scholarly journals Are do-not-resuscitate orders associated with limitations of care beyond their intended purpose in patients with acute intracerebral haemorrhage? Analysis of the ABC-ICH study

2021 ◽  
Vol 10 (1) ◽  
pp. e001113
Author(s):  
Jatinder S Minhas ◽  
Camilla Sammut-Powell ◽  
Emily Birleson ◽  
Hiren C Patel ◽  
Adrian R Parry-Jones
Keyword(s):  
Critical Care ◽  
Supportive Care ◽  
Intracerebral Haemorrhage ◽  
Qualitative Evaluation ◽  
Respiratory Arrest ◽  
Care Bundle ◽  
Do Not Resuscitate ◽  
Improvement Project ◽  
Improvement In Survival ◽  
Dnr Orders

Implementation of an acute bundle of care for intracerebral haemorrhage (ICH) was associated with a marked improvement in survival at our centre, mediated by a reduction in early (<24 hours) do-not-resuscitate (DNR) orders. The aim of this study was to identify possible mechanisms for this mediation. We retrospectively extracted additional data on resuscitation attempts and supportive care. This observational study utilised existing data collected for the Acute Bundle of Care for ICH (ABC-ICH) quality improvement project between from 2013 to 2017. The primary outcome was whether a patient received an early (<24 hours) DNR order. We used multivariable logistic regression to estimate the adjusted association between clinically meaningful factors, including an indicator for a change in treatment on the introduction of the ABC care bundle. Early DNR orders were associated with a reduced odds of escalation to critical care (OR: 0.07, 95% CI: 0.03 to 0.17, p<0.001). Commencement of palliative care within 72 hours was far more likely (OR: 8.76, 95% CI: 4.74 to 16.61, p<0.001) if an early DNR was in place. The cardiac arrest team were not called for an ICH patient before implementation but were called on five occasions overall during and after implementation. Further qualitative evaluation revealed that on only one occasion was there a cardiac or respiratory arrest with cardiopulmonary resuscitation performed. We found no significant increase in resuscitation attempts after bundle implementation but early DNR orders were associated with less admission to critical care and more early palliation. Early DNR orders are associated with less aggressive supportive care and should be judiciously used in acute ICH.

Abstract 3060: Racial Disparities in Early Institution of “Do Not Resuscitate” Orders Influence Survival in Acute Ischemic Strokes.

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Pratik Bhattacharya ◽  
Ambooj Tiwari ◽  
Sam Watson ◽  
Scott Millis ◽  
Seemant Chaturvedi ◽  
...  
Keyword(s):  
Critical Care ◽  
African American ◽  
Ischemic Stroke ◽  
African Americans ◽  
Acute Ischemic Stroke ◽  
Racial Differences ◽  
Racial Disparity ◽  
Retrospective Chart Review ◽  
Do Not Resuscitate ◽  
Dnr Orders

Background: The importance of early institution of “Do Not Resuscitate” (DNR) orders in determining outcomes from intracerebral hemorrhage is established. In the setting of acute ischemic stroke, African Americans tend to utilize critical care interventions more and palliative care options less than Caucasians. Recent epidemiological studies in acute ischemic stroke have shown a somewhat better survival for African Americans compared with Caucasians. Our hypothesis was that racial differences in early institution of DNR orders would influence mortality in acute ischemic stroke. Methods: a retrospective chart review was conducted on consecutive admissions for acute ischemic stroke across 10 hospitals in Michigan for the year 2006. Subjects with self reported race as African American or Caucasian were selected. Demographics, stroke risk factors, pre morbid status, DNR by day 2 of admission, stroke outcome and discharge destination were abstracted. Results: The study included 574 subjects (144 African American, 25.1%; 430 Caucasian, 74.9%). In-hospital mortality was significantly higher among Caucasians (8.6% vs. 1.4% amongst African Americans, p=0.003). More Caucasians had institution of DNR by day 2 than African Americans (22.5% vs. 4.3%, p<0.0001). When adjusted for racial differences in DNR by day 2 status, Caucasian race no longer predicted mortality. Caucasians were significantly older than African Americans (median age 76 vs. 63.5 years, p<0.0001); and age was a significant predictor of DNR by day 2 and mortality. In the adjusted analysis, however, age marginally influenced the racial disparity in mortality ( table ). Caucasians with coronary disease, atrial fibrillation, severe strokes and unable to walk prior to the stroke tend to be made DNR by day 2 more frequently. Only 27.1% of Caucasians with early DNR orders died in the hospital, whereas 20.8% were eventually discharged home. Conclusions: Early DNR orders result in a racial disparity in mortality from acute ischemic stroke. A substantial proportion of patients with early DNR orders eventually go home. Postponing the use of DNR orders may allow aggressive critical care interventions that may potentially mitigate the racial differences in mortality.

