A Unified Electronic Tool for CPR and Emergency Treatment Escalation Plans Improves Communication and Early Collaborative Decision Making for Acute Hospital Admissions

Improving Completion Rates of Treatment Escalation Plan (TEP) in a London Teaching Hospital: A Quality Improvement Study

Background Treatment escalation plans (TEPs) provide enhanced clarity in planning appropriate decision-making in the management of deteriorating patients by explicitly defining a limit of care. These decisions are discussed with patients or their relatives and mutually agreed upon. We aimed to improve staff adherence to the completion of TEPs upon the admission of patients to the orthopedics wards in a London teaching hospital. Methods This study employed the Plan-Do-Study-Act (PDSA) methodology to investigate the efficacy of interventions implemented within a hospital setting for adult inpatients receiving orthopedic treatment. The approach adopted was cross-sectional, where a comprehensive audit was conducted on all adult inpatients admitted to the hospital. The initial cycle of the study was conducted in March 2022, followed by the implementation of interventions in the form of an internal algorithm. Subsequently, the second cycle of the study was conducted in November 2022. Results We sampled a total of 50 patients (PDSA 1, n=27; PDSA 2, n=23). Following the implementation of a designated local TEP pathway, the proportion of patients with incomplete TEPs fell from 30.4% (n=7, PDSA Cycle 1) to 11.76% (n=2, PDSA Cycle 2). Conclusions The study has demonstrated that interventions such as institutional algorithms and departmental meetings can be useful in improving the adherence of staff to complete TEPs. Ongoing training and education can help overcome some of the barriers to TEP completion.

Responding to the deteriorating patient: The rationale for treatment escalation plans

A Treatment Escalation Plan (TEP) is a communication tool designed to improve quality of care in hospital, particularly if patients deteriorate. The aims are to reduce variation caused by discontinuity of care; avoid harms caused by inappropriate treatment and promote patients’ priorities and preferences. The TEP is based on the goals of treatment – ‘What are we trying to achieve?’ The goals take account of the context of acute illness, the consequences of interventions and discussion with the patient. They should reflect a shift away from ‘fix-it’ medicine to what is realistic and pragmatic. A TEP has three escalation categories: full escalation, selected appropriate treatments and palliative/supportive care. Other appropriate/inappropriate treatments are also recorded. Treatment Escalation Plans are associated with significant reductions in intensive care unit (ICU) admissions, non-beneficial interventions, harms and complaints. Treatment Escalation Plans contribute to staff well-being by reducing uncertainty. Successful implementation requires training and education in medical decision-making and communication skills.

Trends of in-hospital cardiac arrests in a single tertiary hospital with a mature rapid response system

Background

Most studies on rapid response system (RRS) have simply focused on its role and effectiveness in reducing in-hospital cardiac arrests (IHCAs) or hospital mortality, regardless of the predictability of IHCA. This study aimed to identify the characteristics of IHCAs including predictability of the IHCAs as our RRS matures for 10 years, to determine the best measure for RRS evaluation.

Methods

Data on all consecutive adult patients who experienced IHCA and received cardiopulmonary resuscitation in general wards between January 2010 and December 2019 were reviewed. IHCAs were classified into three groups: preventable IHCA (P-IHCA), non-preventable IHCA (NP-IHCA), and inevitable IHCA (I-IHCA). The annual changes of three groups of IHCAs were analyzed with Poisson regression models.

Results

Of a total of 800 IHCA patients, 149 (18.6%) had P-IHCA, 465 (58.1%) had NP-IHCA, and 186 (23.2%) had I-IHCA. The number of the RRS activations increased significantly from 1,164 in 2010 to 1,560 in 2019 (P = 0.009), and in-hospital mortality rate was significantly decreased from 9.20/1,000 patients in 2010 to 7.23/1000 patients in 2019 (P = 0.009). The trend for the overall IHCA rate was stable, from 0.77/1,000 patients in 2010 to 1.06/1,000 patients in 2019 (P = 0.929). However, while the incidence of NP-IHCA (P = 0.927) and I-IHCA (P = 0.421) was relatively unchanged over time, the incidence of P-IHCA decreased from 0.19/1,000 patients in 2010 to 0.12/1,000 patients in 2019 (P = 0.025).

Conclusions

The incidence of P-IHCA could be a quality metric to measure the clinical outcomes of RRS implementation and maturation than overall IHCAs.

Implementation of treatment escalation plans in an old age psychiatry inpatient hospital

A treatment escalation plan (TEP) enables timely and appropriate decision making in the management of deteriorating patients. The COVID-19 pandemic precipitated the widespread use of TEPs in acute care settings throughout the National Health Service (NHS) to facilitate safe and effective decision making. TEP proformas have not been developed for the inpatient psychiatric setting. This is particularly concerning in old age psychiatry inpatient wards where patients often have multiple compounding comorbidities and complex decisions regarding capacity are often made. Our aim for this quality improvement project was to pilot a novel TEP proforma within a UK old age psychiatry inpatient hospital. We first adapted a TEP proforma used in our partner acute tertiary hospital and implemented it on our old age psychiatry wards. We then further refined the form and gathered data about uptake, length of time to complete a TEP and the ceiling of care documented in the TEP. We also explored staff, patient and family views on the usefulness of TEP proformas using questionaries. TEP decisions were documented in 54% of patient records at baseline. Following revision and implementation of a TEP proforma this increased to 100% on our two wards. The mean time taken to complete a TEP was reduced from 7.1 days to 3.2 days following inclusion of the TEP proforma in admission packs. Feedback from staff showed improvements in understanding about TEP and improved knowledge of where these decisions were documented. We advocate the use of TEP proformas on all old age psychiatry inpatient wards to offer clear guidance to relatives and treating clinicians about the ceilings of care for patients. There are potentially wider benefits to healthcare systems by reducing inappropriate transfers between psychiatry and acute NHS hospitals.

