Increasing timely code status discussions in hospitalized children with medical complexity

Children with medical complexity (CMC) have an increased risk of hospitalization and clinical deterioration. Documentation of code statuses concordant with family goals is rare, increasing the risk of serious unintended consequences. We aimed to increase the percentage of patients with documentation of timely code status orders (CSOs) from 5% to 80% over 6 months.

This quality improvement project took place at one freestanding children's hospital and included patients admitted to the complex care team (CCT). Multiple plan-do-study-act cycles were performed focusing on interventions aimed at key drivers, including increasing knowledge in performing code status discussions (CSDs) and improving understanding of institutional policies. A P-chart was used to track the effect of the interventions over time by using established rules for determining special cause. Clinical deterioration events occurring with active CSOs were evaluated by using a Fisher's exact test. Pediatric palliative care (PPC) consultation rates were tracked as a balancing measure.

The average percentage of patients who received a CSO placed in their chart within 72 h of admission to the CCT increased from 5% to 61% over 6 months. Rates of CSO placement before clinical deterioration events improved from 9% to 44% (p = 0.04) and rates of patients who received PPC consultation remained stable (1% of patients to 5%, p = 0.16).

Interventions targeting knowledge in performing CSDs and multidisciplinary stakeholder engagement improved rates of code status discussions on the CCT. Further study is needed to evaluate these interventions in other practice settings.