A Unified Electronic Tool for CPR andEmergency Treatment Escalation PlansImproves Communication and EarlyCollaborative Decision Making forAcute Hospital Admissions

Mae Johnson, Martin Whyte, Robert Loveridge, Richard Yorke, Shairana Naleem

To cite: Johnson M,Whyte M, Loveridge R, et al.A Unified Electronic Tool forCPR and EmergencyTreatment Escalation PlansImproves Communicationand Early CollaborativeDecision Making for AcuteHospital Admissions. BMJQuality Improvement Reports2017;6:u213254.w6626.doi:10.1136/bmjquality.u213254.w6626

Received 20 August 2016Revised 2 March 2017

Kings College Hospital,United Kingdom

Correspondence toMae Johnsonmae.johnson01@doctors.org.uk

ABSTRACTThe National Confidential Enquiry into PatientOutcomes and Death (NCEPOD) report ‘Time toIntervene’ (2012) stated that in a substantial number ofcases, resuscitation is attempted when it was thought a‘do not attempt cardiopulmonary resuscitation’(DNACPR) decision should have been in place. Earlydecisions about CPR status and advance planningabout limits of care now form part of nationalrecommendations by the UK Resuscitation Council(2016).Treatment escalation plans (TEP) document what

level of treatment intervention would be appropriate if apatient were to become acutely unwell and were notpreviously formally in place at King’s College Hospital.A unifying paper based form was successfully pilotedin the Acute Medical Unit, introducing the TEP andbringing together decision making around bothtreatment escalation and CPR status. Subsequently anelectronic order-set for CPR status and treatmentescalation was launched in April 2015 which led to ahighly visible CPR and escalation status banner onthe main screen at the top of the patient’s electronicrecord.Ultimately due to further iterations in the electronic

process by December 2016, all escalation decisions foracutely admitted patients now have high qualitysupporting, explanatory documentation with 100%having TEPs in place.There is now widespread multidisciplinary

engagement in the process of defining limits of carefor acutely admitted medical patients within the first 14hours of admission and a strategy for rolling thisprocess out across all the divisions of the hospitalthrough our Deteriorating Patient Group (DPG).The collaborative design with acute medical,

palliative and intensive care teams and the highvisibility provided by the electronic process in theElectronic Patient Record (EPR) has enhancedcommunication with these teams, patients, nursingstaff and the multidisciplinary team by ensuring claritythrough a universally understood process aboutescalation and CPR.Clarity and openness about these discussions have

been welcomed by patient focus groups facilitated via

our acute medicine patient experience committee.There has been a shift in medical culture wheretransparency about limits of care has contributed toimproving patient safety and quality of care throughreducing unnecessary CPR supported by focus groupsof staff.

PROBLEMThe project took place at King's CollegeHospital NHS Foundation Trust, London, UK.It serves an inner city population of 700,000but also serves as a tertiary referral centre.The Acute Medical Unit (AMU), has 60 bedsand admits approximately 15,500 medicalpatients each year. Multidisciplinary care isprovided for all adult medical admissions witha wide range of presenting pathology. Theunit is staffed by 12 Consultants and a 6monthly-rotating team of 24 junior doctors,and a nursing staff of approximately 100. Keysupporting members of the multidisciplinarycare team include unit-based Pharmacists,Dieticians, Social Workers, OccupationalTherapists and Physiotherapists.The Deteriorating Patient Group is a King’s

College Hospital Trust board group whichevaluates a number of key processes relatingto prevention of deteriorating patients acrossthe hospital in line with up-to-date evidenceto ensure patient safety is optimised. It par-ticularly explores the interface with criticalcare and emergency medicine to ensure thebest outcomes for patients.CPR is too often an instinctive result of an

unforeseen emergency and survival to dis-charge from an in-hospital cardiac arrest isless than 20% in all age groups, and even insurvivors there is significant morbidity.Inappropriate CPR is when the situation isconsidered futile reflecting both a low

