Module 6 Case Report Form Chart Abstraction This

Module 6: Case Report Form (Chart Abstraction)

This training session contains information regarding: n n Overview the CRF Highlights of certain points of data collection from the medical record

At this point you have done the following: Identified Eligible Respondents Obtained Consent Enrolled Respondents Administered the ACP Questionnaire Next… you will need to collect data from the medical record into the Case Report Form Completion (i. e. Chart Abstraction)

Identifying Respondents n In order for the site to be able to access the relevant medical record, they will need to know the unique, hospital assigned, medical record number. We recommend keeping an identification list. You can find a template on the study website.

What is a CRF? n Official clinical data collection document Data abstracted from medical charts n Allows for efficient and complete data processing, analysis and reporting n Study questions determine what data should be collected on the CRF n

CRF Worksheets n A tool to facilitate chart abstraction Instructions Worksheet

Tips for Completing Chart Abstraction Understand what kinds of data you are looking for n Orient yourself to the various sections of your local medical charts n Paper n Electronic n Determine any local standards used to document ACP/AD n Be clear on how information is recorded (e. g. abbreviations, dose units, etc…) n

Tips for Completing Chart Abstraction con’t Sometimes there are several sources for the same information. n The best thing to do is be consistent. n Example: ü ü ü Hospital Admission Date/Time Arrival note listed on ambulance record The first entry in the ED notes Date/time logged in the hospital computer system

Types of CRF Data Comprehensive instructions are available in the CRF Worksheets. The following slides are meant to highlight the types of data collection required.

Comorbidities Patient characteristics that affect outcomes n Medical Chart sources of info: n Admission notes, ED assessments, previous admission notes n Progress notes n Discharge Summary n n Collect only those that appear on the CRF, record them by: Body system n Illness/condition n CRF pg. 4 -5

Vasopressors/Inotropes From the current hospitalization n Usually only administered in the ICU or step-down units. n Record any instance where an infusion is given for > 30 mins n n n Don’t count boluses Record start and stop dates CRF pg. 6 -7

Consultations n List all consultations that were ordered during this hospital stay RACE (Rapid Assessment of Critical Event) Team or Code 66 or Code Blue n Critical Care or Critical Care Outreach n Home Care/Transition Services n Social Work n Spiritual Care n Palliative Team n Palliative Home Care n Geriatrics Team CRF pg. 8 -9 n

Dialysis n Current hospitalization, new onset of acute renal failure requiring any form of dialysis n Start and stop date for dialysis CRF pg. 10 -11

Percutaneous Feeding Tube n Percutaneous feeding tubes are those inserted through the skin and into the stomach or intestine. n n n If nasoenteric or nasogastric do not record here Indicate whether the patient arrived at the institution with a percutaneous feeding tube already in place (removal date) Indicate if the patient ever had a percutaneous feeding tube inserted during the current hospitalization (insertion & removal dates) CRF pg. 10 -11

Mechanical Ventilation n Record if the patient received any ventilation (noninvasive and/or invasive support) throughout the entire hospital admission Non-Invasive ventilation refers to all modalities of ventilation that assist with breathing without the use of an endotracheal tube. (BI-PAP, nasal or mask ventilation, mask CPAP) Invasive mechanical ventilation refers to any mode of intermittent positive pressure delivered via an oral/nasal tracheal tube or tracheostomy with or without positive end expiratory pressure and high frequency jet ventilation or oscillation. Nasal prongs, facemask or supplementation O 2 are NOT considered ventilation since the patient. CRF stillpg. 12 -13 breathes spontaneously.