scholarly journals A quality improvement project for delirium prevention and management over the Greater Manchester Critical Care Network

2020 ◽  
pp. 175114372091270
Author(s):  
Jessica Davis ◽  
Karen Berry ◽  
Rebecca McIntyre ◽  
Daniel Conway ◽  
Anthony Thomas ◽  
...  
Keyword(s):  
Critical Care ◽  
Best Practice ◽  
Point Prevalence ◽  
Screening Tools ◽  
Care Bundle ◽  
Improvement Project ◽  
Care Network ◽  
Critical Care Units ◽  
Patient Morbidity ◽  
Delirium Prevention

Background Delirium is a common complication of critical illness with a significant impact on patient morbidity and mortality. The Greater Manchester Critical Care Network established the Delirium Reduction Working Group in 2015. This article describes a region-wide delirium improvement project launched by that group. Methods Multiple Plan-Do-Study-Act cycles were undertaken. Cycle 1: April 2015 demonstrated only 48% of patients had a formal delirium screen. Following this a network-wide event took place and the Delirium Standards for the Greater Manchester Critical Care Network were produced. Cycle 2: May 2016 quarterly audits across the network monitored compliance against the agreed standards. Group events involved implementation of a delirium care bundle, sharing best practice, educating staff and providing guidance on the management of delirium. Cycle 3: November 2016 quarterly audit continued and a regional delirium study day was rolled out across the region. Results We have 14 different units across our network, all of which have participated in the audit. The first audit showed a delirium point prevalence of 28%, subsequent point prevalence audits demonstrated rates as low as 13%. There has also been an improvement in the use of delirium screening tools. In the first audit 37% of patients had two delirium screens in 24 h, this has increased to 60% in the latest audit. Improvements were also made in availability of sensory aids and pain assessments. Conclusion The project has demonstrated the feasibility of delivering a coordinated delirium improvement project across multiple critical care units.

scholarly journals Promoting subglottic secretion drainage: a quality improvement project in a UK critical care unit

2021 ◽  
Vol 10 (2) ◽  
pp. e001269
Author(s):  
Nicholas Weston Smith ◽  
Michael Spivey
Keyword(s):  
Critical Care ◽  
Critical Care Unit ◽  
Critical Care Patient ◽  
Care Patient ◽  
Care Plan ◽  
Care Bundle ◽  
Improvement Project ◽  
Subglottic Secretion ◽  
Patient Database ◽  
Subglottic Secretion Drainage

The aim of the study was to promote the practice of subglottic secretion drainage (SSD) in a UK critical care unit. SSD is a technique employed to reduce microaspiration of oropharyngeal secretions in patients with cuffed endotracheal airways. Aspiration of oropharyngeal secretions is the accepted cause of the majority of ventilator-associated pneumonia (VAP), a complication of invasive ventilation with high associated mortality. The plan–do–study–act methodology was employed. The local critical care patient database was searched for patients requiring mechanical ventilation via a tracheostomy tube with subglottic port in the 3 months prior to intervention. Patient records were interrogated for evidence of the practice of SSD. The intervention involved the introduction of a tracheostomy care bundle to be prescribed on insertion of a tracheostomy on the critical care unit, in combination with departmental teaching. The bundle included prompts for nursing staff to practise regular SSD and to complete a tracheostomy care plan at the end of shift. A total of 24 patients were included. A review of practice was conducted every 3 months for 1 year. This showed an improvement in documented evidence of SSD from 0% of days at baseline to 85.7% of days at 1 year. Implementation of a tracheostomy order set prescribing regular SSD resulted in an improvement in the practice of SSD in patients ventilated via tracheostomy. This has implications for patient outcomes and healthcare costs, given that SSD has been shown to reduce incidence of VAP.

