Johnson Claire E, Chong Jeffrey C, Wilkinson Anne, Hayes Barbara, Tait Sonia, Waldron Nicholas
School of Surgery, The University of Western Australia, Perth, Western Australia, Australia.
Department of Rehabilitation and Aged Care, Armadale Kelmscott Memorial Hospital, Perth, Western Australia, Australia.
Intern Med J. 2017 Jul;47(7):798-806. doi: 10.1111/imj.13454.
Advance cardiopulmonary resuscitation (CPR) discussions and decision-making are not routine clinical practice in the hospital setting. Frail older patients may be at risk of non-beneficial CPR.
To assess the utility and safety of two interventions to increase CPR decision-making, documentation and communication for hospitalised older patients.
A pre-post study tested two interventions: (i) standard ward-based education forums with CPR content; and (ii) a combined, two-pronged strategy with 'Goals of Patient Care' (GoPC) system change and a structured video-based workshop; against usual practice (i.e. no formal training). Participants were a random sample of patients in a hospital rehabilitation unit. The outcomes were the proportion of patients documented as: (i) not for resuscitation (NFR); and (ii) eligible for rapid response team (RRT) calls, and rates of documented discussions with the patient, family and carer.
When compared with usual practice, patients were more likely to be documented as NFR following the two-pronged intervention (adjusted odds ratio (aOR): 6.4, 95% confidence interval (CI): 3.0; 13.6). Documentation of discussions with patients was also more likely (aOR: 3.3, 95% CI:1.8; 6.2). Characteristics of patients documented NFR were similar between the phases, but were more likely for RRT calls following Phase 3 (P 0.03).
An increase in advance CPR decisions occurred following GoPC system change with education. This appears safe as NFR patients had the same level of frailty between phases but were more likely to be eligible for RRT review. Increased documentation of discussions suggests routine use of the GoPC form may improve communication with patients about their care.
预先进行心肺复苏（CPR）讨论和决策并非医院环境中的常规临床实践。体弱的老年患者可能面临接受无益心肺复苏的风险。
评估两种干预措施对住院老年患者增加心肺复苏决策、记录和沟通的效用及安全性。
一项前后对照研究测试了两种干预措施：（i）以病房为基础的包含心肺复苏内容的标准教育论坛；（ii）一种结合了“患者护理目标”（GoPC）系统变革和结构化视频工作坊的双管齐下策略；并与常规做法（即无正规培训）进行对比。参与者是医院康复科的随机抽样患者。结果指标为记录为以下情况的患者比例：（i）不进行复苏（NFR）；（ii）符合快速反应团队（RRT）呼叫条件，以及与患者、家属和护理人员进行记录讨论的比例。
与常规做法相比，采用双管齐下干预措施后，患者更有可能被记录为NFR（调整优势比（aOR）：6.4，95%置信区间（CI）：3.0；13.6）。与患者进行讨论的记录也更有可能（aOR：3.3，95%CI：1.8；6.2）。各阶段记录为NFR的患者特征相似，但在第3阶段后符合RRT呼叫条件的可能性更大（P<0.03）。
随着GoPC系统变革并开展教育，预先心肺复苏决策有所增加。这似乎是安全的，因为各阶段NFR患者的虚弱程度相同，但更有可能符合RRT复查条件。讨论记录的增加表明，常规使用GoPC表格可能会改善与患者关于其护理的沟通。
