Resuscitation Status Research Articles

A Day in the Life: Recording of resuscitation status among elderly in-patients at a major rural referral hospital

A Day in the Life: Recording of resuscitation status among elderly in-patients at a major rural referral hospital

Frailty is associated with adverse outcome from in-hospital cardiopulmonary resuscitation

AimTo assess whether frailty was associated with cardio-pulmonary resuscitation (CPR) outcome in a UK setting. MethodRetrospective review of prospectively collected data on in-hospital cardio-respiratory arrests between 1/1/17 and 31/12/17. Clinical Frailty Scale (CFS) scores were assigned from notes review, patients with CFS scores ≥6 signified moderate or greater frailty. ResultsThere were 179 in-hospital cardiac arrest cases where the CFS could be calculated. The median age on admission was 74 (mean 71, range 27–102), 110 patients were male and 69 female. The initial rhythm was non-shockable in 64% of cases. In 49% of cases return of spontaneous circulation (ROSC) was achieved, 22% of the study population survived to hospital discharge. Moderate or greater frailty was present in 31.3% of patients.Return of spontaneous circulation (ROSC) was achieved in 56.1% of patients with a CFS score of 1–5 and 32.1% with scores 6–9 (p < 0.001).Survival to hospital discharge was also associated with frailty, being seen in 31.7% of CFS 1–5 patients but only in 1.8% of CFS 6–9 patients (p < 0.001). In multivariable analysis adjusting for age, presenting rhythm and admitting specialty the effect of frailty on survival to discharge remained significant (p = 0.044). ConclusionPatients with moderate or greater frailty as determined by CFS score are unlikely to survive to hospital discharge even if ROSC occurs following CPR. This should be considered when making resuscitation status and ceiling of care decisions in this patient group.

Standardization of Inpatient CPR Status Discussions and Documentation Within the Division of Hematology-Oncology at UPMC Shadyside: Results From PDSA Cycles 1 and 2.

In December 2016, 49% of patients admitted to inpatient oncology services at University of Pittsburgh Medical Center Shadyside Hospital had cardiopulmonary resuscitation (CPR) status discussion documentation before discharge. The aim of this project was to improve the rate of CPR status conversations. During Plan-Do-Study-Act (PDSA) cycle 1, a stakeholder workgroup was formed in January 2017 by oncology faculty, fellows, nurses, advance practice providers (APPs), medicine housestaff, and palliative care faculty. All oncology clinicians and inpatient team members were reminded weekly to discuss and document CPR status preferences. APPs received training on efficient and effective CPR status assessment from palliative care faculty. Oncology leadership received monthly e-mail updates of CPR status documentation rates and endorsed CPR status best practice guidelines. For PDSA cycle 2, patient charts without CPR status documentation in March 2018 were reviewed, and themes were shared with oncology leadership and reviewed with APPs. After PDSA cycle 1, CPR status assessment rates increased from 49% to greater than 80%. In 2017, more than 1,500 more CPR status discussions were documented than in 2016. The percentage of patients discharged with "comfort measures only" or "do not resuscitate" orders increased from 14.2% (95% CI, 9.5% to 19.0%) to 19.8% (95% CI, 15.6% to 24.0%). For PDSA cycle 2, charts of 60 patients without CPR assessment were reviewed. Of these, 52% were admitted overnight by nocturnists and 48% by daytime APPs. Fifty-five percent of patients (n = 33 of 60) had metastatic disease. CPR status was documented on previous admissions for 53% of patients (n = 31 of 60) in the past 12 months. Fifteen percent (n = 11 of 60) were admitted for scheduled inpatient chemotherapy. A multipronged approach significantly increased CPR status assessments. More patients transitioned to comfort measures only or do not resuscitate when their preferences were clearly assessed and documented.

Practices and opinions of specialized palliative care physicians regarding early palliative care in oncology.