Orders Not to Resuscitate: The Sharon Siebert Case

1981 ◽  
Vol 2 (5) ◽  
pp. 3-7
Author(s):  
George J. Annas
Keyword(s):  
Do Not Resuscitate ◽  
Lower Court ◽  
Legal Standard ◽  
Dnr Orders

In a previous column I discussed the testimony of a number of nurses in the case of Ms. Sharon Siebert. That case was decided by a lower court on February 13, 1981, and this column discusses Judge Lindsay G. Arthur's opinion. Jane Hoyt, a friend, not a relative, of Ms. Siebert, brought suit to enjoin an order not to resuscitate that had been written on Ms. Siebert. The case raised a number of important issues, including whether the court would allow a suit brought by someone in Ms. Hoyt's position vis-à-vis the patient, and if it did, what legal standard the court might require in the writing of Do Not Resuscitate (DNR) orders.

Evaluation of the safety of inter-hospital transfers of critically ill patients led by advanced critical care practitioners

2021 ◽  
Vol 30 (8) ◽  
pp. 470-476
Author(s):  
Gavin Denton ◽  
Lindsay Green ◽  
Marion Palmer ◽  
Anita Jones ◽  
Sarah Quinton ◽  
...  
Keyword(s):  
Critical Care ◽  
Quality Improvement ◽  
Critically Ill ◽  
Process Of Care ◽  
Related Complication ◽  
Improvement Project ◽  
Hospital Transfer ◽  
The Uk ◽  
Critically Ill Adults ◽  
Ill Adults

Introduction: Ten thousand inter-hospital transfers of critically ill adults take place annually in the UK. Studies highlight deficiencies in experience and training of staff, equipment, stabilisation before departure, and logistical difficulties. This article is a quality improvement review of an advanced critical care practitioner (ACCP)-led inter-hospital transfer service. Methods: The tool Standards for Quality Improvement Reporting Excellence was used as the format for the review, combined with clinical audit of advanced critical care practitioner-led transfers over a period of more than 3 years. Results: The transfer service has operated for 8 years; ACCPs conducted 934 critical care transfers of mechanically ventilated patients, including 286 inter-hospital transfers, between January 2017 and September 2020. The acuity of transfer patients was high, 82.2% required support of more than one organ, 49% required more than 50% oxygen. Uneventful transfer occurred in 81.4% of cases; the most common patient-related complication being hypotension, logistical issues were responsible for half of the complications. Conclusion: This quality improvement project provides an example of safe and effective advanced practice in an area that is traditionally a medically led domain. ACCPs can provide an alternative process of care for critically ill adults who require external transfer, and a benchmark for audit and quality improvement.

scholarly journals ‘CPR for Feet’ care bundle to improve foot assessment in inpatient diabetes

2018 ◽  
Vol 7 (3) ◽  
pp. e000196 ◽  
Author(s):  
Rhea O’Regan ◽  
Ross MacDonald ◽  
James G Boyle ◽  
Katherine A Hughes ◽  
Joyce McKenzie
Keyword(s):  
Quality Improvement ◽  
Nursing Staff ◽  
Quality Improvement Project ◽  
Care Bundle ◽  
Staff Education ◽  
Pressure Relief ◽  
Improvement Project ◽  
The Third ◽  
Inpatient Diabetes ◽  
Pdsa Cycle

