DNAR: All or Nothing: Impact of Education Sessions Re-Audit in a Model 3 Hospital

IF 6 2区 医学 Q1 GERIATRICS & GERONTOLOGY Age and ageing Pub Date : 2024-09-30 DOI:10.1093/ageing/afae178.323
Joshua Ramjohn, Joseph Kelly, Amal Abdalla, Ahmed Hamad, Juliana Carvalho, Ciara Gibbons, Lynn Quigley, Katherine Finan
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Abstract

Background Do Not Attempt Resuscitation (DNAR) orders are implemented to obviate inappropriate Cardio-Pulmonary Resuscitation (CPR) in patients with low chances of survival post-CPR. However, ambiguity regarding ceilings of care for patients with a DNAR order can arise. This re-audit aimed to review DNAR and ceilings of care documentation according to national HSE guidelines after education sessions, comparing results with the pre-education audit in a Model 3 Hospital. Methods A point-prevalence chart review of thirty-one adult medical inpatients with a DNAR order was conducted after two education sessions were held for Non-Consultant Hospital Doctors (NCHDs) and Consultants. Results Of all thirty-one charts, 35% documented DNAR status in the medical notes, with 32% documenting the reasoning for DNAR status, both of which were unchanged from the first audit cycle. There was an increase in documentation of patient discussion (61% versus 45%) and reasons if this was excluded (66% versus 41%). There was no change in documentation of patient relatives’ discussion (48%) but there was an increase in the reasons if this was excluded (25% versus 18%). There was an overall increase in ceilings of care documentation for ICU admission (three-fold increase), intubation (two-fold increase), inotropic support, and comfort measures, but rates of documentation were still less than 15%. This elucidates the efficacy of education sessions in improving DNAR documentation adherence. Recent studies have highlighted uncertainty among NCHDs regarding treatment escalation in acutely unwell patients in the absence of adequately filled DNAR orders and clear documentation of ceilings of care. Therefore, we posit the introduction of a Ceilings of Care document, akin to the United Kingdom’s Medical Advance Plan. Conclusion Accurate recording of DNAR status and ceilings of care is essential for quality care and treatment escalation. While simple education strategies have proven beneficial in enhancing compliance, additional efforts are needed to enhance ceilings of care documentation.
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DNAR:全有或全无:教育会议对一家 3 型医院重新审核的影响
背景 执行 "不尝试复苏"(DNAR)指令是为了避免对心肺复苏术后存活几率较低的患者进行不适当的心肺复苏(CPR)。然而,对于下达了 DNAR 命令的患者,护理的上限可能会出现模糊不清的情况。本次重新审核的目的是在教育课程结束后,根据国家 HSE 指南审核 DNAR 和护理上限文件,并将结果与一家 3 型医院的教育前审核结果进行比较。方法 在为医院非顾问医生(NCHD)和顾问医生举办了两次教育课程后,对 31 名下达了 DNAR 命令的成人住院病人进行了病历点检。结果 在所有 31 份病历中,35% 的病历记录了 DNAR 状态,32% 的病历记录了 DNAR 状态的理由,这两项指标与第一个审核周期相比没有变化。记录患者讨论情况(61% 对 45%)和排除讨论的原因(66% 对 41%)的比例有所上升。病人亲属讨论的记录没有变化(48%),但排除病人亲属讨论的原因有所增加(25% 对 18%)。重症监护病房的入院护理记录上限(增加了三倍)、插管(增加了两倍)、肌张力支持和舒适措施的记录上限总体上有所增加,但记录率仍低于 15%。这说明了教育课程在提高 DNAR 文件记录依从性方面的功效。最近的研究突出表明,在没有充分填写 DNAR 命令和明确记录最高护理级别的情况下,非营利性医疗机构对急性病患者的治疗升级存在不确定性。因此,我们建议采用类似英国医疗预案的护理上限文件。结论 准确记录 DNAR 状态和最高护理级别对于优质护理和治疗升级至关重要。虽然简单的教育策略已被证明有利于提高患者的依从性,但还需要更多的努力来加强最高护理记录。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Age and ageing
Age and ageing 医学-老年医学
CiteScore
9.20
自引率
6.00%
发文量
796
审稿时长
4-8 weeks
期刊介绍: Age and Ageing is an international journal publishing refereed original articles and commissioned reviews on geriatric medicine and gerontology. Its range includes research on ageing and clinical, epidemiological, and psychological aspects of later life.
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