Four consecutive yearly point-prevalence studies in Wales indicate lack of improvement in sepsis care on the wards

The ‘Sepsis Six’ bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016–2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full ‘Sepsis Six’ care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the ‘Sepsis Six’ bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1–26.9) with no difference between each year of study. 90-day survival for years 2017–2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice.Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.

Resuscitation orders in the perioperative setting: A survey of knowledge, practices and perceptions among consultant and trainee anaesthesiologists

Background As advance healthcare directives gain clarity in state legislation in Ireland, anaesthesiologists will come across patients with resuscitation orders that will demand interpretation when encountered perioperatively. Studies show variable perceptions among anaesthesiologists towards the binding nature of resuscitation orders in the context of anaesthesia provision. Currently, knowledge, perceptions and practices of anaesthesiologists in Ireland towards such orders are not known. Methods A cross-sectional online survey was distributed to anaesthesiologists in adult teaching hospitals. Results In this cohort, 65.9% of those surveyed did not know if there was a local hospital policy advance healthcare directive containing, do not attempt resuscitation, decisions in the perioperative period in their current hospital; 57.7% did not know if there was a policy for not for resuscitation orders; 74.8% did not know if there are guidelines for the management of patients with resuscitation orders. Irrespective of the presence of an order stating otherwise, 43.9% would initiate resuscitation in the event of any arrest occurring in theatre, with 66.7% initiating resuscitation if secondary to iatrogenesis. Conclusions By uncovering low self-perceived levels of knowledge and mixed perceptions towards resuscitation orders, the authors hope that the study initiates much-needed conversations on the topic, particularly at a time when advance healthcare directives find a more firm legal footing in Ireland.

484 CHANGING PRACTICES OF DECISION MAKING REGARDING DO-NOT-ATTEMPT-CARDIOPULMONARY-RESUSCITATION ORDERS AMID THE COVID-19 PANDEMIC

Introduction The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation into focus. This study aims to analyse Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic. Methods This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st to May 31 s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period. Pre-COVID-19 pandemic DNACPR documentation rates were also examined. Factors associated with DNACPR order instatement during the first wave of the COVID-19 pandemic were identified. Results Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. 50% of DNAR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of 131 patients aged 65 years or over within the cohort admitted with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 patients ≥65 without COVID-19 (p &lt; 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (p &lt; 0.0001). Independent associations with DNACPR order documentation included increasing age (Odds Ratio [O.R.] 1.12; 95% CI 1.05-1.21); nursing home resident status (O.R. 3.57; 95% CI 1.02-12.50); frailty (O.R. 3.34; 95% CI 1.16-9.61) and chronic renal impairment (O.R. 5.49; 1.34-22.47). The case-fatality-rate of older patients with COVID-19 was 29.8% versus 5.4% without COVID-19. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived. Conclusion The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain clinical practice despite the pandemic.

To resuscitate or not to resuscitate; a question for old age psychiatrists

AimsThe inpatient population of an older adult psychiatric ward will include people with physical and mental health conditions which affect life span and quality of life. Patients may be frail, acutely unwell, or have terminal illnesses such as dementia. It is therefore essential that clinicians review resuscitation status as part of their routine practice. However, we are aware that advanced decision-making – to resuscitate or not to resuscitate – is not routine practice across older adult psychiatric wards in the UK. Our 2017 audit reflected this, demonstrating a very low rate of resuscitation decisions at NELFT.This re-audit aimed to measure the frequency and quality of resuscitation decisions on an older adult psychiatric ward. We expected improvements in these areas, subsequent to changes implemented from the initial audit. We also sought to identify which patient factors influenced clinicians’ decision-making on resuscitation.Please note, this audit was completed prior to the COVID-19 pandemic.MethodIn June 2017, an audit of 25 patients admitted to two older adult psychiatric acute wards was completed. In December 2019, a retrospective analysis of the last 25 admissions to one older adult ward was undertaken. Electronic patient notes and DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) orders were examined. The audit measured frequency of resuscitation decisions and quality of documentation against current standards. DNACPR orders were analysed and clinicians were interviewed to identify the reasons for such decisions.ResultThere was an increase in the number of patients for which resuscitation decisions were made, from 4% in 2017 to 40% (n = 10) in 2019. The majority of patients with a DNACPR decision (n = 8) had a diagnosis of dementia. Prospective quality of life, with this diagnosis, was the most frequent determinant of DNACPR decisions (n = 7). Qualitative analysis indicated that clinicians were more likely to consider a resuscitation decision for patients with an organic disorder rather than functional disorder.Adequate completion of DNACPR orders was seen in each case. Either the patient, a family member or carer was involved in every decision. The standard for recording decisions on the electronic patient record was not met.ConclusionIt is good practice to consider resuscitation decisions for patients admitted to older adult psychiatric wards. This re-audit found an improvement in frequency of resuscitation decisions and also revealed differences in decision-making for patients with organic and functional disorders. Implementation of further change is indicated; decision-making can be improved through reflection, teaching, changes to practice, and technologies.

