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Improving resuscitation decisions: a trust-wide initiative
  1. Michael G Fadel1,
  2. Krishan Parekh2,
  3. Paul Hayden2,
  4. Priya Krishnan2
  1. 1 Department of General Surgery, Medway NHS Foundation Trust, Gillingham, UK
  2. 2 Department of Intensive Care Medicine and Anaesthesia, Medway NHS Foundation Trust, Gillingham, UK
  1. Correspondence to Dr Michael G Fadel; michael.fadel{at}


Introduction Treatment escalation plans (TEPs) are important to ensure that every patient has their ceiling of care discussed and documented formally. At Medway Foundation Trust, we introduced TEP forms in September 2016 which are to be completed by the relevant consultant within 24 hours of admission.

Aims and methods To evaluate whether TEP forms had been effective at improving escalation planning and whether they had a subsequent impact in do not attempt cardiopulmonary resuscitation (DNACPR) decision-making. We carried out three plan-do-study-act cycles over a 2-year period across 100 patients in medicine and surgery.

Results TEP forms were initially found in 66% (66/100) of the patient notes and 34% (34/100) were completed appropriately. There was a 13% relative improvement in resuscitation decision-making, since the introduction of the TEP forms from November 2015 to January 2017. There was also a 12% reduction in inappropriate referrals to critical care during the same period. We decided to revise the TEP form through extensive collaboration and educate all staff members about the importance of escalation planning. This has led to an improvement in TEP discussion and documentation across the entire trust.

Conclusion TEPs can be an effective way of considering and communicating ceilings of care. They should encourage doctors to consider DNACPR decisions for patients who otherwise would not have been considered, and therefore may help reduce inappropriate referrals to critical care. The higher completion rates of the new form and increased clarity among staff regarding escalation planning should lead to an improvement in patient safety outcomes and communication between all patients and staff members. We believe it would be feasible to implement our user-friendly TEP form across other National Health Service organisations in order to develop a universal TEP form.

  • communication
  • critical care
  • decision making
  • patient-centred care
  • quality improvement

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  • Contributors MGF designed and led the audit cycles, collected and analysed and the data, and performed the write-up. KP took part in the audit cycles and helped with collecting and analysing the data. PH supported the data analysis and reviewing of the manuscript. PK supervised the audit cycles, helped with analysing and presenting the work and writing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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