Introduction
Treatment escalation plans (TEPs) and resuscitation forms are essential to communicate a patient's ceiling of care and whether cardiopulmonary resuscitation (CPR) should be attempted or not.1,2 Completion of resuscitation forms is important ‘to protect people from receiving CPR that they did not want, that would not work, or would not give them overall benefit’.3 Discussion regarding escalation status identifies patients unlikely to benefit from escalation to critical care and supports individualised treatment goals.
This project aimed to improve completion rates of TEPs and resuscitation forms for medical inpatients at St George's Hospital, London.
Materials and methods
In September 2021, an audit of 200 medical inpatients admitted through the medical take for more than 24 hours was performed to identify completion rates of TEPs and resuscitation forms.
Our intervention was designed using feedback from a qualitative survey of junior doctors, assessing confidence in form completion, barriers to completion and ideas on effective interventions. It included induction materials for doctors starting in the acute medical unit (AMU) in February 2022. A demonstration of electronic TEP and resuscitation form completion was given to nine doctors, alongside a flowchart of the step-by-step process. A pre- and post-induction survey was completed to assess impact of the intervention.
Results and discussion
Of the 200 patients audited, only 46% (85) of patients had TEPs and resuscitation forms completed during their admission. 17% (54) had previous TEP forms which were not reviewed or reimplemented. In 11% (6), there was an error in documentation in the form.
26 junior doctors answered the qualitative survey, which shaped the intervention. 61% of respondents felt that completing resuscitation forms was ‘very important’. 15% lacked confidence in completing resuscitation forms and 34% lacked confidence in viewing previous forms. Most doctors (38%) completed the form in their clerking, therefore suggesting interventions aimed at AMU doctors would be effective. 23% of respondents felt that induction materials would help. 80% felt that consultant discussion of resuscitation status would be beneficial. The qualitative survey provided insight into cultural and broader challenges of completing TEPs and resuscitation forms, eg time pressures, arduous forms, lack of confidence in DNAPCR discussions and need for consultant ownership.
Following our intervention, 88% of doctors felt more confident in completing TEPs and resuscitation forms and 100% gained confidence in viewing previous forms.
Conclusion
In conclusion, completion of TEPs and resuscitation forms is important in preventing inappropriate interventions and to allow ‘a natural, dignified death in those who would not benefit from CPR.4
In our preliminary audit, the majority of medical inpatients did not have a documented escalation plan. Our qualitative survey of doctors identified barriers to completion including lack of knowledge, lack of time and delay in senior decision making.
Our project overall showed that induction materials can increase confidence in TEP and resuscitation form completion. In accordance with the wider literature, we found that seeking opinions of doctors can help to design interventions that are practical and sustainable, with greater chance of improving patient care.5
Next steps involve reauditing completion rates and adapting the intervention based on survey results.
- © Royal College of Physicians 2022. All rights reserved.
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