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chance of survival and likely poorer quality of life after-wards if spontaneous circulation is returned.1 The Trusthad previously used a DNACPR form that did notincorporate decisions about levels of intervention, whichinevitably led to some lack of clarity around decisionsfor out-of-hours teams. From a retrospective analysisconducted by our resuscitation department, the DPGhighlighted that 10% of patients received what was con-sidered to be inappropriate CPR during 2013-2014 (i.e.75/750 patients) and this was the chief trigger for ourwide-scale collaborative quality improvement endeavour.The overall aim of this project was to improve the

quality of recording CPR status and treatment escalationplans with a view to reducing the risk of inappropriateCPR through early transparent patient engagementand multidisciplinary decision making. This wouldultimately contribute towards optimising quality of care.The primary objective was to develop and embed aTrust-wide intervention to promote early collaborativedecisions about limits of care and CPR status simultan-eously, with standardised supporting documentation.The project was sanctioned by the DPG to ensure a

standardized approach to our recording of CPR andescalation decisions on the front line. Our team con-sisted of representative Consultants from AcuteMedicine, General Internal Medicine, Palliative Care,and Intensive Care, Nursing leads from the care group,IT representation from the Head of our EPR system anda project manager. Implementation was carried out bythe AMU multidisciplinary teams including attendingConsultants, junior doctors, nursing staff and withsupport from Management and Information technology.We aimed for 100% compliance with a documented

CPR decision and TEP within 14 hours of admission forall medical patients. We were aware that in the longterm an electronic process would be more likely toensure visibility and sustainability. A one year time-lineof the process planned for the project to allow the devel-opment from paper to electronic records is outlinedwith the qualitative and quantitative impacts described,the first 6-months refer to the development phase andthe second 6-months to the period after institution andre-audit.

BACKGROUNDThe General Medical Council (GMC), British MedicalAssociation (BMA) and UK Resuscitation Council alladvocate early patient engagement and negotiationtowards shared decision making about resuscitation.2

Decisions about CPR are frequently omitted, and even ifdecided upon poorly documented and communicated.3–6

Palliative care teams in hospital are under utilised andoften contacted late in the patient pathway for end oflife care.7–9 The NCEPOD, report ‘Time to Intervene’(2012) stated that in a substantial number of cases resus-citation was attempted when a DNACPR decision shouldhave been made earlier: only 10% of cases had a

documented decision, on admission, as to the resuscita-tion status. This was due to a failure to formulate anappropriate risk assessment regarding potential todeteriorate and or detailing the escalation plan onadmission. This can lead to adverse medicolegal out-comes, especially if decisions are then determined by‘out-of-hours‘ junior medical teams without detailedunderstanding of the situation or clinical background10.Healthcare professionals do not find it easy to raise theissue of treatment escalation or de-escalation or discussCPR with their patients.4

For patients who are unlikely to benefit from CPR,quality of care can be improved by documenting a man-agement guide in the event of clinical deterioration i.e.a TEP. This subsequently minimises the risk of on-callteams commencing treatments with limited benefit andthat are not aligned with the patient’s pre-stated wishes.TEPs can therefore ensure the treatments given are inthe best interests of the patient documenting what treat-ment options would be appropriate if that patient wereto become acutely unwell. TEPs are increasingly beingused in acute hospital trusts to outline limits of care,however these are often paper based and inconsistentlyadopted, with wide variability at implementation.11–13

The DPG aligned with the London CommissioningStandards in agreeing that all acutely admitted medicalpatients were to have TEPs established and CPR deci-sions made and both clearly documented in a standar-dised format within 14 hours of admission onto theacute medical take i.e. this was advocated by the point ofthe first post-take consultant review.

BASELINE MEASUREMENTA baseline audit of practice on the AMU was undertakenfor two weeks for all acute admissions in November2014. All electronic notes and paper notes for each ofthe 382 patients included were screened for the pres-ence or absence of a documented CPR status or any ref-erence to an escalation plan in the event ofdeterioration. At this time electronic notes were consid-ered inpatient notes whilst accident and emergencynotes remained paper based and were subsequentlyscanned into the electronic record. At baseline, theprevalence of documentation for reference to CPRstatus was 11.8% (n=45) and for reference to treatmentescalation or limits of care was 11.2% (n=42) for patientsadmitted to the AMU. These were mostly weekend plansor specific overnight instructions based on outstandingresults and investigations and did not pertain to the hol-istic outcomes for the patient overall.

