Inclusion, exclusion and audit criteria

DEMO DATA

Customise who to include and who to exclude for this audit cycle. Edits are saved automatically to your workspace.

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Inclusion criteria
  • •Adults aged 16 years or older, unless locally adapted
  • •Adult inpatients with a DNACPR decision, ReSPECT plan or local treatment escalation plan
  • •Adult inpatients where DNACPR / ReSPECT / treatment escalation planning should reasonably have been considered under local policy
  • •Adults with serious illness, frailty, advanced disease, risk of deterioration, end-of-life care needs or treatment escalation uncertainty
  • •Admissions during the selected audit period
  • •Electronic, paper or hybrid records depending on local setup
Exclusion criteria & limitations
  • •Patients under 16 years old unless locally adapted
  • •Paediatric ReSPECT or escalation planning pathways unless locally adapted
  • •Obstetric patients unless locally adapted to maternity policy
  • •Patients where DNACPR / ReSPECT / treatment escalation planning was not clinically relevant under local policy
  • •Duplicate records or duplicate admission episodes
  • •Records outside the selected audit period
  • •Records unavailable for review
  • •Cases where local governance approval is required but has not been obtained
  • •Direct patient identifiers must not be entered into the tool
Audit criteria (26)
Aligned with Resuscitation Council UK (ReSPECT / DNACPR guidance), GMC end-of-life good practice guidance, NICE NG142 and local DNACPR / ReSPECT / treatment escalation planning policy. Compliance is calculated using Yes and No responses only; Not applicable and Unable to determine are excluded from the denominator.
  1. C1
    Relevant DNACPR, ReSPECT or local treatment escalation documentation was present where clinically required or considered.
    Target ≥ 90% · auto-computed from submissions
  2. C2
    Documentation type was clear (DNACPR, ReSPECT, local TEP, advance care plan or equivalent).
    Target ≥ 90% · auto-computed from submissions
  3. C3
    CPR recommendation was clearly documented where applicable.
    Target ≥ 90% · auto-computed from submissions
  4. C4
    Broader treatment escalation recommendations were documented where ReSPECT or local TEP is used.
    Target ≥ 90% · auto-computed from submissions
  5. C5
    Ceiling of care was documented where clinically relevant.
    Target ≥ 85% · auto-computed from submissions
  6. C6
    Clinical rationale for the recommendation or decision was documented.
    Target ≥ 90% · auto-computed from submissions
  7. C7
    Senior clinician responsibility was documented in line with local policy.
    Target ≥ 90% · auto-computed from submissions
  8. C8
    The documentation was completed, reviewed or authorised by an appropriate clinician according to local policy.
    Target ≥ 90% · auto-computed from submissions
  9. C9
    Patient capacity was documented where a decision or discussion was required.
    Target ≥ 90% · auto-computed from submissions
  10. C10
    Patient involvement was documented where appropriate.
    Target ≥ 85% · auto-computed from submissions
  11. C11
    Where the patient was not involved, the reason was documented.
    Target ≥ 85% · manual review
  12. C12
    Family, carer, legal proxy or important-person communication was documented where appropriate.
    Target ≥ 90% · auto-computed from submissions
  13. C13
    Where family / important-person communication was not undertaken, the reason was documented where relevant.
    Target ≥ 85% · manual review
  14. C14
    Best interests decision-making was documented where the patient lacked capacity and a decision was required.
    Target ≥ 90% · auto-computed from submissions
  15. C15
    Advance decision to refuse treatment or legal proxy status was considered where relevant.
    Target ≥ 85% · auto-computed from submissions
  16. C16
    Patient wishes, values, goals or priorities were documented where possible.
    Target ≥ 85% · auto-computed from submissions
  17. C17
    ReSPECT, DNACPR or TEP form was complete according to local documentation requirements.
    Target ≥ 90% · auto-computed from submissions
  18. C18
    The plan was visible and accessible in the clinical record.
    Target ≥ 95% · auto-computed from submissions
  19. C19
    The plan was communicated to the MDT, nursing team or relevant clinicians where appropriate.
    Target ≥ 85% · auto-computed from submissions
  20. C20
    The plan was reviewed after significant clinical change, transfer, new senior review or change in goals of care where relevant.
    Target ≥ 85% · auto-computed from submissions
  21. C21
    Out-of-hours deterioration plan was documented where clinically relevant.
    Target ≥ 80% · auto-computed from submissions
  22. C22
    Discharge communication included DNACPR / ReSPECT / TEP status where relevant and locally appropriate.
    Target ≥ 85% · auto-computed from submissions
  23. C23
    Uncertainty, conflict, disagreement or unresolved decision-making was escalated where relevant.
    Target ≥ 90% · manual review
  24. C24
    Reason for delayed, missing or incomplete documentation was recorded where applicable.
    Target ≥ 85% · manual review
  25. C25
    Documentation was clear enough for another clinician to understand CPR and treatment escalation recommendations.
    Target ≥ 90% · auto-computed from submissions
  26. C26
    Any DNACPR / ReSPECT / treatment escalation safety concern was escalated or actioned where identified.
    Target ≥ 100% · auto-computed from submissions