To describe the practices and opinions of specialized palliative care (SPC) physicians regarding early palliative care for patients with cancer, determine characteristics associated with receiving early referrals; and solicit opinions regarding renaming the specialty "supportive care." The survey was distributed by mail and e-mail to physicians who had previously self-identified as providing palliative care. SPC physicians were defined as receiving palliative care referrals from other physicians and not providing palliative care only for their own patients. The response rate was 71% (531/746), of whom 257 (48.4%) practiced SPC. Of these SPC physicians, 84% provided mainly cancer care; > 90% supported early palliative care referral in oncology and had referral criteria facilitating this, but only 20% received early referrals (> 6-month prognosis). There was ambivalence regarding caring for patients with full resuscitation status and responsibility for managing cancer treatment-related complications. SPC physicians receiving early referrals were more likely to be female (p = 0.02) and have a postgraduate degree (p = 0.02), and less likely to provide mainly cancer care (p = 0.03) and to agree that patients should stop chemotherapy before referral (p = 0.009). Although 60% agreed that patients perceive the term "palliative care" negatively and 39% believed a name change to supportive care would encourage early referral, only 21% supported renaming the specialty. Although most SPC physicians supported early palliative care in oncology, the timing of referrals was often late, and was associated with characteristics of SPC physicians. Few SPC physicians supported renaming palliative care.

Frequency of Ethical Issues on a Hospitalist Teaching Service at an Urban, Tertiary Care Center.

Little is known about the daily ethical conflicts encountered by hospitalists that do not prompt a formal clinical ethics consultation. We describe the frequencies of ethical issues identified during daily rounds on hospitalist teaching services at a metropolitan, tertiary-care, teaching hospital. Data were collected from September 2017 through May 2018 by two attending hospitalists from the ethics committee who were embedded on rounds. A total of 270 patients were evaluated and 113 ethical issues were identified in 77 of those patients. These issues most frequently involved discussions about goals of care, treatment refusals, decision-making capacity, discharge planning, cardiopulmonary resuscitation status, and pain management. Only five formal consults were brought to the Hospital Ethics Committee for these 270 patients. Our data are the first prospective description of ethical issues arising on academic hospitalist teaching services and are an important step in the development of a targeted ethics curriculum for hospitalists.

QIM19-127: Novel Admission Checklist for Malignant Bowel Obstruction

Background: Malignant bowel obstruction (MBO) is a frequent presentation of advanced abdominal malignancy. Despite the frequency of MBO and the availability of NCCN Guidelines for its management, clinicians struggle to create a personalized care plan accounting for a patient’s current condition, prognosis, and goals of care. The aim of this project is to develop a discussion tool to implement on admission to ensure realistic prognostication and appropriate involvement of the patient, caregivers, and multidisciplinary team in treatment decisions. Methods: At our tertiary care center, a multidisciplinary team composed of surgical oncologists, medical oncologists, palliative care specialists, hospitalists, social workers, and nutritionists developed an algorithm to implement when a patient is admitted with MBO. The algorithm was influenced by the NCCN Guidelines for palliative care but was designed as a single-page checklist that could be easily executed by all team members. Results: The MBO admission checklist is divided into 4 sections. The general assessment section includes information about the etiology, severity, and reversibility of the current and past MBO. Also, the patient’s resuscitation and functional status are reviewed. The cancer care coordination/communication section covers the patient’s oncological history and estimated lifespan, as well as the need for further coordination of care and a goals of care discussion. The subsequent portion covers the management plan, with specific decisions resulting from a goals of care discussion as well as the need for specialized consults. The medical, procedural, and operative interventions the team and patient discussed as options are also documented. A key portion is the risks and benefits discussion for each treatment modality. Lastly, the discussion about future considerations section explores the patient’s wishes for the next episode of MBO. Conclusions: The goal of this checklist is to ensure that a comprehensive discussion is held between the different services involved in a patient’s care at every admission for MBO in order to provide a personalized management plan and improve communication. The next step in our study is to assess the effectiveness of implementation of the checklist as well as its impact on patient satisfaction, quality of life, early hospice referral, and outcomes.