Understanding the Effect of Electronic Prehospital Medical Records in Ambulances: A Qualitative Observational Study in a Prehospital Setting

Little is known of ambulance professionals’ work practices regarding the use of medical records, their communication with patients, before and during hand over to Emergency Departments (ED). An electronic Prehospital Medical Record (ePMR) has been implemented in all Danish ambulances since 2015. Our aim was to investigate the use of ePMR and whether it affected the ambulance professionals’ clinical practice. We performed a qualitative study with observations of ePMR use in ambulance runs in the North Denmark Region. Furthermore, informal interviews with ambulance professionals was performed. Analysis was accomplished with inspiration from grounded theory. Our main findings were: (1) the ePMR is an essential work tool which aided ambulance professionals with overview of data collection and facilitated a checklist for ED hand overs, (2) mobility and flexibility of the ePMR facilitated conversations and relations with the patients, and (3) in acute severe situations, the ePMR could not stand alone in hand over or communication with the ED. The ePMR affected the ambulance professionals’ work practice in various ways and utilization of ePMR while simultaneously treating patients in ambulances does not obstruct the relation with the patient. To this end, the ePMR appears feasible in collaboration across the prehospital setting.

Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study

BACKGROUND

US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied.

DESIGN AND METHODS

Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences.

RESULTS

The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital's code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories.

CONCLUSIONS

There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.

Bringing into focus treatment limitation and DNACPR decisions: How COVID-19 has changed practice

BACKGROUND

The COVID-19 pandemic has introduced further challenges into Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. Existing evidence suggests success rates for CPR in COVID-19 patients is low and the risk to healthcare professionals from this aerosol-generating procedure complicates the benefit/harm balance of CPR.

METHODS

The study is based at a large teaching hospital in the United Kingdom where all DNACPR decisions are documented on an electronic healthcare record (EHR). Data from all DNACPR/TEAL status forms between 1st January 2017 and 30th April 2020 were collected and analysed. We compared patterns of decision making and rates of form completion during the 2-month peak pandemic phase to an analogous period during 2019.

RESULTS

A total of 16,007 forms were completed during the study period with a marked increase in form completion during the COVID-19 pandemic. Patients with a form completed were on average younger and had fewer co-morbidities during the COVID-19 period than in March-April 2019. Several questions on the DNACPR/TEAL forms were answered significantly differently with increases in patients being identified as suitable for CPR (23.8% versus 9.05%; p < 0.001) and full active treatment (30.5% versus 26.1%; p = 0.028). Whilst proportions of discussions that involved the patient remained similar during COVID-19 (95.8% versus 95.6%; p = 0.871), fewer discussions took place with relatives (50.6% versus 75.4%; p < 0.001).

CONCLUSION

During the COVID-19 pandemic, the emphasis on senior decision making and conversations around ceilings of treatment appears to have changed practice, with a higher proportion of patients having DNACPR/TEAL status documented. Understanding patient preferences around life-sustaining treatment versus comfort care is part of holistic practice and supports shared decision making. It is unclear whether these attitudinal changes will be sustained after COVID-19 admissions decrease.

From paper to paperless: Do electronic systems ensure safe and effective communication and documentation of DNACPR decisions?

INTRODUCTION

An electronic resuscitation system, implemented in 2015, within electronic patient records (EPR) at King's College Hospital NHS Foundation Trust was studied, aiming to review and improve decision documentation and communication.

METHOD

The study (January 2018 - June 2018) included all gerontology inpatients with electronic do not attempt cardiopulmonary resuscitation (e-DNACPR) decisions. Cases were identified weekly, followed by retrospective analysis of discharges. Amendments to the electronic system and improvements were implemented between cycles. CYCLE 1: One-hundred and thirty-three patients were included; 85% had an e-DNACPR form; 86% of all forms had senior doctor involvement; 68% evidenced patient/relative discussion; 13% documented multidisciplinary team (MDT) discussion.

INTERVENTIONS

A mandatory 'named nurse' field was added to the form and trust-wide education programme implemented. CYCLE 2: One-hundred and twenty-six patients were included; 100% had an e-DNACPR form; 93% evidenced senior doctor involvement; 71% evidenced patient/relative discussion; 57% documented MDT discussion.

CONCLUSION

Changes to the process and trust-wide education resulted in more robust documentation and communication.

Patient and family engagement in communicating with electronic medical records in hospitals: A systematic review

BACKGROUND

Use of electronic medical records (EMRs) in hospitals affects how individuals communicate with each other.

OBJECTIVE

To examine how EMRs mediate communication between inpatients, their families, and health professionals to support patient and family engagement in care.

METHODS

The following electronic bibliographic databases were searched for relevant studies: Association for Computing Machinery Digital Library, CINAHL, Medline, the Cochrane Central Register of Controlled Trials, PsycInfo, and EMBASE.

RESULTS

The search identified 850 papers, and of these, 32 met the inclusion criteria. Interactions with the EMR tended to be unidirectional in nature, where health professionals consulted with patients and families to update patient information. Engagement rarely extended to facilitating patient and family participation beyond consultation. There were few examples of patient and family partnership and shared leadership, mainly with secure messaging and use of the patient portal. Strategies that worked in facilitating active engagement involved patients and families employing creative means of gathering information and directing this information to health professionals. Use of such strategies were rare and involved the attributes of particular individuals, rather than considering the inherent culture of clinical settings.

CONCLUSION

Further research is urgently needed to examine possibilities of patient and family involvement in treatment modalities, and partnership and shared governance in using the EMR.