• Jack Chase and San Francisco General Hospital Workgroup on Patient Capacity and Medical Decision Making.
• Family Medicine Inpatient Service, San Francisco General Hospital, and Department of Family and Community Medicine, University of California San Francisco, San Francisco, California.
• J Hosp Med. 2014 Aug 1; 9 (8): 527-32.

BackgroundImpaired decision-making capacity is a frequent complication of inpatient hospitalization, with potential negative impacts on patients and the healthcare system. Studies of clinician behavior show difficulty in diagnosis and management of capacity impairment. Appropriate management of incapacitated patients may benefit safety, medical outcomes, and healthcare expenditure.ObjectiveTo create a clinical decision algorithm for identification and management of hospital inpatients with impaired capacity.MethodsThe Department of Risk Management at San Francisco General Hospital (SFGH) convened a multidisciplinary workgroup to improve management of incapacitated patients. The workgroup studied institutional data and case experience, solicited mental health expertise, and performed a brief review of published tools for management of incapacitated patients. The workgroup produced a clinical decision algorithm for hospital inpatients with impaired decision-making capacity.ResultsThe algorithm is explained via 3 common scenarios, and notable details include identification and management in a single visual diagram, emphasis on safety planning for a high-risk subset of incapacitated patients, and explanation for multiple disciplines of consultation. The algorithm was disseminated to providers, workshops were conducted, and associated quality improvements were implemented. Initial feedback was positive, relating to clinical competency, decreased practice anxiety, and improved teamwork.ConclusionsImpaired decision-making capacity is frequent among hospitalized patients, including at SFGH. An algorithm, based on institutional review and prior published work, is presented as an example to address the common challenge of acutely ill patients with impaired decision-making capacity.© 2014 Society of Hospital Medicine.

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