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Validation of Physician Orders for Life‐Sustaining Treatment: Electronic Registry to Guide Emergency Care

2012; Wiley; Volume: 60; Issue: 7 Linguagem: Inglês

10.1111/j.1532-5415.2012.04027.x

1532-5415

Elizabeth Olszewski, Craig D. Newgard, Dana Zive, Terri A. Schmidt, K. John McConnell,

Palliative Care and End-of-Life Issues

In 1990, healthcare leaders in Oregon created a concise, standardized form that documents medical orders based on a patient's preferences regarding life-sustaining treatments, known as the Physician Orders for Life Sustaining Treatment (POLST) form (Figure 1).1 More than 34 states and communities are currently using or in the process of adopting POLST programs (see www.polst.org for a current list of programs).2 In 2009, Oregon implemented the first electronic POLST Registry, disseminating form information through a 24/7 call center to emergency medical services (EMS) providers, emergency departments, and acute care units. To function effectively and provide the intended service to the public, a registry must accurately match patients to their forms. This study sought to validate the current real-time search algorithm that the Oregon POLST Registry uses. This was a secondary analysis of a prospective cohort of emergency healthcare provider calls to the registry to locate a POLST form for direct patient care between December 3, 2009, and July 31, 2010. A standardized data collection tool was used to systematically collect demographic information from the medical charts of each patient for whom the registry was called. Probabilistic linkage was then used to compare these with the patient population in the registry at the time of each request that did not initially result in a match to confirm whether the patient had a form in the Registry (LinkSolv version 5.0; Strategic Matching, Inc., Morrisonville, NY). Probabilistic linkage is a method used to link patient care records from two different settings when unique identifiers are not available.3-6 To ensure that all true matches were identified, all cases with a positive cumulative match weight from the linkage analysis and the matches that the current algorithm initially identified were manually reviewed. For a patient to be considered a true “match,” identical information for their first name, last name, and date of birth needed to be present. Descriptive analysis was then used to describe the sample and compare it with all registrants (SAS version 9.2; SAS Institute, Inc., Cary, NC). The institutional review boards of Oregon Public Health, Oregon Health & Science University, and EMS agencies and hospitals participating in the study (where applicable) approved this study. Two hundred thirty telephone requests were made to the registry during the 8-month period. Fourteen EMS agencies and 25 hospitals were represented in the 207 requests for which the requester's institution (EMS agency or hospital) was recorded. Of these 207 requests, 180 charts were received, forming the primary sample. Of the 180 charts received, 93 (51.7%) came from EMS. The median age of patients was 83 (range 5 months–104 years), and 42.8% of the sample was male. There were 32 matches to registry patients identified during the study period, including 29 confirmed matches identified by the current algorithm and three “missed matches” identified through probabilistic linkage methods. Further analysis of these revealed that two of the three missed matches were due to name mismatches—the first name searched did not match the first name in the registry (i.e., alternate spelling searched or middle name searched). The third match was missed because the year of birth searched did not match the birth year recorded in the registry. The overall sensitivity of the current algorithm was 90.6% (75.0–98.0%) and specificity was estimated at 100% (97.5–100%), indicative of no false matches. This study describes the validation of an algorithm that the Oregon POLST Registry uses to match patients with their POLST form and thus guide care based on patient preferences during real-time emergencies. The current algorithm has high specificity and sensitivity, suggesting that it is safe and effective in matching patients and forms. This is critically important given the clinical implications of acting (or not acting) based on false information and possibly withholding resuscitation from a patient who wants it. This study has some limitations. First, it was possible to track information from only 180 of the initial 230 registry requests. Recording information on the requester's institution (or agency) is not a standardized process, which resulted in several cases in which the original chart could not be located. Second, the sample size was modest, resulting in wide confidence intervals around accuracy estimates, particularly for sensitivity. In conclusion, these findings reinforce the importance of electronic POLST registries to potentially alleviate unnecessary suffering and the burden placed on family and caregivers by facilitating access to predetermined patient wishes, even in an emergency. Conflict of Interest: Elizabeth A. Olszewski was employed by the Oregon POLST Registry as a Research Assistant and Research Associate from October 2009 to June 2011, although this study was completed independently of that employment. Dana Zive is the Sr. Manager of Operations and Research for the registry, and Terri A. Schmidt is the registry's Medical Director. Dana Zive and Terri A. Schmidt currently receive salary support through the registry. Author Contributions: Study design: Olszewski, Newgard, McConnell. Acquisition of subjects: Olszewski, Zive, Schmidt. Data analysis and interpretation: Olszewski, Newgard. Manuscript preparation: Olszewski, Newgard, Zive, Schmidt, McConnell. Sponsor's Role: This research was not sponsored.