Early resuscitation orders in hospitalized oldest-old with COVID-19: A multicenter cohort study

Background: In particular older people are at risk of mortality due to corona virus disease 2019 (COVID-19). Advance care planning is essential to assist patient autonomy and prevent non-beneficial medical interventions. Aim: To describe early (taken within 72 h after hospital admission) resuscitation orders in oldest-old hospitalized with COVID-19. Setting/participants: A cohort of patients aged 80 years and older admitted to the acute hospital in March and April 2020 with COVID-19 were retrospectively recruited from 10 acute hospitals in Belgium. Recruitment was done through a network of geriatricians. Results: Overall, 766 octogenarians were admitted of whom 49 were excluded because no therapeutic relationship with the geriatrician and six because of incomplete case report form. Early decisions not to consider intensive care admission were taken in 474/711 (66.7%) patients. This subgroup was characterized by significantly higher age, higher number of comorbidities and higher frailty level. There was a significant association between the degree of the treatment limitation and the degree of premorbid frailty ( p < 0.001). Overall in-hospital mortality was 41.6% in patients with an early decision not to consider intensive care admission (67.1% in persons who developed respiratory failure vs 16.7% in patients without respiratory failure ( p < 0.001)). Of 104 patients without early decision not to consider intensive care admission but who developed respiratory failure, 59 were eventually not transferred to intensive care unit with in-hospital mortality of 25.4%; 45 were transferred to the intensive care unit with mortality of 64.4%. Conclusions: Geriatricians applied all levels of treatment in oldest-old hospitalized with COVID-19. Early decisions not to consider intensive care admission were taken in two thirds of the cohort of whom more than 50% survived to hospital discharge by means of conservative treatment.

Lack of improvement in sepsis care on the wards: results of four consecutive yearly point-prevalence studies in Wales

Background: The ‘Sepsis Six’ bundle was promoted as a more deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Methods: Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-hour point prevalence studies, carried out in fourteen hospitals across Wales from 2016-2019. Results: Out of the 26,947 patients screened 1,651 fulfilled inclusion criteria and were recruited. The full ‘Sepsis Six’ care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the ‘Sepsis Six’ bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p<0.0001)Overall, 1349 patients (81.2%) survived to 30 days with a mean survival time of 26.5 days (95% CI 26.1-26.9) with no difference between each year of study. 90-day survival for years 2017 – 2019 was 74.7%, with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Conclusions: Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice.Trial registration: Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016

Do-not-attempt-resuscitation orders: attitudes, perceptions and practices of Swedish physicians and nurses

Background The values and attitudes of healthcare professionals influence their handling of ‘do-not-attempt-resuscitation’ (DNAR) orders. The aim of this study was a) to describe attitudes, perceptions and practices among Swedish physicians and nurses towards discussing cardiopulmonary resuscitation and DNAR orders with patients and their relatives, and b) to investigate if the physicians and nurses were familiar with the national ethical guidelines for cardiopulmonary resuscitation. Methods This was a retrospective observational study based on a questionnaire and was conducted at 19 wards in two regional hospitals and one county hospital. Results 210 physicians and 312 nurses (n = 522) responded to the questionnaire. Every third (35%) professional had read the guidelines with a lower proportion of physicians (29%) compared to nurses (38%). Around 40% of patients had the opportunity or ability to participate in the DNAR discussion. The DNAR decision was discussed with 38% of patients and the prognosis with 46%. Of the patients who were considered to have the ability to participate in the discussion, 79% did so. The majority (81%) of physicians and nurses believed that patients should always be asked about their preferences before a DNAR decision was made. Conclusions Swedish healthcare professionals take a patient’s autonomy into account regarding DNAR decisions. Nevertheless, as 50% of patients were considered unable to participate in the DNAR discussion, questions remain about the timing of patient participation and whether more discussions could have been conducted earlier. Given the uncertainty about timing, the majority of patients deemed competent participated in DNAR discussions.

The Last Gift: Advanced Healthcare Directives and the Family Members of Incapacitated Patients

This article will provide an overview of the law related to the withdrawal of treatment from incapacitated adult patients in Ireland and the role of family members in such decisions. This overview will touch on the best interests test, how the wishes of an incapacitated patient may be assessed, and the tension that may arise between medical assessments and the views of the family of the patient. Cases arising in the UK and the USA will be discussed where relevant. It will be argued that family members should be provided with more information, particularly with respect to Do Not Attempt Resuscitation orders. The article calls for greater discussion about death and dying, and greater use of advance healthcare directives.