A hundred heart failure deaths: lessons learnt from the Dr Foster heart failure hospital mortality alert

BackgroundDespite advances in evidence-based pharmacotherapy, the latest National Heart Failure Audit (NHFA) has shown that in-hospital mortality of heart failure (HF) remains high with large interhospital variations. University Hospitals Coventry...

A quality improvement project to improve the documentation of resuscitation and ceiling of care decisions in elderly patients at a large district general hospital

All elderly patients seen on post-take ward rounds should be assessed by the Gold Standards Framework (GSF), with resuscitation status and ceiling of care discussed and documented accordingly in the medical notes and discharge letters. We opportunistically reviewed the medical notes and discharge letters of all patients aged over 75 years immediately prior to discharge. We conducted three cycles of data collection, each lasting 1 week in duration, from November 2017 to January 2018. Data was recorded into an anonymised Excel template. We determined a pre-intervention …

Venous Physiology Predicts Dehydration in the Pediatric Population

BackgroundNo standard dehydration monitor exists for children. This study attempts to determine the utility of Fast Fourier Transform (FFT) of a peripheral venous pressure (PVP) waveform to predict dehydration. Materials and methodsPVP waveforms were collected from 18 patients. Groups were defined as resuscitated (serum chloride ≥ 100 mmol/L) and hypovolemic (serum chloride < 100 mmol/L). Data were collected on emergency department admission and after a 20 cc/kg fluid bolus. The MATLAB (MathWorks) software analyzed nonoverlapping 10-s window signals; 2.4 Hz (144 bps) was the most demonstrative frequency to compare the PVP signal power (mmHg). ResultsAdmission FFTs were compared between 10 (56%) resuscitated and 8 (44%) hypovolemic patients. The PVP signal power was higher in resuscitated patients (median 0.174 mmHg, IQR: 0.079-0.374 mmHg) than in hypovolemic patients (median 0.026 mmHg, IQR: 0.001-0.057 mmHg), (P < 0.001). Fourteen patients received a bolus regardless of laboratory values: 6 (43%) resuscitated and 8 (57%) hypovolemic. In resuscitated patients, the signal power did not change significantly after the fluid bolus (median 0.142 mmHg, IQR: 0.032-0.383 mmHg) (P = 0.019), whereas significantly increased signal power (median 0.0474 mmHg, IQR: 0.019-0.110 mmHg) was observed in the hypovolemic patients after a fluid bolus at 2.4 Hz (P < 0.001). The algorithm predicted dehydration for window-level analysis (sensitivity 97.95%, specificity 93.07%). The algorithm predicted dehydration for patient-level analysis (sensitivity 100%, specificity 100%). ConclusionsFFT of PVP waveforms can predict dehydration in hypertrophic pyloric stenosis. Further work is needed to determine the utility of PVP analysis to guide fluid resuscitation status in other pediatric populations.

Abstract TP507: Sex-Related Differences in Neonatal Stroke: International Maternal Newborn Stroke Registry

Background: There is evidence that male neonates have higher incidences of ischemic stroke and associated limitations in brain repair compared to female neonates. We used data from the International Maternal Newborn Stroke Registry (IMNSR) to further explore neonatal sex differences in demographics, birth characteristics, stroke onset, and maternal factors. Methods: Eleven international sites participated; 8 entered data for this analysis. Eligible participants with newborn (28 weeks gestation to 28 postnatal days) ischemic or hemorrhagic stroke or cerebral venous thrombosis were identified prospectively and retrospectively and enrolled. Preterm infants born before 28 weeks and neonates with germinal matrix intraventricular hemorrhage were excluded. We collected APGAR scores at 1 and 5 minutes, resuscitation status, demographics, stroke type, maternal and gestational age at birth, and mother’s health conditions at birth. Descriptive statistics were performed to identify differences in female versus male neonate cases related to demographics, pregnancy-related factors, and birth-related factors. Results: We analyzed 68 cases, 38 males and 30 females. Median maternal age for all cases was 31 y (IQR 29-34). Compared to females, males were more likely to have a lower APGAR 1 score and receive resuscitation, and more likely to have a stroke onset within the first week of life. This data set did not show significant gender-related differences in stroke type, or maternal health concerns during pregnancy (Table). Conclusions: We found that males with newborn strokes had more complications at birth and were more likely to have strokes present in the first week of life than females. Further research on the reasons for these sex differences is needed.