AimsThe Scottish Inpatient Diabetes Foot Audit conducted in 2013 revealed that 57% of inpatients had not had their feet checked on admission, 60% of those at risk did not have pressure relief in place and 2.4% developed a new foot lesion. In response, the Scottish Diabetes Foot Action Group launched the ‘CPR for Feet’ campaign. The aim of this project was to raise awareness of the ‘Check, Protect and Refer’ (CPR) campaign as well as improve the assessment and management of inpatients with diabetes.MethodsA quality improvement project underpinned by Plan-Do-Study-Act (PDSA) methodology was undertaken. The first and second cycles focused on staff education and the implementation of a ‘CPR for Feet’ assessment checklist using campaign guidelines, training manuals and modules. The third and fourth cycles focused on staff feedback and the implementation of a ‘CPR for Feet’ care bundle.ResultsBaseline measurements revealed 28% of patients had evidence of foot assessment. Medical and nursing staff reported to be largely unaware of the ‘CPR for Feet’ campaign (13%). Fifty-two per cent of inpatients with diabetes had their feet assessed and managed correctly following the second PDSA cycle. After completion of the third and fourth PDSA this number improved further to 72% and all staff reported to be aware of the campaign.ConclusionsThe introduction of a ‘CPR for Feet’ care bundle improved the assessment of inpatients with diabetes.

scholarly journals Importance of Individual Elements for Perineal Protection in Childbirth: An Interventional, Prospective Trial

2018 ◽  
Vol 08 (04) ◽  
pp. e289-e294 ◽  
Author(s):  
Ole Rasmussen ◽  
Annika Yding ◽  
Finn Lauszus ◽  
Charlotte Andersen ◽  
Jacob Anhøj ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Quality Improvement ◽  
Prospective Trial ◽  
Care Bundle ◽  
Number Needed To Treat ◽  
Improvement Project ◽  
Nulliparous Women ◽  
Hands On ◽  
Five Elements ◽  
The Individual

Objective To analyze the association between each element of a hands-on intervention in childbirth and the incidence of obstetric anal sphincter injuries (OASIS). Study Design We conducted a prospective, interventional quality improvement project and implemented a care bundle with five elements at an obstetric department in Denmark with 3,000 deliveries annually. We aimed at reducing the incidence of OASIS. In the preintervention period, 355 vaginally delivering nulliparous women were included. Similarly, 1,622 nulliparous women were included in the intervention period. The association of each element with the outcome was estimated using a regression analysis. Results The incidence of OASIS went down from 7.0 to 3.4% among nulliparous women delivering vaginally (p = 0.003; relative risk = 0.48; 95% confidence interval [CI]: 0.30–0.76). Number needed to treat was 28. Logistic regression analysis showed that using hand on the head of the child significantly reduced the risk of OASIS (odds ratio = 0.28; 95% CI: 0.14–0.58). Conclusion Using a quality improvement framework, we documented the individual elements of the intervention. Hand on the infant's head reduced the risk of OASIS.

National Guidelines for Statewide Implementation of EMS “Do Not Resuscitate” (DNR) Programs

1994 ◽  
Vol 9 (2) ◽  
pp. 137-139 ◽  
Author(s):  
◽  
Keyword(s):  
Home Health Care ◽  
Terminal Illness ◽  
Respiratory Arrest ◽  
Chronic Illnesses ◽  
Do Not Resuscitate ◽  
National Guidelines ◽  
Loved One ◽  
Statutory Authority ◽  
Attending Physicians ◽  
Dying Patient

With the growth of hospice and home health care, more patients with terminal illness are electing to avoid hospitalization until the final stages of illness. Many of these patients, as well as others with advanced chronic illnesses, have decided with the help and support of their attending physicians, that they do not wish to be resuscitated in the event of cardiac or respiratory arrest. However, as death draws near, well-meaning family or friends, or perhaps the patient, may call emergency medical services (EMS) personnel to transport the dying patient to the hospital; the prehospital providers who respond to these calls may be the last medical persons to attend terminally ill patients at home or in nursing homes. In many cases, these calls to EMS personnel are intended only to obtain transportation or comfort measures for the loved one. However, unless the state provides statutory authority for EMS personnel to honor a “do not resuscitate” (DNR) order, there may be a requirement for such personnel to attempt resuscitation, regardless of the patient's wishes and the physician's directive.

Do Not Resuscitate (DNR) Orders

2004 ◽  
pp. 149-153
Author(s):  
Ronald L. Eisenberg
Keyword(s):  
Do Not Resuscitate ◽  
Dnr Orders
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