When it comes to communicating do-not-resuscitate (DNR) orders, hospitals rely on a bewildering array of paper documentation, electronic records, and colored wristbands that can easily be misinterpreted.
These are the findings reported in the November-December issue of the Journal of Hospital Medicine by Niraj Sehgal, MD, and Robert Wachter, MD. Dr. Wachter is associate chair of the department of medicine at the University of California, San Francisco. Dr. Sehgal is an assistant clinical professor of medicine at the school.
In a survey of 69 nursing executives representing hospitals in a consortium of academic medical centers, “More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care,” the authors say.
Everyone has a “near-miss” story, says Dr. Sehgal.
In one budget-minded hospital where materials were recycled, someone forgot to remove a DNR sticker from a previous patient’s folder before the folder was assigned to someone else. Several nurses told of instances in which patients were resuscitated inappropriately because hospital staff members did not see DNR stickers in the patient’s chart, the patient was off the unit for a procedure without a complete chart, or the DNR order was buried under other materials.
Much of the problem stems from the lack of a standardized method for making a patient’s DNR wishes known, Dr. Sehgal explains.
For example, in 2004 Dr. Sehgal saw a newspaper report that BayCare Health hospitals, in and around Tampa, Fla., were covering yellow “Livestrong” bracelets issued by the Lance Armstrong Foundation and worn by some patients to support those living with cancer. BayCare uses yellow bracelets for DNR patients. Nearly 20% of Americans wear “Livestrong” bracelets, posing a challenge for any hospital that also uses yellow bracelets to indicate DNR.
The newspaper story was the impetus for this study, Dr. Sehgal recalls. “I saw that article and thought, ‘What a great metaphor for the need for standardization.’”
He and Dr. Wachter designed a brief survey and distributed it via an e-mail listserve to senior nursing staff members of the University HealthSystem Consortium, an alliance of 97 academic medical centers and their affiliated hospitals. Those institutions represent 90% of the nation’s nonprofit academic medical centers.
Of the 127 nursing executives who received survey announcements, 69 (54%) returned completed questionnaires. Of those, 39 (56%) reported that their hospitals documented patients’ DNR preferences only in the charts, while 11 (16%) used only electronic health records (EHRs). Seventeen (25%) augmented the paper charts or EHRs with color-coded wristbands in eight colors.
“We expected variability, but even so we were struck by how much variability existed in our findings,” Dr. Sehgal says.
Hospitals use wristbands in a rainbow of colors to convey many messages. Of the hospitals represented in this survey, 55% used them to warn of allergies, fall risks, and even same last names. The authors found “12 different indications were depicted by various colors, with variations in both the color choice for a given indication (e.g., red and yellow used for allergy wristbands at different hospitals) and across indications (e.g., red for allergy at one hospital and red for bleeding risk at another).”