Access to Pediatric Palliative Care in the Neonatal Intensive Care Unit by Minorities and Rural-Dwellers in the Deep South: Patterns of Care from 2009-2017 (S816)

1.Describe patterns of pediatric palliative care and care disparities in neonatal intensive care unit (NICU) patients and families hospitalized in the Deep South (Alabama, Louisiana, and Mississippi).2.Describe implications for practice related to current trends of pediatric palliative care use in the NICU and implications for future research. Pediatric mortality is the highest in the first year of life. In 2013, 23,446 infants died in the U.S. Access to timely pediatric palliative care (PPC) services are limited for seriously ill infants and their families in the U. S. Deep South. Patterns of PPC in the neonatal intensive care unit (NICU) and the extent of PPC disparities in the Deep South are unknown. Examine racial and geographical differences in pediatric palliative care (PPC) consultation for seriously ill infants in the neonatal intensive care unit. This was a retrospective medical record review of infant decedents who received PPC while hospitalized in a level III NICU at an academic children’s hospital in Alabama from 2009-2017. Demographic characteristics, timing of palliative care consultation, hospice enrollment, final resuscitation status, circumstances at time of death, and interventions received in the last 48 hours of life. Data were analyzed in SPSS using descriptive statistics and t-tests. The percentage of infants receiving PPC in the NICU increased over time from 7% in 2009 to 38% in 2017. Infant decedents (N=140) who received PPC in the NICU were mostly Caucasian (58%) and African American (39%), receiving Medicaid (84%), and had genetic (53%) and prematurity (34%) diagnoses. There were no statistically significant differences between racial or urban versus rural groups in the timing of PPC consultation during the NICU admission. Infants who lived over 1 hour away received PPC significantly later than infants living less than 1 hour away from the NICU (p= 0.03). There were no racial or rurality differences in PPC timing during hospitalization; however, traveling over an hour to the hospital was associated with a delay in receiving PPC.

Timing of emergency interhospital transfers from subacute to acute care and patient outcomes: A prospective cohort study

BackgroundAustralian and international data show that transfer from inpatient rehabilitation to acute care hospitals occurs in one in ten patients. Early unplanned transfers from subacute to acute care hospitals raises questions about the safety of patient transitions between health sectors. ObjectivesTo explore the characteristics of early and late emergency interhospital transfers from subacute to acute care. The investigators defined early transfers as occurring within 1 day and late transfers occurring after 1 day after subacute care admission. DesignThis prospective, exploratory cohort study is a subanalysis of data from a larger case-time-control study. SettingTwenty-two wards of eight subacute care hospitals in five major health services in Victoria, Australia. All subacute care hospitals were geographically separate from their health services’ acute care hospitals. ParticipantsAll patients with an emergency transfer from inpatient rehabilitation or geriatric evaluation and management wards to an acute care hospital within the same health service were included. Patients receiving palliative care were excluded. MethodsData were collected between 22 August 2015 and 30 October 2016 by record audit. To compare patient and admission characteristics between early and late transfers Cochran-Mantel-Haenszel test (CMH) or logistic regression were used to account for health service clustering effect. ResultsThere were 602 transfers: 54 early (48 patients) and 548 late transfers (505 patients). There was no difference in median age (79.5 vs 80, p = 0.680) or Charlson Comorbidity index (both groups = 3, p = 0.933). Early transfer patients had lower functional independence measure scores on subacute care admission (median 45 vs 66, p < 0.001). Prior to transfer, fewer early transfers had a limitation of medical treatment order in place during their subacute care admission (25.9% vs 48.7%, p < 0.001). The majority of both early and late transfers resulted in acute care hospital readmission (85.1% vs 77.7%, p = 0.204). For patients admitted to acute care, there was no difference in median acute care length of stay (6.5 vs 8 days, p = 0.367). Early transfer patients had fewer in-hospital deaths than late transfer patients (3.8% vs 16.1%, p = 0.004). ConclusionsThe high rates of acute care readmission in both groups suggest that transfer was warranted. Early transfer patients had lower in-patient mortality so emergency interhospital transfers, while resource intensive, appear to have a safety benefit. Early transfer patients were less likely than late transfer patients to have limitation of medical treatment orders, so the influence of resuscitation status and patient goals of care on transfer decisions warrants further investigation.