DESIGNThe initial pilot intervention was an easy-to-use two-sidedpaper based form, comprising a CPR section and a TEPsection (Figure 1). This was initially piloted on paperand then incorporated into an electronic orderset forCPR and TEP. The design of the TEP form was a

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collaborative endeavour based upon expertise ofConsultants and contributions from junior doctors andfrontline multidisciplinary nursing staff and alliedhealth professionals within acute medicine, intensivecare, palliative care. There was additional input fromthe resuscitation and IT departments regarding viabil-ity. The basic structure of the original DNACPR formwas maintained.The pilot form was made widely available on the AMU

supported by education for consultants, junior doctorsand the acute medical unit staff. Data was again col-lected for the presence of a documented TEP/DNACPRdecision in the medical notes of each patient, bothpaper and electronic.The results of improved documentation rates were

presented to the AMU Consultant team, at a

quarterly internal audit meeting and to a Hospitalwide multidisciplinary audience at the medicalGrand Round in October 2015. Further to the pilotsuccess, an identical electronic TEP form and accom-panying order-set was designed to encourage record-ing of CPR status and TEP for all acute admissions.The orderset for CPR status and TEP and the elec-tronic TEP form was designed by the EPR team, dis-cussed at the Documents and Legal Review Paneland subsequently instituted formally as trust protocolto be completed for all acute admissions within thefirst 14 hours. The electronic CPR form was alreadyin existence but the order-set widely drew attentionto compliance with this to ensure CPR statustogether with TEP was always actively considered andrecorded for all patients.

Figure 1

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STRATEGYThree PDSA cycles were used to develop the final TEP.PDSA Cycle 1An Acute Medicine Patient Experience Committee wasestablished in January 2015, with patient representation,to facilitate the discussion and planning process of CPRstatus and TEP. The committee initiated five patientfocus groups. Four out of five groups reported that theywould want to be involved in making decisions abouttheir wishes for both CPR status and TEP. Patients wereclear that they would not object to these issues beingraised in the early stages of an acute hospital admissionand valued clarity. Drawbacks highlighted were thatsome patients felt that raising the topic at all might beconsidered to be directly linked to their prognosis onthat admission, or that those with chronic disabilitymight be selected out for discussion leading to feelingsof discrimination or judgement. Transparency was fun-damental to all patients and it was strongly felt that suchdiscussions should be a routine policy for all patientsupon admission to avoid feeling selected out or that thetopic was being raised only because of imminent deteri-oration. This underpinned our practice going forwardin terms of embedding the consideration and documen-tation of CPR status and escalation for all our patientsregardless.A paper-based TEP, including CPR status, was collab-

oratively designed between acute medicine, intensivecare, elderly medicine and palliative care to ensure thatlimits of care were clearly documented for the multidis-ciplinary team. The advice of consultants was soughtbecause they frequently engage in decision makingabout what treatments would be in an individual’s bestinterests in the event of clinical deterioration and areultimately responsible for patient care. It was agreed thatresuscitative treatment options in order of least invasiveto the most invasive were outlined and described inlevels of organ support. Level 1 care being defined asward based care, Level 2 as single organ support includ-ing non-invasive ventilation in a high dependency envir-onment and level 3 as multi-organ support or invasiveventilation. A section allowing for de-escalation wasincluded so that dying or terminal patients were recog-nised early and that end of life care could be instituted.(Figure 1). This version was made available to allmedical staff via the weekly protected educational meet-ings for junior doctors and at the consultant meetings.The form was explained step-by step and case examplesdiscussed, all questions addressed.Each morning for two consecutive weeks, over one

hundred TEP forms were distributed across the emer-gency department, ambulatory care unit and two acutemedical unit ward bases. The forms were carried by thejunior doctors to allow completion by the ConsultantPhysicians after every new patient review and filled within the paper notes and an entry added to the electronicpatient records. All staff were reminded to complete theform at the morning handover meeting.

After two weeks of this pilot (n=150 patients) thedocumentation of TEP and CPR decisions on AMU hadimproved from 11.8% to 21.2%.

