meaningful conversations demonstrates caring and respect for the patient, and honors the organizational commitment to Watson's Theory of Caring. As the institution expands the electronic best practice alert throughout the hospital, further education to other departments and nursing staff must take place.
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