Assessment of cardiopulmonary resuscitation knowledge and skills among healthcare providers at an urban tertiary referral hospital in Tanzania

BackgroundEarly and effective CPR increases both survival rate and post-arrest quality of life. In limited resource countries like Tanzania, there is scarce data describing the basic knowledge of CPR among Healthcare providers (HCP). This study aimed to determine the current level of knowledge on, and ability to perform, CPR among HCP at Muhimbili National Hospital (MNH).MethodsThis was a descriptive cross sectional study of a random sample of 350 HCP from all cadres and departments at MNH from October 2015 to March 2016. Each participant completed a with 25 question multiple choice and fill-in-the-blank CPR test and a practical test using a CPR manikin where the participant was videotaped for 1–2 min. Two expert observers independently viewed the videos and rated participant performance on a structured data form. The primary outcome of interest was staff member overall performance on the written and practical CPR testing.ResultsWe enrolled 350 HCPs from all 12 MNH clinical departments. The median participant age was 35 (IQR 29–43) years, 225 (64%) were female and 138 (39%) had clinical experience of less than 5 years. Only 57 (16%) and 88 (25%) scored above 50% in written and practical tests, respectively according to local minimum passing test score and 13(4%) and 30 (9%) scored above 75% in written and practical tests, respectively according to international minimum passing test score on CPR. The 233(67%) HCP who reported prior experience performing CPR on an adult patient scored higher on testing than those without; 40% (IQR 28–54) versus 26% (IQR 16–42) respectively, but both groups had median scores <50%.ConclusionThe level of CPR knowledge and skills displayed by all cadres and in all departments was poor despite the fact that most providers reported having performed CPR in the past. Since MNH is a tertiary referral hospital, it may reflect the performance of resuscitation status of other local health centers in Tanzania and other low-income countries to employ a formal system of training every HCP in CPR. Staff should be certified and assessed regularly to ensure retention of resuscitation knowledge and skills.

Impact of Timing and Location of Goals of Care Discussions for Patients with Blood Cancers