PDSA Cycle 2The resulting changes were recognised as a benefit toboth patients and clinicians in terms of encouragingearly decision making in the interests of patient safety.As Kings College Hospital operates an electronicpatient record system (EPR) and the intervention wasnot sustainable in terms of distributing the volume ofpaper based forms on a daily basis, an electronic orderset was designed for both TEP and CPR status with theEPR team and launched on April 1st 2015. Consultantphysicians, identified as clinical champions, helped toembed the use of this order-set for every patient,aiming to encourage clinicians to consider both thepossibility of deterioration and the appropriateness ofindividual treatment modalities when making decisionsabout CPR.The trust progressed with support from the DPG and

legal team to formally launch the TEP electronically onEPR. This was published as trust protocol for recordingCPR status and TEP on the intranet. The EPR waslinked to ‘ward-view’ screens in staff-only areas so thatescalation and CPR status could clearly be seen, for allAMU patients, by the nursing & medical staff. Thechanges in TEP and CPR status are easily reflected elec-tronically and ceilings of care and DNACPR decisionsare highlighted for each patient at midday board roundsto ensure the discussion is up to date and all teams aremade fully aware to ensure good communication andpatient safety.Based upon the monthly percentage of CPR decisions

recorded, on paper forms, from January to March 2015(18.8±2.1%), the study had 90% power, at alpha levelof 0.01, to detect an improvement to 24%, or greater, ofCPR status recorded with electronic documentation with6-months or more of follow-up data.

PDSA Cycle 3To ensure the legally binding UK Resuscitation Councilnational form was electronically completed in additionto completion of the order-set fields alone, a furtheriteration to the electronic process incorporating a directlink to the CPR form was successfully launched on 1stDecember 2016.

RESULTSThe documentation of CPR decisions (within 14 hoursof acute admission) increased from 18.8±2.1% Jan2015 to March 2015 (paper-based order forms) to 80.2±9.6 April 2015 to December 2016 (electronic orderforms); two-tailed independent t-test, P<0.0001.(Figure 2)After just six months, feedback from practising divi-

sions indicated that clinicians felt empowered to makeearly TEP/CPR decisions and were involving the

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multidisciplinary team. Nurses felt increasingly confi-dent in efficiently escalating care and involving criticalcare outreach to ensure the most effective outcomes forpatients.A further iteration to the electronic process was

launched on 1st December 2016. This involves a (man-datory) direct link to be completed after entering theCPR status on the home page of the patient’s notes, tothe supporting documentation.

LESSONS AND LIMITATIONSUndertaking a new trust wide initiative regarding treat-ment escalation plans for patients requires engagementof all the key stake holders from the outset includingintensive care to palliative care, all acute specialties,nursing teams, allied health professionals, IT and thehospital board.An important limitation to this work is a lack of feed-

back about the qualitative personal impact upon patientsin practice. While patient focus groups from the firstPDSA cycle suggested that it would potentially reducepatient anxiety and ease decision making for doctors,there were also concerns raised that patients’ may linkthese discussions to assuming their prognosis was poor,or that they were being targeted due to age or disability.This study did not collect further feedback from thepatients’ perspective after the form was introduced andtherefore it is not clear at this point whether the adventof the TEP/CPR acute admissions process improved thepatient and family experience. This would be valuable toevaluate in a further improvement study.Ensuring compliance from senior health care profes-

sionals in utilising the electronic order-set to recordCPR status/TEP upon admission for every patient

involved a huge cultural shift and active championing ona daily basis and is a limitation in that there was variableengagement. This was mitigated through actively makingthis a question highlighted for every patient in AMU andgeriatrics at board rounds by our clinical administrators,so this practice was increasingly adhered to.Quality of discussions among clinicians remains variable

and is a further limitation, with many reluctant to under-take the task in acute or outpatient settings. Implementingtrust-wide training on the recording process and improv-ing quality of discussions has been a challenging processwith our palliative care team driving this work and requiresengagement and support of all clinical and nursing leadsto support implementation and practice.As this is resource intensive sustainability of training is

another limitation as consistent encouragement andcontinuous training across the trust is required. This isparticularly crucial as these discussions may be challen-ging in those acute admissions lacking capacity to thisparticular issue for reasons such as delirium, dementia,fluctuating consciousness, acute alcohol withdrawal etcto name but a few. As such the default position would beto ensure the decision is recorded as full escalationunless a previous established decision has been clearlyidentified with evidence of previous patient involvement.All healthcare professionals would ideally be up to dateon the process, legal and multidisciplinary aspects andthere are now further discussions taking place aboutpotentially embedding this within trust mandatory train-ing. For now, it has been made part of the EPR lessonplan for all new users to ensure familiarity with theprocess.As the electronic CPR form originally lay out-with the

order-set until December 2016, we found up to 20% ofpatients with DNACPR selected on the order-set did not

