Documentation of Do Not Attempt Cardiopulmonary Resuscitation (DNA-CPR) Decision within 24 Hours of Emergency Admission

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Background & Problem:

National recommendations (NCEPOD, Time to Intervene, 2012) state CPR status should be assessed within the first 12 hours of emergency admission during a consultant review. Trust DNA-CPR Audit in December 2018 demonstrated poor compliance (56%) within first 24hours with ¼ of decisions made > 3 days (deteriorated since previous annual audits).

Aim:

Our aim was to improve documentation of DNA-CPR decisions within the first 24 hours of emergency admissions by 20% by December 2019.

Method:

Initially, we conducted literature searches, benchmarking local and national drivers/ initiatives. Discussions with stakeholders identified local problems and enthusiasm for improvement. Three wards were recruited (Respiratory Medicine, Care of the Elderly and T&O). Five randomly selected patients’ notes on each ward, were reviewed for presence of an Unwell/ Potentially deteriorating Patient Plan or ReSPECT Form (>10th October) and completion date.

PDSA Cycles included staff education, considering existing ward-round checklists used in AMU being adapted for wards and implementation of national ReSPECT Form. We abandoned the PDSA cycle to implement checklists to wards after it was reviewed. Throughout and post QI we provided feedback to ward areas.

Outcome measures included:

• Primary- “Was the DNA-CPR decision documented?
• Secondary- “Was the decision made within 24hrs of emergency admission?”
• The balancing measure analysed if admission day effected compliance?

Results:

Results demonstrated outcome improvements in all wards and although compliance initially dipped during implementation of ReSPECT, trends improved. (40% point improvement in overall documentation of DNA-CPR and 67% point improvement of decision < 24 hours).

Implications:

The day of admission slightly influenced compliance with patients admitted on a Friday.

Next steps:

We plan to implement changes to other areas across the Trust (collaborating with other ReSPECT QI projects), ensuring maintenance and support of project areas. Identified concerns around discharge were addressed with IM&T (electronic prompt for discharge summary to communicate new/ adapted ReSPECT to Primary Care).