Increasing Quality and Frequency of Goals-of-Care Documentation in the Highest-Risk Surgical Candidates

• Published in: JB & JS open access Vol. 8; no. 2
• Main Authors: Anthony A. Oyekan, MD, Joon Y. Lee, MD, Jacob C. Hodges, MS, Stephen R. Chen, MD, Alan E. Wilson, MD, Mitchell S. Fourman, MD, MPhil, Elizabeth O. Clayton, MS, Confidence Njoku-Austin, BA, Jared A. Crasto, MD, Mary Kay Wisniewski, MA, Andrew Bilderback, MS, Scott R. Gunn, MD, William I. Levin, MD, Robert M. Arnold, MD, Katie L. Hinrichsen, MSN, Christopher Mensah, MBA, MaCalus V. Hogan, MD, MBA, Daniel E. Hall, MD
• Format: Journal Article
• Language: English
• Published: Wolters Kluwer 01.06.2023
• ISSN: 2472-7245
• DOI: 10.2106/JBJS.OA.22.00107

Background:. Patient values may be obscured when decisions are made under the circumstances of constrained time and limited counseling. The objective of this study was to determine if a multidisciplinary review aimed at ensuring goal-concordant treatment and perioperative risk assessment in high-risk orthopaedic trauma patients would increase the quality and frequency of goals-of-care documentation without increasing the rate of adverse events. Methods:. We prospectively analyzed a longitudinal cohort of adult patients treated for traumatic orthopaedic injuries that were neither life- nor limb-threatening between January 1, 2020, and July 1, 2021. A rapid multidisciplinary review termed a “surgical pause” (SP) was available to those who were ≥80 years old, were nonambulatory or had minimal ambulation at baseline, and/or resided in a skilled nursing facility, as well as upon clinician request. Metrics analyzed include the proportion and quality of goals-of-care documentation, rate of return to the hospital, complications, length of stay, and mortality. Statistical analysis utilized the Kruskal-Wallis rank and Wilcoxon rank-sum tests for continuous variables and the likelihood-ratio chi-square test for categorical variables. Results:. A total of 133 patients were either eligible for the SP or referred by a clinician. Compared with SP-eligible patients who did not undergo an SP, patients who underwent an SP more frequently had goals-of-care notes identified (92.4% versus 75.0%, p = 0.014) and recorded in the appropriate location (71.2% versus 27.5%, p < 0.001), and the notes were more often of high quality (77.3% versus 45.0%, p < 0.001). Mortality rates were nominally higher among SP patients, but these differences were not significant (10.6% versus 5.0%, 5.1% versus 0.0%, and 14.3% versus 7.9% for in-hospital, 30-day, and 90-day mortality, respectively; p > 0.08 for all). Conclusions:. The pilot program indicated that an SP is a feasible and effective means of increasing the quality and frequency of goals-of-care documentation in high-risk operative candidates whose traumatic orthopaedic injuries are neither life- nor limb-threatening. This multidisciplinary program aims for goal-concordant treatment plans that minimize modifiable perioperative risks. Level of Evidence:. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.