Increasing timely code status discussions in hospitalized children with medical complexity

Area of Science:

• Pediatric Healthcare Quality Improvement
• Medical Ethics in Pediatrics
• Complex Care Management

Background:

• Children with medical complexity (CMC) face high hospitalization and deterioration risks.
• Lack of documented code status orders (CSOs) concordant with family goals leads to unintended consequences.
• Timely CSOs are critical for aligning care with patient and family wishes.

Purpose of the Study:

• To increase the percentage of patients with timely code status orders (CSOs) from 5% to 80% within 6 months.
• To improve documentation of care preferences for children with medical complexity.
• To reduce the risk of adverse events due to undocumented code status.

Main Methods:

• A quality improvement project at a children's hospital involving the complex care team (CCT).
• Utilized plan-do-study-act cycles targeting knowledge of code status discussions (CSDs) and institutional policies.
• Employed P-charts for intervention tracking and Fisher's exact test for clinical deterioration events.

Main Results:

• The percentage of patients with CSOs within 72 hours of CCT admission increased from 5% to 61%.
• CSO placement before clinical deterioration improved from 9% to 44% (p=0.04).
• Pediatric palliative care consultation rates remained stable (1% to 5%).

Conclusions:

• Interventions improved code status discussion rates on the CCT by targeting knowledge and stakeholder engagement.
• Multidisciplinary efforts are effective in enhancing code status documentation.
• Further research is needed to validate these interventions in diverse settings.