Evidence-base: A recent audit of CPR and CoC decision making at our institution demonstrated poor practice within Geriatric and Acute Medicine, with no improvements since 2006 despite development of a clear policy and pathway. The recent NCEPOD report (Time to Intervene, 2012) has highlighted the need to make such decisions as regularly and early as possible. A more robust method to ensure such decisions are made was piloted on our HASU in the form of a PTWR checklist.
Change strategies: Retrospective data was collected from clinical notes for the pre-intervention audit (26/10/12 to 24/01/13), after which a PTWR checklist designed to improve decision making was introduced. Doctors were educated at a departmental meeting and encouraged to include the sheet in the clerking proforma. A post-intervention audit was completed two months later (25/01/13 to 27/03/13).
Change effects: Pre-intervention audit: n = 184 patients (mean age 72 years) with Post-intervention audit: n = 136 patients (mean age 74 years). The PTWR sheet was completed in 61% (83/136) of patients. There was a significant increase in the number of CPR decisions (48/184 versus 84/136, p < 0.0001), with over twice as many patients having a decision made <24 hours (31 versus 67). Significant consultant variability in decision-making still occurred (15-37% versus 21-92%). There was a significant increase in documentation of CoC (32/48 versus 73/85; p < 0.05). There was no significant difference in the reason for DNACPR decisions, or documentation of discussions with patient and/or next of kin.
Conclusion: Introducing a PTWR checklist significantly increased the number of CPR and CoC decisions being made. Consultant variability remained an issue. Documentation of discussions around DNACPR could be further improved. We plan to improve compliance with the PTWR checklist by fully integrating it into the admission clerking proforma, followed by a further audit.