CODE: a practical framework for advancing patient-centred code status discussions

Preoperative Code Status Discussion Workflows: Targets for Improvement in Multidisciplinary Pathways

CONTEXT

Discussion of perioperative code status is an important element of preoperative care and a component of the American College of Surgeons' Geriatric Surgery Verification (GSV) program. Evidence suggests code status discussions (CSDs) are not routinely performed and are inconsistently documented.

OBJECTIVES

Because preoperative decision making is a complex process spanning multiple providers, this study aims to utilize process mapping to highlight challenges associated with CSDs and inform efforts to improve workflows and implement elements of the GSV program.

METHODS

Using process mapping, we detailed workflows relating to (CSDs) for patients undergoing thoracic surgery and a possible workflow for implementing GSV standards for goals and decision-making.

RESULTS

We generated process maps for outpatient and day-of-surgery workflows relating to CSDs. In addition, we generated a process map for a potential workflow to address limitations and integrate GSV Standards for Goals and Decision Making.

CONCLUSION

Process mapping highlighted challenges associated with the implementation of multidisciplinary care pathways and indicated a need for centralization and consolidation of perioperative code status documentation.

Improving Code Status Documentation Rates Using Communication Skills Training in Vascular Surgery: A Quality Improvement Initiative

Introduction: Code status discussions are poorly understood by patients and variably performed by admitting providers, yet they are used as a quality metric. Surgical specialties, such as Vascular Surgery, admit patients with urgent and life-threatening illness. Surgical trainees are less likely to receive communication skills interventions when compared with nonsurgical specialties. Without a documented code status, nurses and physicians lack guidance on patient preference in the case of cardiopulmonary arrest and may deliver unwanted measures, which may also result in poor outcomes. Methods: We conducted a before-after Plan-Do-Study-Act quality improvement project between May 2018 and May 2019. A needs assessment included baseline code status documentation rates for the Vascular Surgery department admissions. A communication skills training (CST) and documentation intervention was provided to all Vascular Surgery trainees and advance practice providers (APPs). Departmental e-mails were sent over the 12-month intervention period, which demonstrated the code status documentation rates and served as reminders to document code status. Results: A total of 29 vascular surgery trainees and APPs received the intervention. At completion of the intervention, learners reported increased comfort initiating a code status discussion, making a recommendation for cardiopulmonary resuscitation (CPR) status, and having a strategy to discuss code status. A total of 2762 patient admissions were reviewed, with 1562 patient admissions occurring during the 12-month intervention period. The average code status documentation rate for the three months before the intervention was 7.8%. At the end of the 12-month intervention, documentation rates were 44.9% and 6 months after completion of the study period, average rates remained 45.2%. There was no change in admission rates during the study period. Discussion: CST and regular reminders increased vascular surgery residents' and APPs' comfort in engaging in code status discussions. After intervention, documentation of code status discussions increased with persistence up to six months after the intervention.

Perioperative Code Status Discussions: How Are We Doing?

Approximately 15% of patients with a code status of do-not-resuscitate (DNR) or do-not-intubate (DNI) present for surgery. Despite professional guidelines requiring discussions with patients regarding perioperative resuscitation, it is unclear whether these recommendations are consistently followed. Our review of 158 patient encounters with established DNR/DNI code status found that code status discussions (CSDs) were documented only 70% of the time, and code status orders were inconsistently entered to reflect those discussions. We present solutions to improve CSD documentation, including refining perioperative workflows, simplifying code status choices, optimizing electronic health record order entry, and a supplementary consent form to facilitate code status review.