▪INTRODUCTION: Timely goals of care (GOC) discussions improve end-of-life (EOL) care for patients with solid malignancies. Although timely GOC discussions might also improve EOL care for patients with blood cancers, data are sparse regarding such discussions for this population. We studied the impact of timing and location of GOC discussions on quality of EOL care for a cohort of patients who died of blood cancers.METHODS: We assembled a retrospective cohort of blood cancer decedents from Dana-Farber Cancer Institute, Boston, MA. We included patients diagnosed with a blood cancer, who had ≥ 2 outpatient visits at the study institution, and who died between January 1 and December 31, 2014. Using the established definition from Mack et al, JCO 2012, we classified patients as having had a GOC discussion if there was any documentation in the medical record of a discussion involving resuscitation status, hospice, or preferred location of death. We abstracted content and location of the first documented GOC discussion. Next, we ascertained intensity of care near the EOL (i.e. chemotherapy ≤ 14 days before death, intensive care unit [ICU] admission ≤ 30 days before death, and hospital death) and hospice enrollment. Of note, decreased intensity of medical care and high rates of hospice enrollment are accepted indicators of quality EOL care. In univariable and multivariable models, we assessed the potential relationship between timing (> or ≤ 30 days before death) and location (outpatient or inpatient) of GOC discussions with intensity of medical care and hospice use near the EOL.RESULTS: Of the 384 eligible deceased patients, 39.1% had leukemia/myelodysplastic syndromes, 37.2% had lymphoma, and 23.7% had myeloma. 40.6% had undergone a hematopoietic stem cell transplant (HCT). Overall, 235 (61.2%) had a documented GOC discussion. The median time between first documented discussion and death was 15 days, with 33.2% of first discussions occurring > 30 days before death, and the minority (36.2%) occurring in the outpatient setting. The most commonly discussed topic was resuscitation preferences (82.6%), followed by hospice (30.6%); preferred location of death was rarely discussed (3.4%).Of the entire cohort, 16.9% received chemotherapy ≤ 14 days before death, 21.6% had at least one ICU admission ≤ 30 days before death, and 38.0% died in the hospital. 49.5% of the study population experienced at least one indicator of high-intensity medical care near the EOL. The rate of hospice use was 24.2%.In univariable analyses among those who had EOL discussions (n=235), having the first GOC discussion > 30 days before death was significantly associated with a lower likelihood of ICU admission ≤ 30 days before death (14.1% vs. 40.8%, p<0.001) and a lower likelihood of hospital death (37.2% vs. 63.1%, p=0.0002; Figure). Significant differences persisted in multivariable models controlling for sex, age, diagnosis, and HCT status. There were no significant differences in chemotherapy receipt close to death or hospice use by timing of GOC discussions in univariable or multivariable models. Having the first GOC discussion in an outpatient setting was significantly associated with a lower likelihood of ICU admission ≤ 30 days before death (9.4% vs. 44.7%, p<0.001), lower likelihood of hospital death (25.9% vs. 70.7%, p<0.001) but no significant difference in chemotherapy use near death (Figure). Outpatient location of first GOC discussion was also significantly associated with higher rates of hospice use (41.2% vs. 24.0%, p=0.006). Significant associations persisted in multivariable analyses.CONCLUSIONS: In this large cohort of patients who died of blood cancers, nearly 40% did not have a documented GOC discussion. For those who did, most GOC discussions occurred close to death and in the inpatient setting. Moreover, when patients had GOC discussions greater than a month before death and in the outpatient setting, they were more likely to experience high-quality EOL care. DisclosuresNo relevant conflicts of interest to declare.

Laboratory alerts to guide early intensive care team review in surgical patients: A feasibility, safety, and efficacy pilot randomized controlled trial

AimCommon blood tests can help identify patients at risk of death, unplanned intensive care unit (ICU) admission, or rapid response team (RRT) call.We aimed to test whether early ICU-team review triggered by such laboratory tests (lab alert) is feasible, safe, and can alter physiological variables, clinical management, and clinical outcomes. MethodsIn prospective pilot randomized controlled trial in surgical wards of a tertiary hospital, we studied patients admitted for >24 h. We applied a previously validated risk assessment tool to each set of common laboratory tests to identify patients at risk and generate a “lab-alert”. We randomly allocated such lab-alert patients to receive early ICU-team review (intervention) or usual care (control). ResultsWe studied 205 patients (males 54.1%; average age 79 years; 103 randomized to intervention and 102 to usual care). Intervention patients were more likely to trigger RRT activation during their first lab-alert (10.7 vs. 2.0%; P < 0.001) but less likely to receive an allied health referral (18.0% vs. 24.5%; p = 0.007). They were less likely to trigger RRT activation in the 24-h before subsequent alerts (18.4 vs. 22.4%; p = 0.008) and less likely to generate further alerts (204 vs. 320; p < 0.001), but more likely to receive a not for resuscitation or endotracheal intubation status in the 24-h before subsequent alerts (26.6 vs. 17.3%; p = 0.05). Mortality at 24 h was 1.9% for the intervention group vs. 2.9% in the control group (p = 0.63). Finally, overall mortality was 19.4% for intervention patients vs. 23.5% for control patients (p = 0.50). ConclusionAmong surgical patients, lab alerts identify patients with a high mortality. Lab alert-triggered interventions are associated with more first alert-associated RRT activations; more changes in resuscitation status toward a more conservative approach; fewer subsequent alert-associated RRT activations; fewer subsequent alerts, and decreased allied health interventions (ANZCTRN12615000146594).

