Yichun Michelle Fang, DNP, FNP

Abstract:

Background: Heart failure (HF) is a progressive, chronic disease that can be complicated or caused by pulmonary hypertension (PH). Goals of Care Conversations (GoCCs) are discussions to: identify a healthcare surrogate, initiate and review advance directives, and refer for palliative care consultation. Providers struggle with determining HF prognosis and initiating GoCCs. Gagne Combined Comorbidity Score prognosticates a one-year mortality risk. Purpose: Implementation of an electronic prognostication tool, Gagne Score, for clinicians to identify and increase documentation of GoCCs with high-risk HF patients. Design: Pre- and Post-intervention quality improvement (QI) project at an ambulatory clinic to evaluate use of a prognostication tool in improving documentation of GoCCs with HF patients. Methods: Prior to each clinic, providers notified of high-risk HF patients, identified using prognostication tool. Medical record data on provider documentation of four aspects of GoCCs: presence and review of advance directives, documented healthcare surrogates, and referral for palliative care consultation, collected for nine weeks pre and post intervention. Demographic and medical data on PH patients treated during pre and post intervention. Demographic, education and experience data collected by survey from provider participants. Descriptive statistics, chi square analysis, and t-tests used to compare documentation of GoCCs pre- and post-intervention. Results: Providers were female, specialized in cardiology with 26 ± 8.5 years of experience, including a physician, clinical nurse specialist, and nurse practitioner. No differences existed in age, gender, ethnicity, PH diagnosis, or Gagne Score for patients treated during pre and post intervention. Documentation of GoCCs was significantly greater post intervention compared to pre-intervention (0%, n=0/47 and 88%, n=35/40 respectively, p<0.001). Documentation of each of the four aspects of GoCCs was variable with the greatest improvement in documentation of healthcare surrogate and review of advance directives. Referral for palliative care consultation remained low (0%, n=0/47 and 0%, n=0/40). Conclusion: Implementation of an electronic prognostication tool using Gagne Score was effective in increasing documentation of GoCCs in 3 criteria of GoCCs: advance directives, healthcare surrogate, and reviewing of previously completed advance directives. Referral for palliative care did not increase with this intervention and indicates an area for improvement. 

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