Improving Code Status Discussion and Documentation for Patients 65 Years or Older at Osceola Regional Medical Center – a Quality Improvement Project

From the 2022 HVPA National Conference

Faris Matanes MBBS (University of Central Florida HCA Healthcare GME, Greater Orlando, Florida), Taylor Murphy MD, Keishla Garcia MD, Raj Shah MD, Mark Duros MD, George Alvarez DO, Ashwini Komarla MD, Joshua Shultz MD, Olga Karasik MD

Background

The purpose of code status discussion and documentation is to make sure patients receive medical care that is consistent with their values, goals and preferences. A large multi-center study showed that 47% of physicians believe that patients prefer a full code status when the patient actually wants a do-not-resuscitate order (1).
Our quality improvement project focused on ensuring compliance with code status discussion, documentation and ordering among internal medicine residents at Osceola Regional Medical Center for patients aged 65 years or older.

Purpose

Improving the percentage of patients aged 65 years or older on the resident teaching services who have a code status ordered and those with code status documented to 85% or more.

Methods

• We reviewed patients on residents teaching services to assess percentage of patients with code status order and documentation.
• We sent a survey to the residents to assess their comfort level with discussing goals of care and their perceived frequency of such conversations.
• Our first intervention was in the form of education. We presented a session focused on discussion, documentation and ordering of goals of care. We also reviewed the note templates with dedicated area for documentation of goals of care and created guiding posters for resident workrooms.
• As a second intervention, we set up a challenge for all teams. The challenge consists of achieving 100% compliance among all resident teams with code status documentation and order for patients ≥65 years old. Once the challenge is achieved, program leadership will provide donuts for everyone on that week.

Results

• Survey of the residents showed that 10/28 (35.7%) were uncomfortable or neutral towards discussing code status with patients. About 60.7% of residents said they have code status discussion with patients ≥65 years of age within 24 hours of admission ≥50% of the time. Some 78.6% said they are not aware of separate code status section in note templates or use it <10% of the time.
• Common barriers to code status discussion were time, not having a good outline with such discussion and patients being too overwhelmed on admission to discuss this topic.

Conclusions

• There was a noticeable progressive increase in the percentage of code status ordering and documentation with our 2 interventions. Dedicated section for documentation of goals of care in the notes was used about 50% of the time.
• The interventions had marked improvement likely due to constant reminders to the residents of this issue. Competition reminders were made weekly.

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