Armband labeling could prevent DNR confusion

medwireNews: Implementation of an electronic ordering and armband labeling process for patients with Do Not Resuscitate (DNR) orders improved correct documentation of their wishes as well as physicians' ability to recognize and act on them during a cardiac arrest scenario, report US researchers.

The computerized physician order entry program (CPOE) resulted in a 17% increase in patients having an armband that reflected their documented wishes, and significantly reduced the time it took physicians to ascertain a patient's resuscitation status.

"Utilization of a systematic design process, which included human factors expertise, resulted in a much safer armband," say Nicola Schiebel, from the Mayo Clinic in Rochester, Minnesota, and colleagues.

"The multidisciplinary team approach, including simulation for assessment, proved to be extremely innovative and effective," they add, in BMJ Quality and Safety.

The team developed the CPOE over a 3-year period using data for a 2059-bed academic hospital. Fifty medical charts with DNR orders were initially identified from 210 charts screened, and 8% of these adult patients had multiple DNR-related orders with no quick mechanism to identify which was the most up to date.

Furthermore, the time taken to review a single chart to ascertain patient resuscitation wishes was an average of 5 minutes, with 10 minutes more to screen for discrepancies.

However, 11 months after implementation of the CPOE, it took one physician a total of 8 hours to screen 4288 patients' data, with the patients' most recent order clearly displayed.

Before the CPOE (baseline), Schiebel and team tested physician teams for recognition of the old armband used to designate DNR status (a white armband with red dots) during a scenario based on a real-life cardiac arrest situation. Not quite two-thirds (61%) could recognize the band.

After implementing new, purple armbands showing patients' resuscitation status and identifying information, 100% of teams recognized the bands, representing a significant increase.

The number of patients with an armband that accurately reflected their documented wishes also increased significantly after the CPOE was introduced, from 81% to 98%.

"DNR orders and policies are intended to safeguard patients' autonomy, prevent unwanted resuscitative care, and promote the appropriate application of life-support interventions," explain Schiebel and co-investigators.

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