Was there a bias in DNACPR decision-making during the COVID-19 pandemic in St David's Hospital (SDH)?

Introduction
SDH is a community hospital within Cardiff and Vale University Health Board. There are 60 -70 beds, over three geriatric wards. The primary focus is for patients requiring rehabilitation and complex discharge planning. All admissions are transfers from the acute setting. There is a high level of frailty. There are ward doctors and a consultant geriatrician within working hours (Monday-Friday), OOH cover is provided by primary care. The concern of ‘blanket’ DNACPR orders, during the COVID-19 pandemic has featured in national news reports. In part, this led to our question and audit. Method 30 sets of notes for 3 time periods: - September – November 2019 – “pre-COVID” - April – July 2020 – “COVID” - May – July 2022 – “post-COVID” Each set of notes were independently audited by two doctors – a Geriatrician and ED physician

Factors assessed:

• DNACPR Appropriateness
• Where the DNACPR decision made?
• Quality of DNACPR documentation

Results

• Sept – Nov 2019 – 22 patients. 1 for resus, 3 did not specify. 18 audited.
• Apr-July 2020 – 31 patients. 1 for resus, 3 no DNACPR form. 27 audited.
• May -July 2022 – 43 patients. 4 for resus, 1 no DNACPR form. 38 audited.

Time period Number of patients DNACPR (%) 2019 18/22 81 2020 27/31 87 2022 38/43 88

• Comparable % of DNACPR forms across time periods.
• Every DNACPR decision was felt appropriate by 2 independent auditors. 10 sets of notes outstanding for 2019 period

Conclusions

1. Appropriate decision-making and no significant change in practice during COVID period
2.  Relatively high DNACPR rates are appropriate for the patient group in this setting- reflecting frailty levels and comorbidity in this cohort
3. Audit illuminates the need for a clear escalation plan prior to patient leaving the referring hospital.