Influence of guidelines on CPR decisions: an audit of clerking proforma

Abstract

, as new guidelines and a proforma were introduced. For the first audit, data were collected from 75 departmental discharges. Following introduction of a proforma, six point prevalence audits were performed of all elderly care inpatients. Consultant documentation improved from 27/75 (36%) to 102/109 (94%), 135/148 (91%), 133/140 (95%), 96/119 (81%), 148/157 (94%) and 167/169 (98%) in audits 2, 3, 4, 5, 6 and 7 respectively. The percentages of decisions that were Do Not Attempt Resuscitation (DNAR) were 64% 72%, 45%, 68% and 62% in audits 3 to 7 respectively. For audit 5 our guidelines required discussion with patient before making a DNAR order, whereas the guidelines applicable for the other audits did not stipulate discussion. The fall in documentation rates and proportion of CPR decisions that were DNAR in audit 5 were statistically significant. There was no significant difference in age, diagnosis, cognitive function or disability between patients in those audits (3-7) when these parameters were recorded. Introducing a proforma significantly improved CPR decision documentation. Obligatory discussion with a patient before issuing a DNAR order was associated with a fall in documentation of decisions.

Communicating information on cardiopulmonary resuscitation to hospitalised patients

“…3 There is evidence that obligatory discussions with patients before making every CPR decision results in a significant fall in the number of decisions relating to CPR. 4 In our study only 53% of patients who had seen the document chose to read it, indicating that a considerable proportion declined information on CPR when given the opportunity. Of those who did read the summary document only a quarter requested the detailed CPR information leaflet and they did not discuss it any further.…”

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

“…Diggory's team 37 continued the audit cycles from their 2003 study and found that removing the statement indicating that all DNACPR decisions should be discussed with the patient increased the recording of resuscitation status and the number of DNACPR decisions issued. Piers et al 38 updated the DNACPR form to emphasise the reason for the DNACPR decision and involvement of others (surrogates, nurses) in the decision-making process.…”

“…Over half (20/37) of the studies were conducted in the USA, 22,25,[28][29][30][31]39,41,42,45,[47][48][49][50][52][53][54][55][56][57] nine were conducted in the UK, 26,[32][33][34][35]37,40,43,44 two were conducted in Australia 23,24 and one study was conducted in each of Germany, 46 Belgium, 38 Switzerland, 51 the Netherlands, 16 Singapore 36 and Saudi Arabia. 27 …”

“…Of the 37 studies, eight were randomised controlled trials, [22][23][24]30,45,54,55,57 27 were before-and-after studies 16,[25][26][27][28][29][31][32][33][34][35][36][37][38][39][40][41][42][43][44][48][49][50][51][52][53]56 and two were cluster controlled studies. 46,47 Two studies were assessed as providing strong evidence, 24,40 12 were assessed as providing moderate evidence 16,22,23,29,30,[35][36][37][38]54,55,…”

“…46,47 Two studies were assessed as providing strong evidence, 24,40 12 were assessed as providing moderate evidence 16,22,23,29,30,[35][36][37][38]54,55,57 and 23 were assessed as providing weak evidence. [25][26][27][28][31][32][33][34]39,[41][42][43][44][45][46][47][48][49][50][51][52][53]56 REVIEW OF PUBLISHED EVIDENCE NIHR Journals Library www.journalslibrary.nihr.ac.uk…”