Audit of CPR documentation Dr Gwenllian Davies

Setting Inpatient palliative medicine unit Patients admitted from home or acute hospital CPR forms used in each set of notes to denote if patient is for or not for CPR Fields for documentation of why decision was reached and what communication there has been with patient and family, if any. Point 3 – this differs to hospital DNACPR forms

Why did I choose this audit? Not many forms completely filled Topical – national (UK and Wales)and locally National review of DNACPR decision making Time to Intervene? A report by the National Confidential Enquiry into Patient Outcome and Death (June 2012) August 2011 –health secretary and hospital court sued over use of DNACPR order 7/573 patients who underwent CPR were on an end of life care pathway. All seven patients died in hospital. NCEPOD summary report page 13

Standards ABMU guidelines Resuscitation council guidelines 1) ABM Resuscitation Policy issued June 2009 2) http://www.resus.org.uk/pages/DNARrstd.htm

Standards All DNACPR (100%) forms should be signed by the consultant in charge of the patient’s care, within a week of admission. All DNACPR (100%) forms should have all fields completed i.e. what, if anything has been communicated to others (colleagues/patient/relatives) re. decision. 1Local/trust guidelines(1) state that “The overall responsibility for decision about DNACPR orders rests with the consultant in charge of the patient’s care”, in keeping with guidelines by BMA/RCN/Resuscitation council(uk) “The decision must be endorsed by the most senior healthcare professional responsible for the patient’s care at the earliest opportunity. Further endorsement should be signed whenever the decision is reviewed. A fixed review date is not recommended. Review should occur whenever circumstances change” (2)

Resuscitation council guidelines (March 2009) re communication Effective communication and explanation of DNAR decisions where appropriate with the patient.  State clearly what was discussed and agreed. If this decision was not discussed with the patient state the reason why this was inappropriate    

Resuscitation council guidelines (March 2009) re communication Effective communication and explanation of DNAR decisions where appropriate and with due respect for confidentiality with the patient’s family, friends, other carers or other representatives.  State the names and relationships of relatives or friends or other representatives with whom this decision has been discussed. More detailed description of such discussion should be recorded in the clinical notes where appropriate.

Resuscitation council guidelines (March 2009) re communication Effective communication of DNAR decisions between all healthcare workers and organisations involved with the patient.   Summary of the main clinical problems and reasons why CPR would be inappropriate, unsuccessful or not in the patient’s best interests

Method Retrospective audit of 50 case notes Admissions between 1st of June and 24th of August Unable to find forms in 5 of 45 case notes therefore only 45 for analysis

Consultant endorsement 1 not dated and 1 signed after 7/7

Summary of clinical problem All 45 had something documented in ‘reason for decision’ box. Did not feel that ‘terminally ill’ was an adequate summary of clinical problem

Reasons why decision made Example of words used on the form

Documentation of what had been communicated to patient i.e. have they documented if it was discussed or not. If it was discussed have they documented what was said? CPR “against wishes of patient” Not discussed as would cause distress

Documentation of what had been communicated to family. 4/45 forms had some documentation No names/relationships documented when spoken to “open conversation that patient dying” “family aware that patient does not want life prolonged”

Changes made Change form to health board form (2/4/12) Departmental education on guidelines Ask consultant to sign (i.e. endorse decision) on ward round/MDT - twice weekly opportunities.

Re-audit 50 case notes for admissions from May to July 2012 3 patients for CPR therefore no CPR form in notes to audit.

Consultant endorsement

Reason Given why CPR not offered?

Documentation of what had been communicated to patient i.e. nothing communicated or told not for CPR etc.

Documentation of what had been communicated to family i.e. nothing communicated or told not for CPR

Meeting Standards Standard 1 All DNACPR (100%) forms should be signed by the consultant in charge of the patient’s care, within a week of admission. 1st audit 0% met standard 2nd audit 91% met standards

Meeting standards Standard 2 All DNACPR (100%) forms should have all fields completed i.e. what, if anything has been communicated to others re decision Broken down into 3 sections:

Meeting standards Audit 1 Audit 2 Summary of why decision made 51% 100% Documenting of what had been discussed with patient 11% 47% Documenting of what had been discussed with family 8% 55%

Possible reasons for not meeting standards Not writing a new form when patient transferred from acute setting Documenting elsewhere i.e. in clerking sheets or ‘significant conversations pages’ Did I set the standards too high?