QI Presentation: DNR Policy

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QI Presentation DNR Policy

• June 6, 2016
• Lyndsey Graber, Sam Wallum, Jennifer Wu
• Cristina Wood, Jose Melendez

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History of DNR

• Development of CPR in 1960s (Scott)
• Closed chest cardiac massage
• Providers determined who received CPR vs. slow
  codes (Walker)
• Erosion of trust between public and providers
  (Walker)
• 1974 AMA suggested DNR orders
• 1976 Boston hospitals develop DNR policies

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Background

• Prior to 1990s DNR orders automatically
  suspended for perioperative and immediate
  postoperative periods (Truog)
• 1990 Patient Self Determination Act passed by
  Congress patients have right to make their own
  healthcare decisions
• ASA guidelines in 1993 automatic suspension of
  DNR orders in the perioperative period does not
  support a patients rights to autonomy and
  self-determination

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DNR in the OR

• Up to 15 of patients presenting for surgery have
  a DNR order (La Pluma)
• Presence of DNR order is a risk factor for poor
  surgical outcome and postoperative mortality
  (Kazaure)
• BUT
• Perioperative CPR has highest likelihood of
  returning patients to prior level of function
  (Speicher)

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University DNR Policy review

• Effective in 1999, Revised 7/2015
• Found on University Source intranet home
  pagegtPoliciesgtDo Not Resuscitate, Allow Natural
  Death policy
• 10 pages
• 1 page Perioperative or Procedural Cases
  involving DNAR

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University Perioperative DNR Policy summary

• Patient can keep DNR status for operation if they
  wish
• Resuscitation status must be discussed by
  attending anesthesiologist and surgeon
• Complete form
• Must change order in Epic when appropriate
• If suspension, duration of suspension should be
  determined and recorded
• Purple DNR wristband to be removed/reattached as
  appropriate
• Any limitations to resuscitation to be documented
  on form, Epic, and wristband
• Resuscitation status reviewed as part of time out

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Root cause analysis-Fishbone diagram
Problem DNR patients not identified, discussion
not happening
Individual factors
Task factors
Patient factors
Difficulty in having discussion, provider
attitudes towards DNR
Difficult to find protocol
Patient understanding of anesthesia, patient
capacity
Lack of training for residents/nurses new
attendings
Lack of knowledge of purple arm bands, lack of
obvious signage
Signs/highlighting in Epic could be added
Education factors
Communication factors
Equipment and resources
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Root cause analysis-Fishbone diagram
Problem DNR patients not being identified,
discussion not happening
Organizational and strategic factors
Team factors
Difficult to find protocol
New staff New mid-level providers Differing
attending attitudes
Urgent/emergent surgical culture Pressure to meet
time deadlines Add-on cases
Working condition factors
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Possible interventions

• Epic pop-up window
• Education
• Code status sign on whiteboard
• Patients identified in surgery clinic
• Code discussions in preoperative clinic
• Easier policy access from Epic

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Ideal process map
Have discussion about perioperative DNR and sign
form
Identified in surgery clinic for preoperative
clinic
Preoperative clinic
Elective DNR patient
Pre-op nurse sees form/Epic pop-up
Pre-op for surgery
Purple wristband applied/sign on whiteboard
OR
Teams confirm DNR or fill out paperwork if not
finished
Epic order
PACU
Wrist band re-applied/new Epic order
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• PDSA Cycle for DNR project

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Quiz to assess DNR knowledge

• 1. If a patient has a DNAR order and needs to go
  to the operating room, the patient's DNAR
• A-is cancelled with an operation
• B-is automatically cancelled and reinstated with
  an operation
• C-Needs to be discussed by the anesthesiologist
  and the proceduralist prior to the OR and
  documented
• 2. This needs to be completed after the DNAR
  discussion
• A-DNAR form
• B-DNAR order
• C-Modify armband if needed
• D-EHR note
• E-all of the above
• 3. A patient may undergo a palliative, urgent, or
  appropriate surgical procedure while maintaining
  a DNAR order
• A-True
• B-False

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References

• La Pluma J, Silverstein MD, Stocking CB, Roland
  D, Siegler M. Life-sustaining treatment a
  prospective study of patients with DNR orders in
  a teaching hospital. Arch Intern Med.
  1988148(10)2193-2198.
• Kazaure H, Roman S, Sosa JA. High mortality in
  surgical patients with do-not-resuscitate orders
  analysis of 8256 patients. Arch Surg.
  2011146(8)922-928.
• Speicher PJ, Lagoo-Deenadayalan SA, Galanos AN,
  Pappas TN, Scarborough JE. Expectations and
  outcomes in geriatric patients with
  do-not-resuscitate orders undergoing emergency
  surgical management of bowel obstruction. JAMA
  Surg. 2013148(1)23-28.
• Scott TH, Garvin JR. Palliative surgery in the
  do-not-resuscitate patient Ethics and practical
  suggestions for management. Anesthesiol Clin.
  201230(1)1-12.
• Truog RD. Do-not-resuscitate orders during
  anesthesia and surgery. Anesthesiology.
  199174606-608.
• Walker RM. DNR in the OR resuscitation as an
  operative risk. JAMA. 199126624072412.