DNACPR and TEP completion rates: a multi-cycle audit from paper forms to an online system

Introduction 

DNACPR and TEP documentation is a common source of complaints and distress for patients and relatives, particularly when decisions and communications with patients and next of kin (NOK) are poorly recorded. We identified a risk at our hospital: these forms remained paper-based while all other documentation had moved online. We conducted a multi-cycle audit to improve DNACPR/TEP documentation, using the findings to advocate for a transition to online forms, then supported the rollout with education and re-audited to assess impact. 

Method 

We audited paper DNACPR forms on care-of-elderly wards against five parameters: consultant countersignature, discussion with patient, discussion with NOK, documented clinical reasoning for escalation status, and Mental Capacity Assessment. Staff feedback on the paper forms' usability supplemented this quantitative data to support the case for change. Ahead of the online rollout, we communicated via email, grand round, and small-group teaching, with ward walk-arounds on rollout day. A safety-check audit followed one week post-rollout, after which we distributed a "how-to" poster. A full re-audit of the same five parameters followed at 4 months. 

Results 

The number of patients with a documented DNACPR increased across cycles: 67 (baseline) → 90 (post-rollout) → 103 (4 months), suggesting escalation status was more consistently considered and recorded after the move online. The change did not improve completion of 4 of the 5 parameters, though documented clinical reasoning improved from 77% to 97%. A staff survey on the transition experience and to understand remaining barriers is ongoing. 

Conclusion 

Transitioning to online forms, supported by targeted education, was associated with more consistent consideration and documentation of escalation status. However, most individual completion parameters remained stable and did not improve, indicating further work - potentially small-group teaching - is needed to address remaining barriers.