Publication Date
8-17-2026
Degree Awarded Date
August 14, 2026
Abstract
Background & Significance: Advance care planning (ACP) is essential for ensuring (GOC), particularly in acute care settings, defined in this paper as inpatient hospital environments, including critical and intensive care units (ICU), where a patient’s decision-making capacity could become impaired. ICU patients are often critically ill and may lose the ability to make health care decisions. Family uncertainty regarding patient preferences frequently exacerbates psychological distress regarding GOC. Restricted access to ACP may result in non-concordant medical care, as well as elevated healthcare expenditures driven by the underutilization or inappropriate allocation of critical resources. Despite the recognized importance of ACP and GOC discussions, documentation remains inconsistent and is often difficult to locate within the electronic health record (EHR).
Review of Literature Findings: Evidence reveals contributing barriers to ACP include limited training among ICU providers, particularly Advanced Practice Providers (APPs) which is comprised of Nurse Practitioners (NPs) and Physician Assistants (PAs), low level of knowledge and confidence, absence of structured education and standardized documentation processes (Lupi et al., 2021; Kim & Fleigher, 2023). However, facilitators such as education and structured frameworks to guide workflow have the ability to absolve these barriers (Henage et al., 2020).
Methods: The project was implemented over 12-weeks and included a pre- and postintervention survey of provider knowledge, confidence, self-reported barriers to conducting GOC conversations and documentation practices, as well as a pre- and post- intervention chart audit to assess frequency and quality of documentation. The intervention combined ACP education with reinforcement of a standardized Epic ACP Smartphrase. Data collected was evaluated to determine how does implementing an educational program and standardized Epic-based documentation workflow for ACP, compared with current documentation practices affect ACP documentation quality, frequency, APP confidence, knowing and perceived barriers in the Barnes-Jewish Hospital (BJH) Surgical/Oncological ICU (SICU).
Results/Discussion of Findings: Overall, unit ACP documentation remained stable (50% pre-intervention vs 49% post-intervention), but APP completion of ACP notes increased from 19% to 74%. Documentation of GOC increased from 46% to 80%, surrogate identification from 84% to 97%, and notes containing both elements from 32% to 77%. Standardized epic template use remained 97%. Post intervention, 100% of participating apps strongly agreed that initiating ACP discussions was within their responsibility and scope of practice (M= 5.00, SD = 0.00), and 100% recommended continuing the standardized workflow and ACP education. Lack of time remained one of the most frequently reported barriers both before and after the intervention.
Implications: Findings support continued ACP education, standardized workflow reinforcement, periodic chart audits, and integration of ACP education into onboarding and ongoing competency. Education may not eliminate system-level barriers, but it can help address provider-level barriers. Recommendations for sustainability of these changes include integration of the ACP education into new APP onboarding, annual competency and continuing education; Periodic chart audits of frequency, quality, and template use; Unit level feedback at APP or QI meetings; Continued identification of barriers; Designation of app ACP mentors; and ongoing leadership and stakeholder support.
Summary: The findings from this quality improvement project suggest that combining provider education with workflow standardization can be an effective strategy for addressing identified gaps in ACP documentation and integrating more consistent advance care planning practices into routine SICU care.
Language
English (en)
Document Type
Other
Advisor
Fritz, Bradley, MD, MSCI (Chair) Washington University School of Medicine in St. Louis
Associated Committee
Beyatte, Beth, DNP, RN, ACNP-BC (Committee Member) Barnes-Jewish College, Goldfarb School of Nursing
Recommended Citation
Rutter, Michelle N. and Goldstein, Emily, "Improving Advanced Care Planning Conversations and Documentation through APP Education and Standardized Epic Workflow: A Quality Improvement Initiative" (2026). Doctor of Nursing Practice (DNP) Student Projects. Paper 30.
Retrieved from https://digitalcommons.wustl.edu/dnp_golfarb/30
