Think Ahead! A Quality Improvement Initiative for Advance Directives in Young Adult Heart Transplant Recipients at a Pediatric Center

Purpose Advance care planning (ACP) is best practice for young adults with time-limited palliations such as heart transplant (HTx). A quality improvement (QI) project was previously conducted at our center to build a sustainable infrastructure for routine ACP discussions and advance directive (AD) documentation for young adults in our heart failure and transplant (HF-HTx) clinic. We describe a continuation of this QI project. Methods The study population was patients ≥18 years old seen in our HF-HTx clinic. The primary outcome measure was percentage of population with documented AD. The secondary outcome measure was percentage of patients with documented ACP discussion. The previous QI project (March 2016-February 2017) included a series of interventions implemented in our HF-HTx clinic: 1) identification of providers to conduct ACP 2) standardization of ACP conversation and EMR documentation 3) preparation of providers and patients for ACP. For the project continuation, baseline data were ascertained. PDSA cycle 1 consisted of refining the providers who led ACP discussions. In PDSA cycle 2, Voicing My Choices (an ACP guide) was introduced after face-to-face discussions with patients instead of prior to the encounter. Results During the previous QI project, the percent of adults seen per month with documented AD and ACP discussion peaked at 42% and 63% respectively. During the project continuation, the percent of adults seen per month with documented AD peaked at 59% (goal 50%). The percent of adults seen per month with a documented ACP discussion peaked at 97% (goal 100%). Conclusion ACP discussions can be successfully integrated and sustained at a busy clinical practice by engaging key stakeholders such as HTx coordinators and social workers. Patient engagement in ACP discussions is improved when the topic is introduced in person. Ongoing and timely discussion of ACP between patients and their healthcare team is warranted.