Standardization of Inpatient CPR Status Discussions and Documentation Within the Division of Hematology-Oncology at UPMC Shadyside: Results From PDSA Cycles 1 and 2

Abstract

PURPOSE: In December 2016, 49% of patients admitted to inpatient oncology services at University of Pittsburgh Medical Center Shadyside Hospital had cardiopulmonary resuscitation (CPR) status discussion documentation before discharge. The aim of this project was to improve the rate of CPR status conversations. METHODS: During Plan-Do-Study-Act (PDSA) cycle 1, a stakeholder workgroup was formed in January 2017 by oncology faculty, fellows, nurses, advance practice providers (APPs), medicine housestaff, and palliative care faculty. All oncology clinicians and inpatient team members were reminded weekly to discuss and document CPR status preferences. APPs received training on efficient and effective CPR status assessment from palliative care faculty. Oncology leadership received monthly e-mail updates of CPR status documentation rates and endorsed CPR status best practice guidelines. For PDSA cycle 2, patient charts without CPR status documentation in March 2018 were reviewed, and themes were shared with oncology leadership and reviewed with APPs. RESULTS: After PDSA cycle 1, CPR status assessment rates increased from 49% to greater than 80%. In 2017, more than 1,500 more CPR status discussions were documented than in 2016. The percentage of patients discharged with “comfort measures only” or “do not resuscitate” orders increased from 14.2% (95% CI, 9.5% to 19.0%) to 19.8% (95% CI, 15.6% to 24.0%). For PDSA cycle 2, charts of 60 patients without CPR assessment were reviewed. Of these, 52% were admitted overnight by nocturnists and 48% by daytime APPs. Fifty-five percent of patients (n = 33 of 60) had metastatic disease. CPR status was documented on previous admissions for 53% of patients (n = 31 of 60) in the past 12 months. Fifteen percent (n = 11 of 60) were admitted for scheduled inpatient chemotherapy. CONCLUSION: A multipronged approach significantly increased CPR status assessments. More patients transitioned to comfort measures only or do not resuscitate when their preferences were clearly assessed and documented.

Changing prescribing practice for rapid tranquillization–a quality improvement project based on the Plan-Do-Study-Act method

“…Other studies [ 20 , 21 ] working with the improvement of medical documentation in a similar context to ours with guidelines, training, collection of data, and feedback to staff have resulted in an increase in documentation using PDSA cycles. In one study, the rating of the cardiopulmonary resuscitation status of patients was raised from 49% to > 80% [ 20 ]. One of the applied initiatives was to place a highly visible field in the patient’s EMR to remind the staff about what to do.…”

“…In our study, the visual reminder considerably improved our documentation rate. A main difference to our study is that both studies [20,21] made an early barrier analysis or conducted key informant interviews to assess the barriers to QI. This was not done systematically and rather late in our study since the COVID-19 pandemic made it impossible to go Gemba.…”

Ensuring Rapid Response Team Care Aligns With Patients' Limitations of Medical Therapy

“…Another quality improvement project by Garcia et al5 aimed to increase discussion and improve the documentation of CPR status for hematology-oncology patients. The multipronged approach included palliative care experts educating APPs on how to have conversations with patients and families, development of a system-wide CPR policy, and regular communication of CPR status documentation rates.…”

“…Researchers compared a convenience sample of patients' records before and after instituting a form for documentation of resuscitation orders that re-sulted in a significant increase in documentation of LOMTs. 5,10,11 Reed et al 11 noted an improvement in documented LOMTs from 41% to 75% following a quality improvement initiative at a large academic medical center that used an interdisciplinary team to identify patients who needed resuscitation orders written and to seek written orders from the physician. In addition, the team completed activities to raise awareness of the need for written LOMT orders that included nurse and physician education, a decision support tool embedded into the electronic health record, and discussion of LOMT documentation rates at staff meetings.…”

“…A systematic review and meta-analysis of 150 studies with 795 909 patients published between 2011 and 2016 concluded that up to 36.7% of Americans had completed some form of an advance directive 4. Even when documentation exists, patients can receive care that is not aligned with their wishes if standardized processes are not in place 5–8…”