Use of resuscitation plans at a tertiary Australian hospital: room for improvement

Advance care and resuscitation plans in a tertiary hospital: a multimodal approach

OBJECTIVES

Advance care planning (ACP) is the process of documenting a person's preference for medical treatment in the event of future deterioration. This audit aimed to improve discussion and documentation of ACP in patients who die during a hospital admission.

METHODS

We performed a clinical audit in 2021 of inpatients at a tertiary hospital in Sydney, Australia to evaluate the benefit of multimodal interventions to improve ACP compared with previous audits from 2016 and 2011.

RESULTS

In 2021, 97% of audited patients had a documented ACP prior to death compared with 80% in the 2016 audit. The completion of NFR documentation on admission in 2016 was 33%, while in 2021 65% of ACPs were completed within 24 hours of admission.In 2021, 94% of patients had a paper resuscitation form filled; however, identification stickers, which are associated with risk of error, were used in 64%; and 25% of forms were only partially completed. Palliative care was consulted for 44% of patients prior to death; 33% on the day of or prior to death.

CONCLUSIONS

Improvement in prevalence and timing of ACP prior to death is seen in the postintervention audit. A repeat audit in 5 years will be conducted, with interventions focused on improving documentation of ACP.

Impact of electronic medical records and COVID-19 on adult Goals-of-Care document completion and revision in hospitalised general medicine patients

BACKGROUND

Conversion from paper-based to electronic medical records (EMR) may affect the quality and timeliness of the completion of Goals-Of-Care (GOC) documents during hospital admissions, and the COVID-19 pandemic may have further impacted this.

AIMS

Determine the impact of EMR and COVID-19 on the proper completion of GOC forms, and the factors associated with inpatient changes in GOC.

METHODS

We conducted a cross-sectional study of adult general medicine admissions (Aug 2018-Sep 2020) at Dandenong Hospital (Victoria, Australia). We used interrupted time series to model the changes in the rates of proper GOC completion (adequate documented discussion, completed ≤2 days) after the introduction of EMR and arrival of COVID-19.

RESULTS

We included a total of 5147 patients. The pre-EMR GOC proper completion rate was 27.7% (overall completion, 86.5%). There was a decrease in the proper completion rate by 2.21% per month (95% CI: -2.83%, -1.58%) after EMR implementation despite an increase in overall completion rates (91.2%). The main reason for the negative trend was a decline in adequate documentation despite improvements in timeliness. COVID-19 arrival saw a reversal of this negative trend, with proper completion rates increasing by 2.25% per month (95% CI: 1.35%, 3.15%) compared to the EMR period, but also resulted in a higher proportion GOC changes within 2 days of admission.

CONCLUSION

EMR improved the timeliness and overall completion rates of GOC at the cost of a lower quality of documented discussion. COVID-19 reversed the negative trend in proper GOC completion but increased the number of early revisions. This article is protected by copyright. All rights reserved.

Patient factors affecting the proper completion of a goals-of-care form in a general medicine hospital admission

BACKGROUND

The goals-of-care (GOC) form is a resuscitation planning tool used to document informed decisions tailored for individual patients admitted to hospital. Proper and timely completion of the GOC form is essential for its effective utility.

AIMS

To identify patient factors which may affect the timely discussion and documentation of GOC forms in patients admitted under a general medicine unit.

METHODS

We performed a cross-sectional study of 2589 patients during 3093 admissions under the general medicine unit from January 2017 to July 2017 at Dandenong Hospital in Melbourne, Australia. The main outcome was the proper completion of GOC forms, defined as GOC completion within 48 h of admission and adequate discussion with the patient or substitute decision maker. We used logistic regression to determine the association between the main outcome and several patient-related independent variables.