Figure 2

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have an accompanying explanatory legal CPR form,although there was often evidence of patient discussionson the EPR clinical notes. This would mean a legal obli-gation to perform CPR unless the situation could berapidly evaluated with a consensus agreement by thecrash team in real time. We have since launched a newunifying electronic process in December 2016 thatensures the selection of DNACPR within the ordersetautomatically opens the electronic CPR form to promotecompletion of this essential legal documentation.In the longer term, we hope to evaluate the potential

statistical impact upon inappropriate cardiac arrest andwhile preliminary data suggests that there is already sig-nificant improvement, it is acknowledged this may bemultifactorial.

Next stepsAlthough we have demonstrated an improvement in thedocumentation of CPR status and TEP within the acutecare setting, the question remains as to whether this isthe most appropriate time and place to discuss limits ofcare and patient wishes.Patients may feel uncomfortable hearing about the

subject for the first time from a frontline hospital doctorthey may have never met, especially when they arealready under significant stress having been admittedwith a potentially critical illness. Clinical responsibilitymay be repeatedly transferred in an acute care setting,which also compromises the continuity of the discussionif it is held for the first time in this forum. Patients pre-senting acutely may lack capacity to discuss theirthoughts, feelings and concerns due to delirium,dementia, withdrawal from alcohol, reduced conscious-ness due to head injury or sepsis, exacerbation ofmental illnessIn future, improvement goals could explore under-

standing how much discussion of CPR status and TEP istaking place in the community setting and how toensure this information is transferred across theprimary/secondary care interface.Our experience with rolling out the TEP suggests that

by ensuring this is discussed transparently with all ourpatients, it avoids any patient feeling like they are beingsingled out, isolated or targeted because of theirmedical condition. Another alternative, therefore, is forthe trust to explore implementing these discussions inthe outpatient clinic. Being able to dedicate time to dis-cussing this in detail when the patient is well mightenable patients to have confidence that even if they arein an obtunded state, everything possible will be done totheir satisfaction and they have been involved in thedecision making about their care and understand anylimits and reasons for this in advance.Supplying written information in leaflet form for

patients and families when they are admitted to acuteadmissions units regarding CPR decision-making, mediadisplays in areas with screens and electronic pages forpatients with evidence based extractions from key

reports may be useful complements to raise awarenessand transparency that these crucial conversations aremandatory in the interests of optimising patient safetyand delivering high quality care. We are currentlyexploring this further through our Acute MedicinePatient Experience Committee.

CONCLUSIONThe evolution of a TEP form is not specific to KingsCollege Hospital and many trusts in the UK are nowadopting similar approaches11–12, however the transla-tion to an electronic mandatory process has increasedvisibility of this important part of patient managementand embedded it in local culture ensuring it is a keyconsideration for all acute admissions. The approachand findings of this project are therefore widely applic-able to other UK trusts.By tailoring the individual patient’s clinical manage-

ment and documenting it clearly upon admission in astandardized universally understood trust-wide format,ambiguity in critical cases is systematically avoiding, espe-cially where patients may deteriorate out of hours. Theconcept was that treatment modalities are ideally dis-cussed with the patient early in their illness while cap-acity to make specific decisions about future lifesustaining treatments is still preserved. This was consid-ered especially important in patients at high risk ofdeterioration determined by any or a combination ofmultiple co-morbidities, pre-morbid performance status,physiological reserve and organ failures. In addition itwas considered vital that there would be clear communi-cation documented in the clinical notes with the patientand their next-of-kin, or legal power of attorney whererelevant and reference to any advanced directive couldbe reviewed.The aim of establishing a trust-wide Treatment