Resuscitation status in psychogeriatric and general medical inpatients aged 65 years and older: a retrospective comparison study

Objective The aims of the present study were to establish rates of resuscitation order documentation of patients aged ≥65 years from both psychogeriatric and general medical units and to compare patients on predictors of resuscitation status, particularly examining the effect of depression. Methods A retrospective case note audit of psychogeriatric (n=162) and general medical (n=135) unit admissions within a tertiary teaching hospital was performed. Multivariate logistic regression was used to determine significant clinical and demographic predictors of resuscitation status. Results Resuscitation orders were documented in more psychogeriatric (94.4%) than general medical (48.1%) files. Depression did not significantly predict resuscitation status in either group. Having undergone competency assessment significantly predicted resuscitation status for the total sample and separately for psychogeriatric and medical patients. Older age (overall sample), poorer prognosis (overall sample), living in residential care (overall sample and medical group) and self-consenting to resuscitation status (overall sample and medical group) significantly predicted resuscitation status. Conclusions Resuscitation orders were more frequently documented on the psychogeriatric unit. Further prospective analysis is needed of how resuscitation orders are made before depression is discounted as a predictor of end-of-life decision-making. What is known about the topic? Despite increased community, media and research attention to end-of-life decision-making, resuscitation preferences of older patients are often poorly documented. Existing research into patient clinical and demographic factors that influence end-of-life decision-making have largely focused on general medical rather than psychogeriatric settings. There is a need to investigate rates of resuscitation documentation in psychogeriatric and general medical units and specific factors associated with having a 'do not attempt resuscitation' order in place, particularly the effect of current depression on decision-making. What does this paper add? Resuscitation orders were more frequently documented on the psychogeriatric than medical unit. Depression was not a significant predictor of resuscitation status in either group of patients. Although having undergone a competency assessment, older age and poorer prognosis predicted not being for resuscitation for the total sample, living in residential care and self-consenting to resuscitation status predicted not being for resuscitation for the overall sample and the medical group specifically. What are the implications for practitioners? This paper suggests that the need for clinicians to ensure documentation of preferences is a focus of day-to-day work with older patients. Clinicians should consider patient competency in end-of-life decision-making and how factors associated with depression, such as helplessness, may be more closely related to resuscitation decision-making in older patients.

Improving out-of-hours surgical patient care

PurposeThe Royal College of Surgeons recognises patient handover as the point at which patients are collectively at their most vulnerable. Concerns were raised in a London teaching hospital surgical department regarding an unstructured handover system, poor access to relevant clinical information, and inadequate weekend staffing. A quality improvement programme was designed and implemented to respond to these concerns and improve patient safety. The paper aims to discuss these issues.Design/methodology/approachA structured questionnaire was distributed to staff and results used to construct a diagram outlining the main factors influencing weekend patient safety. This framework was used to design changes, including a new electronic handover tool, regular handover meetings and additional weekend staff. Regular staff training was provided, and success was assessed in a continuous audit cycle with the results fed back to team leaders.FindingsOver a three-month period, the handover meeting recorded an attendance rate consistently above 80 per cent. The electronic handover entries were scored according to seven criteria (correct layout; key information, i.e.: patient location, clinical priority, active issues, resuscitation status, test results and weekend plan), averaging between 42.2 and 92.9 per cent, with progressive improvement seen over the assessment period. Weekend staffing was increased by 50 per cent, allowing a dedicated team to care for stable inpatients and to oversee discharges.Originality/valueThis improvement programme delivered lasting and significant change in response to staff concerns. It resulted in a more structured and reliable weekend system and established key mechanisms for dynamic performance feedback.