RESULTS

A GOC form was completed in 66% of all admissions but only 35% were considered properly completed (timely and adequately discussed). In the general multivariable logistic regression model, the variables associated with proper completion of GOC forms were age (OR = 1.58), English as the main spoken language (OR = 1.43) and readmissions (OR = 1.27). In patients 75 years and older, additional factors associated with proper GOC completion were confusion on admission (OR = 1.31) and number of comorbidities (OR = 1.27).

CONCLUSIONS

The proper GOC form completion rates were suboptimal in general medicine admissions, particularly in younger patients with fewer comorbidities. Additional effort is needed to improve GOC completion in these patients and those whose primary spoken language is not English.

Knowledge and confidence of junior medical doctors in discussing and documenting resuscitation plans: A cross-sectional survey

BACKGROUND

A Resuscitation Plan is a medically authorised order to use or withhold resuscitation interventions. Absence of appropriate resuscitation orders exposes patients to the risk of invasive medical interventions that may be of questionable benefit depending on individual circumstances.

AIMS

To describe among junior doctors: (1) self-reported confidence discussing and completing resuscitation plans; (2) knowledge of resuscitation policy including whether resuscitation plans are legally enforceable and key triggers for completion; and (3) the factors associated with higher knowledge of triggers for completing resuscitation plans.

METHODS

A cross-sectional survey was conducted at five hospitals. Junior doctors on clinical rotation were approached at scheduled training sessions, before or after ward rounds, or at change of rotation orientation days and provided with a pen-and-paper survey.

RESULTS

A total of 118 junior doctors participated. Most felt confident discussing (79%, n = 92) and documenting (87%, n = 102) resuscitation plans with patients. However, only 45% of doctors (n = 52) correctly identified that resuscitation plans are legally enforceable medical orders. On average, doctors correctly identified 6.8 (SD = 1.8) out of 10 triggers for completing a resuscitation plan. Doctors aged >30 years were four times more likely to have high knowledge of triggers for completing resuscitation plans (OR 4.28 (95% CI 1.54 to 11.89), p = 0.0053).

CONCLUSION

Most junior doctors feel confident discussing and documenting resuscitation plans. There is a need to improve knowledge about legal obligations to follow completed resuscitation plans, and about when resuscitation plans should be completed to ensure they are completed with patients who are most at risk. This article is protected by copyright. All rights reserved.

Communicating end-of-life care goals and decision-making among a multidisciplinary geriatric inpatient rehabilitation team: A qualitative descriptive study

BACKGROUND

In geriatric inpatient rehabilitation settings, where the goal is to optimise function, providing end-of-life care can be challenging.

AIM

The aim of this study is to explore how end-of-life care goals and decision-making are communicated in a geriatric inpatient rehabilitation setting.

DESIGN

The design is a qualitative descriptive design using semi-structured individual and group interviews.

SETTING/PARTICIPANTS

This study was conducted in a 154-bed facility in metropolitan Melbourne, Australia, providing geriatric inpatient rehabilitation for older patients; medical, nursing and allied health clinicians, who had cared for an inpatient who died, were recruited.

DATA COLLECTION

Participants were interviewed using a conversational approach, guided by an 'aide memoire'.

RESULTS

A total of 19 clinicians participated in this study, with 12 interviewed individually and the remaining 7 clinicians participating in group interviews. The typical patient was described as older, frail and with complex needs. Clinicians described the challenge of identifying patients who were deteriorating towards death, with some relying on others to inform them. How patient deterioration and decision-making was communicated among the team varied. Communication with the patient/family about dying was expected but did not always occur, nor was it always documented. Some clinicians relied on documentation, such as commencement of a dying care pathway to indicate when a patient was dying.

CONCLUSION

Clinicians reported difficulties recognising patient deterioration towards death. Uncertainty and inconsistent communication among clinicians about patient deterioration negatively impacted team understanding, decision-making, and patient and family communication. Further education for all members of the multidisciplinary team focusing on how to recognise and communicate impending death will aid multidisciplinary teams to provide quality end-of-life care when required.