Authors (including presenting author) :
Cheng Benjamin (2), Lee Q (1), Tang PF (1), Man C W (2)
Affiliation :
(1) Quality and Safety Division, The New Territories West Cluster (2) Department of Medicine and Geriatrics, The New Territories West Cluster
Introduction :
TMH developed the clinical indicator on serious clinical deterioration (SCD) in 2013 and has used this indicator to quantitatively monitor the performance of TMH in caring for patients with SCD and to guide patient care improvement initiatives.1 However, there was no audit conducted so far to understand the appropriateness of Do-not-attempt cardiopulmonary resuscitation (DNACPR).
Objectives :
Project aims to review the appropriateness of signed DNACPR order in patients with serious clinical deterioration.
Methodology :
Review on medical notes and electronic Patient Record for the pre-morbid status by using the Age-combined Charlson Co-morbidity Index (ACCI) 2,3, the timing of DNACPR, the dates of admission and discharge for patients with serious clinical deterioration during winter surge (between Dec 2018 and Mar 2019). Co-morbidities were assessed prior to the SCD as ICD-11 codes according to the ACCI. Both deceased and stayed alive patients (alive for 30 days after CPR) were audited. Screenings on advanced cancer, organ failure, advanced dementia, Troponin-I level were conducted. Signed DNACPR in-situ was reviewed based on the pre-morbid status and the decision and timing of DNACPR. Late discussion on DNACPR was defined as discussion on DNACPR within 48 hours before death4.
Result & Outcome :
Total 84 cases (72 deceased cases and 12 stayed alive cases) with SCD were audited. 61.1% (n=44) were male in deceased group, while 66.7% (n=8) were male in patients who stayed alive. The median age of death cases was 69.5, while the median age of alive cases was 56.5 (p< 0.05). For the death cases, 68.1% of the cases with CPR performed were in M&G, 15.3% in O&T, 9.7% in Surgery, 5.6% in Oncology, and 1.4% in Neurosurgery departments respectively. For cases stayed alive, 33.3% with CPR performed were in CCU, 16.7% in ICU and Operation Theatre, and 8.3% in all general wards ofSurgery, ENT&OPH and M&G Rehab wards. For cases with low burden of ACCI (0-4 points), we observed a low percentage of DNACPR in-situ prior to SCD (17.9% in deceased group and 10% in alive group). This reflected appropriateness in performing CPR, as previous study demonstrated reasonably good 30-day survival after in-hospital cardiac arrest in patients with low burden of ACCI.3 On the other hand, in patients with moderate or severe burden of ACCI (defined as 5-7 points & >=8 points respectively), previous study demonstrated minimal chance in 30-day survival of no more than ten percent after in-patient cardiac arrest.3 In our study group of patients with moderate to severe burden of ACCI, 47.7% had no DNACPR signed prior to SCD. Moreover, another 40.9% only had DNACPR documented less than 48 hours before death. Conclusion: Patients with a moderate to severe burden of ACCI often had a minimal chance of survival after SCD. However, DNACPR documentation as part of advance care planning (ACP) process were often delayed or even neglected by front-line clinical staff. This indicated that there were rooms for improvement in appropriate timing and signing of DNACPR for patients with poor pre-morbid status. Education and collaboration with palliative care specialists might enhance front-line clinical staff competence in handling ACP discussion in the modern medical era.5 References to be provided due to limited word count.
