Improving Health Care Proxy Documentation for Patients With Cognitive Impairment in an Acute Care Setting: A Quality Improvement Project.

Abstract

Purpose: Advanced care planning supports discussions about patients' preferences for end-of-life care, frequently resulting in the completion of health care proxy documentation (HCP). This quality improvement project aimed to increase HCP documentation rates for hospitalized patients with cognitive impairment, including those diagnosed with dementia and delirium.

Primary practice setting: This project was implemented at a 216-bed acute care, community-based teaching hospital in the northeastern United States.

Methodology and sample: The intervention targeted case managers and nursing staff in medical-surgical and stepdown units. Case managers completed an asynchronous educational module on revised workflows for identifying and documenting health care proxy among cognitively impaired patients, followed by a post-training assessment. Concurrently, nursing staff received a practice alert reinforcing their role in verifying patient-designated health care agent upon admission. Program evaluation included demographic data, staff feedback, and aggregate chart reviews to measure changes in documentation rates and process adherence.

Results: HCP documentation for hospitalized patients with cognitive impairment increased from an average of 62% to an average of 75.44% over the 12-week implementation period.

Implications for case management practice: A structured, case manager-led workflow significantly improved the documentation of health care proxies for patients with cognitive impairment. Future initiatives should integrate nurse-led education on HCP verification and promote interdisciplinary collaboration to enhance advance care planning practices across care teams.