Escalation Plan has optimised multidisciplinary com-munication, particularly that with our critical care out-reach team and intensive care colleagues regardingrapid escalation of treatment. It has also enhancedcommunication with our palliative care colleagues inrecognising the need for appropriate de-escalation oftreatment in terminal cases and encouraging theirearly involvement. Clearly defining any limits of treat-ment for each patient upon admission gives both clin-ical multidisciplinary teams and patients’ confidence inthe delivery of high quality medical care, especiallyout-of-hours — when senior decision-makers may notbe available.The sophisticated and streamlined supporting elec-

tronic process has enhanced the dissemination of thisinformation effectively to the multidisciplinary team andencourages early collaborative decision making andgood record keeping in line with GMC good medicalpractice. It has also ensured high rates of compliancewith the process which encourages visibility and trans-parency and is sustainable for the future.

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Acknowledgements Dr Zohra Khattak, Dr Geraldine Walters, Jennifer Karno,Dr Jane Evans

Declaration of interests Nothing to declare

Ethical approval According to the policy activities that constitute research atKings College Hospital, London, as guided by the HRA this project metcriteria for operational improvement exempt from ethics review as it iscategorised as a service evaluation.

Open Access This is an open-access article distributed under the terms ofthe Creative Commons Attribution Non-commercial License, which permitsuse, distribution, and reproduction in any medium, provided the original workis properly cited, the use is non commercial and is otherwise in compliancewith the license. See:• http://creativecommons.org/licenses/by-nc/2.0/• http://creativecommons.org/licenses/by-nc/2.0/legalcode

REFERENCES1. Meaney PA. Nadkarni VM, Kern KB et al. Rhythms and outcomes of

adult in-hospital cardiac arrest. Crit Care Med 2010;38:101–20.2. Decisions relating to cardiopulmonary resuscitation. BMA, Resus

Council (UK), RCN. 2016.3. Dahill M, Powter L, Mallett M, et al. Improving documentation of

treatment escalation decisions in acute care. BMJ Qual ImprovReport 2013;2:doi:10.1136/bmjquality.u200617.w1077.

4. Mockford C, Fritz Z, George R, et al. Do not attemptcardiopulmonary resuscitation (DNACPR) orders: a systematicreview of the barriers and facilitators of decision-making andimplementation. Resuscitation 2015;88:99–113.

5. Seward E, Greig E, Preston S, et al. A confidential study of deathsafter emergency medical admission: issues relating to quality ofcare. Clin Med 2003;3:425–434.

6. Freemantle N, Richardson M, Wood J et al. Weekend hospitalizationand additional risk of death: an analysis of inpatient data. J R SocMed 2012;105:74–84.

7. Low C, Finucane A, Mason B, et al. Palliative care staff 'sperceptions of do not attempt cardiopulmonary resuscitationdiscussions. Int J Palliat Nurs. 2014;20:327–33.

8. The College of Emergency Medicine — clinical effectivenesscommittee (2012) End of life care for adults in the Emergencydepartment — best practice guidance.

9. Grewal B, Johnson F. To escalate or to palliate? An audit of patientsat risk of deterioration on medical wards. BMJ Support Palliat Care2014;4:A81.

10. National Confidential Enquiry into Patient Outcome and Death(2012) Time to Intervene

11. Obolensky L, Clark T, Matthew G, Mercer M. A patient and relativecentred evaluation of treatment escalation plans: a replacement forthe do-not-resuscitate process. Journal Medical Ethics2010;36:518–20.

12. Stockdale C, Trivedi B, Jerome E, Salih S. Implementation of acombined Cardiopulmonary Resuscitation and Treatment EscalationPlan document in a District General Hospital. BMJ Qual ImprovReport 2013;2.

13. Stupple A, Geocadin R, Celi L. Conversation prior to resuscitation:The new CPR. Resuscitation 2016;99:e3. .

14. Paes P, O’Neill C. Treatment escalation plans - A tool to aid end oflife decision making? British Medical Journal Support Palliative Care.2012, Supplement 1.

15. Govier M, Metcalf P. Living for the weekend: electronicdocumentation improves patient handover. Clin Med 2012;12:124–7.

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