Creating a pause: An EHR intervention supporting goal-concordant care during acute care transitions.

Abstract

629 Background: Patients with advanced illness often establish outpatient goals-of-care preferences, including do-not-resuscitate (DNR) and do-not-intubate (DNI) status. However, outpatient code status documentation may not reliably carry forward into emergency department (ED) or inpatient encounters, creating risk for care inconsistent with patient wishes. We implemented and evaluated an EHR-based intervention to improve visibility of outpatient code status and support goal-concordant transitions of care. Methods: On 4/21/26, a system-wide Epic clinical decision support intervention was implemented across an 8-hospital healthcare network. The intervention was triggered when providers attempted to place inpatient full-code admission orders for patients with documented outpatient DNR/DNI status. It included (1) a visual banner highlighting outpatient code status and (2) an interruptive alert prompting reassessment of goals-of-care alignment during admission order entry. Prospective operational data were collected from 4/21/26–6/7/26. Outcomes included alert frequency, provider acknowledgment reasons, and downstream workflow actions. Results: Following implementation, the alert fired 521 times during hospital admissions on patients with documented outpatient DNR/DNI status, including 197 (38%) encounters involving patients with cancer. Notably, pending full-code orders were removed in 125 encounters (24%) following alert presentation, highlighting potential discordance between intended inpatient resuscitation orders and previously documented outpatient DNR/DNI preferences. Providers reported that patients and/or families wished to change code status in 172 encounters (33%) and identified inaccurate code status documentation in 61 (12%). Providers canceled the alert in 138 encounters (26%) and acknowledged it without further action in 23 (4%). Conclusions: A prospective, multi-hospital evaluation of an EHR intervention to highlight outpatient code status during emergency department and inpatient admissions was feasible to implement and increased awareness of preexisting goals-of-care preferences. Notably, nearly one-quarter of alerts resulted in removal of pending full-code orders, highlighting potential discordance between intended inpatient resuscitation orders and previously documented outpatient DNR/DNI preferences. In addition, one-third of alerts involved patients and/or families requesting code status changes, underscoring the dynamic nature of goals-of-care preferences during acute illness. By introducing a deliberate pause during admission workflows, this EHR-based intervention helps align inpatient resuscitation orders with patient preferences and supports more goal-concordant care.