Background: Documentation of code status is critical to goal-concordant care. Historically, documentation rates have been low due to time, the sensitive nature of discussions, and lack of experience. The COVID-19 pandemic, due to the risk of rapid decompensation and in-hospital mortality, created an urgent need for documentation of code status preferences among patients admitted to the hospital for COVID-19. Conversations to document code status during the COVID-19 pandemic faced additional challenges like high inpatient volumes and prognostic uncertainty. The human connection needed for these sensitive discussions was disrupted by medical equipment such as respirators and provider personal protective equipment. Our hospital, which serves predominantly low-income, African American urbanites, had a dedicated COVID unit during the first three months of the pandemic. It was staffed as an opt-in service amongst hospital medicine (HM), anesthesia and pulmonary critical care faculty and general internal medicine (IM) and anesthesia residents. For HM and IM faculty orientation, code status was emphasized. Amongst HM providers, code status was part of every hand off. It was also included as part of an automated dot phrase in the EMR.Given these changes, we investigated how the COVID-19 pandemic impacted code status ordering across our academic medical center among all patients comparing ordering status among COVID-19 patients and the spillover effects of among patients without COVID-19.
Methods: Our study is a retrospective cohort reviewing all patients admitted to the hospital from January 1st, 2019 to December 31st, 2020. Patient data was collected from the electronic health record reporting database including patient demographic data, encounter admission and discharge date and time, and code status orders. Rates were compared before and during the pandemic using Pearson’s Chi-squared tests and two-sample t-tests. We classify pre- pandemic as before February 1st, 2020, when the first COVID test was ordered.
Results: 59,471 unique patient encounters were analyzed (n=35,317 before and N=24,154 during the pandemic). 1,631 cases of COVID-19 cases were seen. The before and during groups were equivalent in gender (55% female) and ethnicity (6% hispanic). The proportion of black patients in the total sample rose from 62% to 66% with corresponding decrease in white patients from 30% to 26% (p= < 0.001). The overall rate of code status orders among all inpatients during this time period increased from 22% pre-covid to 29% during covid (p < 0.001). Code status orders for COVID negative patients increased to 32% (p < 0.001). COVID positive patients were more than twice as likely to have a code status order placed than COVID negative patients during the COVID period with 65% of patients. (p < 0.001). Race had a significant effect overall on code status ordering before and during the COVID period, and among COVID negative patients (p<.05), but did not have a significant effect on code status ordering among COVID positive patients.
Conclusions: Code status documentation is far from optimal, however the pandemic has impacted our frequency of ordering. Documentation among COVID-19+ patients was double that of the standard population. We observed a spillover effect in the rate of code status documentation in all inpatients, and among non-COVID inpatients. Race impacted ordering among COVID- patients but not COVID+ patients. Additional analysis is needed to evaluate time and provider-level effects.