Dataset Information

A Quality Improvement Project to Improve Documentation and Awareness of Limitations of Life-Sustaining Therapies.

ABSTRACT:

Purpose

Poor documentation and understanding of the limitations of life-sustaining therapies upon admission to the pediatric intensive care unit (PICU) can result in moral distress for both providers and families. Limitations of life-sustaining treatments are often not documented and/or understood by members of the health care team.

Methods

We performed a quality improvement initiative to improve the care teams' understanding and paper documentation of the limitations of life-sustaining therapies in the PICU of a quaternary children's hospital from January 2018 to March 2019. We implemented a series of plan-do-study-act cycles, including initiation of an updated rounding tool that included limitations of interventions, in-person and electronic information sessions, and implementation of a visual bedside tool to remind providers when limitations were present. Pre- and postintervention surveys were administered.

Results

Nursing paper documentation of limitations of life-sustaining therapies increased sequentially from 0% to 88% during plan-do-study-act cycles. Creating a specific area to document limitations on the nursing sheet resulted in the most significant increase in documentation (36.6 points). Nurses reported that they "always" document limitations, which increased from 10% to 38%. The percentage of nurses who understood patients' intervention limitations increased from 28% to 33%.

Conclusions

Limitations of life-sustaining therapies in the PICU are nuanced and involve multiple stakeholders. Nursing education and designation of a section of intervention limitations in nursing daily goal paper documentation can increase comfort with therapeutic limitations in the PICU. Future studies should explore impacts on patient care and serve as a framework for the ultimate goal of improving documentation of care limitations and code status in the electronic medical record.

SUBMITTER: Jones AH

PROVIDER: S-EPMC7297404 | biostudies-literature | 2020 May-Jun

REPOSITORIES: biostudies-literature

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Publications

A Quality Improvement Project to Improve Documentation and Awareness of Limitations of Life-Sustaining Therapies.

Jones Amy H AH Heneghan Julia A JA Brooks Bonnie B Maamari Mia M Ahmad Ali A October Tessie W TW Corriveau Christiane C

Pediatric quality & safety 20200528 3

<h4>Purpose</h4>Poor documentation and understanding of the limitations of life-sustaining therapies upon admission to the pediatric intensive care unit (PICU) can result in moral distress for both providers and families. Limitations of life-sustaining treatments are often not documented and/or understood by members of the health care team.<h4>Methods</h4>We performed a quality improvement initiative to improve the care teams' understanding and paper documentation of the limitations of life-sust ...[more]

PMID: 32607460

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Project description:ImportanceCritically ill patients often receive high-intensity life sustaining treatments (LST) in the intensive care unit (ICU), although they can be ineffective and eventually undesired. Determining the risk factors associated with reversals in LST goals can improve patient and provider appreciation for the natural history and epidemiology of critical care and inform decision making around the (continued) use of LSTs.MethodsThis is a single institution retrospective cohort study of patients receiving life sustaining treatment in an academic tertiary hospital from 2009 to 2013. Deidentified patient electronic medical record data was collected via the clinical data warehouse to study the outcomes of treatment limiting Comfort Care and do-not-resuscitate (DNR) orders. Extended multivariable Cox regression models were used to estimate the association of patient and clinical factors with subsequent treatment limiting orders.Results10,157 patients received life-sustaining treatment while initially Full Code (allowing all resuscitative measures). Of these, 770 (8.0%) transitioned to Comfort Care (with discontinuation of any life-sustaining treatments) while 1,669 (16%) patients received new DNR orders that reflect preferences to limit further life-sustaining treatment options. Patients who were older (Hazard Ratio(HR) 1.37 [95% CI 1.28-1.47] per decade), with cerebrovascular disease (HR 2.18 [95% CI 1.69-2.81]), treated by the Medical ICU (HR 1.92 [95% CI 1.49-2.49]) and Hematology-Oncology (HR 1.87 [95% CI 1.27-2.74]) services, receiving vasoactive infusions (HR 1.76 [95% CI 1.28, 2.43]) or continuous renal replacement (HR 1.83 [95% CI 1.34, 2.48]) were more likely to transition to Comfort Care. Any new DNR orders were more likely for patients who were older (HR 1.43 [95% CI 1.38-1.48] per decade), female (HR 1.30 [95% CI 1.17-1.44]), with cerebrovascular disease (HR 1.45 [95% CI 1.25-1.67]) or metastatic solid cancers (HR 1.92 [95% CI 1.48-2.49]), or treated by Medical ICU (HR 1.63 [95% CI 1.42-1.86]), Hematology-Oncology (HR 1.63 [95% CI 1.33-1.98]) and Cardiac Care Unit-Heart Failure (HR 1.41 [95% CI 1.15-1.72]).ConclusionDecisions to reverse or limit treatment goals occurs after more than 1 in 13 trials of LST, and is associated with older female patients, receiving non-ventilator forms of LST, cerebrovascular disease, and treatment by certain medical specialty services.

Dataset Information

A Quality Improvement Project to Improve Documentation and Awareness of Limitations of Life-Sustaining Therapies.

Purpose

Methods

Results

Conclusions

Publications

A Quality Improvement Project to Improve Documentation and Awareness of Limitations of Life-Sustaining Therapies.

Similar Datasets

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