Impact of Combining a Code Status Order with Admission Orders for Patients Admitted Through the Emergency Department. (TH341D)

Abstract

•Describe the impact of requiring Emergency Medicine physicians to place a code status order at the time of admission.•Appraise the ability of emergency physicians to identify patients who would select a do not resuscitate code status.•Assess whether adding a mandatory code status order for Emergency Department admissions could benefit your health care system's rates of code status definition at the time of admission. Some have argued that Emergency Physicians (EPs) lack the time, skills, and rapport to effectively engage patients in code status (CS) discussions. And some have claimed that EPs default to full treatment regardless of patient preference. However, identifying patients' code status preference prior to admission can expedite the alignment of treatment with patients' goals of care. In April 2017 we added a mandatory code status order (CSO) for all admissions requested by EPs. To assess EPs' ability to identify patients with “do not resuscitate” (DNR) preferences and to measure the impact of adding a mandatory CSO on the rate of defining CS prior to hospital admission. We identified 17,884 patients admitted through our ED during two study periods: Sep 2017-Mar 2018 (n=8850) and May 2018-Nov 2018 (n=9034). The first CSO identified in the ED and inpatient setting were classified as missing, full code, other code, or DNR. Differences between cohorts were measured through chi-squared tests. We evaluated the relative risk (RR, 95% CI) of identifying DNR preference in the ED between the time periods. There were no significant differences in age, gender, ethnicity, religion, acuity, and in-hospital mortality between cohorts. Compared to the pre-intervention period, defining CS at the time of admission increased from 1.3% to 96.8% (p <0.001), identifying DNR preference prior to admission increased from 0.4% to 4.8% (p <0.001), overall rate of DNR orders in the inpatient setting was unchanged (8.9% pre, 8.8% post, p=0.787). After our intervention DNR preference was 12.8 times more likely to be identified prior to hospital admission (95% CI = 5.3-31.0). These data suggest that adding a code status order to Emergency Department admission requests can substantially increase the rate of code status definition on admission without diminishing the overall proportion of admitted patients electing to be DNR.