Abstract P-401: THE DO-NOT-RESUSCITATE (DNR) ORDER IN A PEDIATRIC INTENSIVE CARE UNIT (PICU) OF A DEVELOPING COUNTRY

Aims & Objectives: The DNR order is one of the most widely recognized medical abbreviations. It is part of most hospitals’ policies on the process of making and communicating decisions about a patient’s resuscitation status. Yet it has not become a part of our society’s ritual of dying especially among children in the Middle East (1). As it did in 1976, the concept today evokes controversy regarding the larger issue of appropriate care of dying patients (2). Objectives: 1. To determine the prevalence of the DNR order among mortality patients in the PICU of a tertiary academic hospital in a developing country 2. To discuss potential reasons and cultural issues behind accepting or refusing the DNR order in the PICU Methods An ongoing retrospective chart review Design: Retrospective review of medical records over 6 years (Jan.2012-Jan.2018) Setting and Participants: The PICU of a tertiary academic hospital in a developing country. Charts of all mortalities within the selected time period will be reviewed. Main Outcomes: Descriptive quantitative analysis of the PICU characteristics, admission information, patient demographics. The number of times next of kin discussed the DNR Order, with whom, reasons for refusal and/or acceptance. Results The study is ongoing, data collection and analysis will be completed in April 2018. The main outcomes will be quantitatively analyzed using the statistical software SPSS. Conclusions We anticipate cultural and religious values to play a role in parents’ decision to consent or refuse the DNR Order.

Abstract P-362: PEDIATRIC INTENSIVE CARE PROVIDERS END-OF-LIFE PRACTICES AND ATTITUDES IN VIETNAM

Aims & Objectives: Although there has been a significant reduction in childhood mortality in Vietnam, the rate remains high. Few studies exist on physician attitudes towards life-sustaining treatment and decision-making in the Vietnamese pediatric intensive care unit. This study aims at understanding pediatric intensivist perceptions, attitudes and practices surrounding the end of life in a PICU in Vietnam. Methods A mixed-method study utilizing paper survey and semi-structured interviews were conducted at a tertiary care pediatric hospital in Vietnam. NICU and PICU physicians and nurses were included. A total of 18 interviews and 68 surveys were completed and subsequently analyzed. Results Qualitative analysis demonstrates three major themes surrounding end of life care: socioeconomic and religious/cultural factors influence decision to withdraw treatment or not; lack of physician experience and infrastructure influence physician decisions, and who initiates (parent vs. physician) discussion about treatment decisions influences dynamics of the end of life processes. Quantitative analysis demonstrates that intensivists largely agree on involving parents in decisions to withdraw or not escalate life sustaining treatment, but not as readily with alternative resuscitation status. Intensivists find it important to try all potentially lifesaving interventions, however, chronic medical conditions may influence that decision. Most intensivists regard it as a personal disappointment if the patient dies. Conclusions Many opportunities for improvement are present: infrastructure and education regarding palliation in the ICU setting may be of benefit. In addition, psychosocial factors that are unique to the Vietnamese population are worth exploring as they intersect with the evolving modern medical technologies and chronically ill children.

Advance care planning: the impact of Ceiling of Treatment plans in patients with Coordinate My Care

ObjectivesThe aim of this evaluation is to describe the components and results of urgent care planning in Coordinate My Care (CMC), a digital clinical service for patients with life-limiting illness,...