Background: CSD’s are an integral component of the inpatient admission process. However, despite their importance, CSD’s are not performed during all admissions. Residents physicians, who are at the forefront of the admission process, are rarely given formal education in the proper way to conduct a CSD, a topic seldom taught in medical schools or residency training. Commonly cited obstacles to performing a CSD by residents include experiencing high levels of discomfort and lack of confidence or training. During many admissions, CSD’s are not even considered if the patient in question is not perceived to fit the “code status gestalt”, often reserving these discussions for the critically-ill. Furthermore, these discussions are usually not clearly documented in the electronic medical records (EMR), a problem increasingly more prevalent as hospitals transition their documentation into EMR.
Purpose: Determine if educating resident physicians using handouts and online videos will augment both the rate of CSD’s and their documentation in the EMR.
Description: Data were collected on the rate of CSD’s documented in EMR by Internal Medicine residents at Northshore University Hospital and Long Island Jewish Hospital, located in Manhasset, NY and Queens, NY respectively. Data were collected in two phases, pre and post intervention. The intervention being studied was the education of residents through the use of handouts and online videos recommended by the department of Palliative medicine on how to perform and document CSD’s. The pre-intervention phase entailed a 2 week period where the rate of CSD’s, as documented in EMR, were collected. Once baseline data were acquired in the initial pre-intervention phase, educational materials were distributed to the residents, whose CSD documentation was collected over the following 4 weeks (post-interventional phase). The data collected from both phases through EMR review were compared using a Fishers exact test.
A total of 111 patients were involved in the project with 53 patients in the pre-intervention group and 58 patients in the post-intervention group. Of the pre-intervention group, 5/53 (9.4%) patients had CSD documentation, consistent with the national average, compared to 13/58 (22.4%) patients in the post-intervention group. There was a trend toward increased rates of CSD’s documentation in the post-intervention group, although it did not meet statistical significance (P= 0.075).
Conclusions: The utilization of educational online videos and handouts improved, but did not significantly increase the rate of CSD’s in this limited study. The most commonly cited reasons by residents for not conducting a CSD were time constraints (80%), personal discomfort (47%) and lack of training (42%). Further investigations are warranted to better understand the obstacles to conducting and documenting CSD’s. This study highlights the need to further explore the effect of resident education on not only the rates but also the quality of CSD’s. Future studies may investigate different teaching models and identify whether certain patient populations may benefit from the development of a standardized script for discussing code status.