Differences in mortality and causes of death between STEMI and NSTEMI in the early and late phases after acute myocardial infarction

Background The detailed causes of death in non–ST-segment–elevation myocardial infarction (NSTEMI) have not been adequately evaluated compared to those in ST-segment elevation myocardial infarction (STEMI). Methods The study population was 6,228 AMI patients who underwent percutaneous coronary intervention (STEMI: 4,625 patients and NSTEMI: 1,603 patients). The primary outcome was all-cause death. Results Within 6 months after AMI, the adjusted mortality risk was not significantly different between NSTEMI patients and STEMI patients (HR: 0.83, 95%CI: 0.67–1.03, P = 0.09). Regarding the causes of death within 6 months after AMI, mechanical complications more frequently occurred in STEMI patients than in NSTEMI patients, while proportions of post resuscitation status on arrival and heart failure were higher in in NSTEMI patients than in STEMI patients. Beyond 6 months after AMI, the adjusted mortality risk of NSTEMI relative to STEMI was not significantly different. (HR: 1.04, 95%CI: 0.90–1.20, P = 0.59). Regarding causes of death beyond 6 months after AMI, almost half of deaths were cardiovascular causes in both groups, and breakdown of causes of death was similar between NSTEMI and STEMI. Conclusion The mortality risk within and beyond 6 months after AMI were not significantly different between STEMI patients and NSTEMI patients after adjusting confounders. Deaths due to post resuscitation status and heart failure were more frequent in NSTEMI within 6 months after AMI.

1248 “Passing the Surgical Torch”- A Review of Appropriate Surgical Handover Protocol on The Acute Surgical Take

Aim Effective handover between shifts is vital to protect patient safety. The Royal College of Surgeons has detailed the necessary information needed for each patient at handover. We aimed to assess compliance with this handover protocol. Method Weekday surgical handover was reviewed over an 8-week period of time. Data was collected on documentation of diagnosis, up to investigations/bloods, clinical state of patient, management plan and resuscitation status/ceiling of care and COVID status. Results 210 patients were reviewed. Of these, a clear diagnosis was documented for 152 patients. Up to date imaging results if applicable was documented in 111 of 153 patients. Up to date bloods were included in 140 of 210 patients. COVID status was only noted in 31 of 210 patients and DNAR status in only 24. After re-audit of 197 a clear diagnosis was seen in 183 patients, COVID status was documented in 170 patients and DNAR status in 169. Conclusions Surgical handover is hugely crucial for provision of patient care. Following clear guidance from the royal college of surgeons, better compliance with handover was noted, including a critical improvement in COVID and DNAR status.

Patient Understanding Of Cardiopulmonary Resuscitation Status

BackgroundCardiopulmonary Resuscitation (CPR) or Code status discussion usually happen late in the hospital admission. Lack of clear communication, various level of training of providers and discrepancy in health literacy among patient act as barrier in proper understanding of code status understanding. In this study we utilized brief video and validated survey to determine if viewing a short, educational video could improve patient understanding of CPR and code status at Robert Packer Hospital.MethodThis study was conducted as single center randomized study at Guthrie Robert Packer Hospital. Total number of participants was 150. Participants were randomly assigned (1:1) to Intervention group where they viewed brief educational video. The primary end point was the composite score ranging from 0 to 15 generated based on correct responses to the questionnaire (supplemental file). ResultThere was statistically significant high understanding of code status among intervention group with mean composite score of 8.6 with a significant difference between the video group (10.3) and control group (6.9) with a p-value < 0.001. The multivariate linear model had a significant F-statistic with a p-value of < 0.001. We found age and randomization group significantly changes the composite scores. On average, the composite score of the intervention group was 3.36 points higher than the control group with 95% confidence interval of 2.36 – 4.35, p<0.001, when adjusted for age and gender of the patient.ConclusionUnderstanding of cardiopulmonary resuscitation status holds important place in guiding management of a patient. Use of short video explaining CPR and code status was found to be effective in improving patient understanding of these issues. It has the potential to save time and improve patient’s understanding if incorporated into code status discussions with hospitalized patients.

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.

80 Improving Documentation of DNAR Decisions on the Acute Medical Take

Introduction The BMA, Resuscitation Council and Royal College of Nursing have set out clear guidelines on documentation of Resuscitation discussions and decisions.1 On the acute medical take documentation of these discussions and decisions can be unclear despite use of an electronic patient record (EPR). The aim of this audit was to improve documentation of Do Not Attempt Resuscitation (DNAR) decisions in EPR. Methods We listed patients admitted on the medical take over 1-week, looking at resuscitation status and the documentation of the DNAR decision. We then implemented a change to the format of the EPR treatment escalation plan (TEP) form. Prior to the change the DNAR form was behind the TEP form which had to be clicked on separately and was not mandatory to complete. After the intervention the DNAR decision was placed in a box on the front page of the TEP form to ensure that it was clear and accessible. Results Pre-intervention we reviewed 114 patients notes of which 94 were DNAR. Of these 94 only 17 (18%) had correctly documented DNAR decisions in EPR. Following the intervention we again looked at all admissions to the medical take over a 1-week period, out of 151 patients 75 were DNAR and of these 75 patients 29 had correctly documented DNAR forms. This shows an increase in the percentage of the DNAR decisions filled in from 18% to 39%. Conclusion The results show that although there has been an improvement in the number of DNAR decisions being documented there are still a large percentage of patients who do not have this correctly documented. We are designing further interventions to ensure that the DNAR documentation is marked as a mandatory part of the TEP form as well as educating around the importance of this documentation.

Exploring the Expanded Role of Pharmacists in Advance Care Planning

PURPOSE: Advance care planning (ACP) is a clinical skill that can be taught. An opportunity exists to teach how to conduct ACP to clinicians not typically engaged in these conversations to increase the likelihood that patients and caregivers engage in ACP. We conducted a prospective study exploring the feasibility of a pharmacist-led ACP intervention. METHODS: We completed a prospective, single-center study from July 2015 to July 2017. We included patients of age ≥ 18 years with incurable cancer referred to the palliative care clinic. A trained pharmacist led an ACP discussion with the patient and selected proxy. We defined feasibility as completion of ≥ 30 pharmacist-led ACP discussions over the study period. Additionally, we defined an informed healthcare proxy as someone who understood three key end-of-life (EOL) treatment preferences: the patient's personal definition of quality of life, desired resuscitation status, and preferred location of death (in or out of the hospital). Patients were followed until the end of the study or death. For those patients who died, the pharmacist contacted the proxy for follow-up and explored satisfaction with the ACP intervention. RESULTS: Thirty-four patients completed the study. All selected proxies completed the intervention and were able to understand the three EOL preferences. At the time of the patient’s death (n = 20), proxies reported that 66.6% received their preferred resuscitation status and 72.2% died in their preferred location. Proxy satisfaction with the ACP process was 7.6 ± 2.5 (mean ± SD) on a 11-point Likert scale. CONCLUSION: These findings indicate the potential for pharmacists to lead and engage in ACP in the outpatient setting.