Mechanical Ventilation con’t n Record start and stop date/time for each episode n n If stopped for > 48 hrs, then restarted, considered it a new episode Use ‘actual’ start date (ED, OR, etc), if initiated externally (i. e. referring hospital) then enter the start date/time as hospital admission

Mechanical Ventilation con’t n MV stop is when patient is off > 48 continuous hrs intubated or breathing through a t-tube OR n tracheostomy mask breathing OR n CPAP ≤ 5 cm. H 2 O without pressure support or intermittent mandatory ventilation assistance n n If transferred out of hospital while vented, stop date is hospital discharge date/time

CPR Use in Hospital n CPR is defined as at least any one of the following occurs: Chest compressions n Defibrillation n Intubation (if not already intubated). n n Enter each episode separately n If CPR was used multiple times in a day, please document it only once. CRF pg. 14 -15

Goals of Care Discussions n Document any goals of care discussions from the current hospitalization CRF pg. 16 -19

Goals of Care Discussions n Each instance in chronological order n Did the patient have an existing Go. C in the medical chart upon admission to hospital? n Yes n → Record the Go. C designation Record all instances of Go. C discussions from the current hospitalization n Date n of Go. C discussion Where did it occur (e. g. ER) n Date of Go. C order written n Go. C decision made

Goals of Care Decision Made n Use the most appropriate Go. C designation system presented: No decision made n Decision made n n No change from previous n Change from previous: n n Alberta BC DNAR BC MOST All other regions

Go. C – All other regions options n Goals of care designation – All other regions n The coordinator should use their own judgment when determining how locally documented designations translate into the options available on the CRF n 1 – Use machines …keeping me alive at all costs. n 2 – Use machines …keeping me alive …no resuscitation. n 3 – Use machines only in the short term … n 4 – Use full medical care … n 5 – Use comfort measures only … n 6 – Unsure, documentation unclear n 7 – no documentation

Processes of Care Upon Hospital Admission n n Upon hospital admission + 1 day Orders written to WITHHOLD LSTs n n Ventilation Vasopressors Dialysis CPR WITHHOLDING LSTs = the patient is NOT currently receiving the applicable life sustaining therapy(ies) and then an order is written to never start therapy or re-start it. CRF pg. 20 -21

Upon Hospital Admission con’t n Enter the date the order was written. n n If there are instances where multiple changes of process of care orders are documented regarding withholding care please collect the first order date written to withhold therapy. Withholding dialysis may not be written in the doctor’s orders, it might be captured in the progress notes. If this is the case then please use the date the note was written.

Upon Hospital Admission con’t Upon hospital admission + 1 day n Orders written to WITHDRAW LSTs n Ventilation n Vasopressors n Dialysis n n n WITHDRAWING LSTs is defined as currently receiving any life sustaining therapy(ies) and then an order is written to stop it for patients whose outcome is not favourable. Enter the date the order was written

Upon Hospital Admission con’t n End of life scenario, this does not apply for orders written for stopping normal every day treatment when no longer needed. NO escalation of care orders n n n Receiving LSTs no escalation = Withholding Receiving LSTs comfort measures = Withdrawing Not receiving LSTs no escalation = Withholding

Process of Care During Hospitalization After Admission orders – Discharge/Death n Orders written to WITHHOLD LSTs n Orders written to WITHDRAW LSTs n CRF pg. 22 -23

Index Hospital Overview n Index hospitalization = Enter the date and time the patient was admitted to hospital n n n initial presentation to ED or hospital ward (earliest) Document all ICU and Step Down admission and discharge dates/times chronologically for the entire hospital stay If patient dies in hospital, date/time of death = discharge CRF pg. 24 -25

Hospital Discharge n n For patients who are discharged to a Rehabilitation ward within the institution, the date/time patient is discharged from the hospital to the Rehabilitation ward = hospital discharge Indicate where the patient was discharged: n n n Home Retirement Residence Long Term Care or Nursing Home Rehabilitation Facility Ward in another hospital If still in hospital at Day 90, check the appropriate box.

Entering Data into REDCap n Once you have: Administered the ACP questionnaire(s) n Collected the CRF data n Degree of system implementation n Proceed to enter the data into REDCap. n See Module 7 for instructions.

Training Module 6 Complete