Background:
Discussing and determining a patient’s code status is an integral part of the initial patient encounter upon admission to the hospital. Code status orders are frequently integrated into admission order sets and direct critical care that is often provided by other members of the healthcare team. The depth of that discussion, who participated and what specific interventions are desired can be difficult to determine retrospectively if not well documented by the admitting physician. We sought to understand the level of detail in code status documentation in an internal medicine residency program and if an educational intervention could improve documentation.
Methods:
The study was completed on general medicine teaching units at a large urban tertiary referral center. The intervention was initially started as a quality improvement project to identify a better workflow and develop an informational handout to aid the code status discussion. The intervention population was a group of internal medicine interns on a 1 month night float rotation, who would complete all night-time admissions. Baseline data on code status documentation in initial history and physical notes were collected during a 2 week period, covering 11 shifts, for all patients admitted to and discharged from the primary unit with admission orders placed during the standard shift hours of the night float team. Additional information related to patient demographics and medical comorbidities, captured as American Society of Anesthesiologists Physical Status classification (ASA), were also collected. An educational intervention was completed by the supervising residents after two weeks, with the interns being given the handout and text for recommended phrasing of the code discussion in the medical record. The data collection was resumed for the following 2 weeks, covering 8 additional shifts.
Results:
A total of 110 admission notes were reviewed, 79 (72%) before the intervention and 31 (28%) afterwards. There was no statistically significant difference in the mean age, gender, or race for all admissions before and after the intervention. The average ASA class was 2.78 ±0.86 for patients before and 2.81 ±0.79 (p=0.90) of patients after the intervention. Code status orders were present 95% before and 94% after the intervention (p=0.77). Specifics of the code status discussion were documented in the admission note at statistically similar rates before and after the intervention (15% vs. 6%, p=0.22). For the entire population, presence of dementia, average ASA, or ASA score above 3 were not significant predictors of code status discussion documentation. Average age was significantly different between those with and without documentation (84.2 ±10.1 vs 59±17.1, p<0.001).
Conclusions:
We did find that one demographic factor was predictive of additional details being included in the code status documentation. Age was shown to be statistically significant. This could be expected; however, a diagnosis of dementia or elevated ASA score were not associated with higher levels of documentation. This suggests that the studied group of providers consciously or subconsciously adjust their code status documentation, and likely the actual discussions, based on age but not on morbidity. While we expected the presence of dementia to this triage effort, our negative result may reflect low numbers of dementia in our sample population. The study also demonstrated that the educational intervention did not alter their practices.