I had the pleasure of interviewing Adina Weinerman, MD, a hospitalist in the Division of General Internal Medicine at Sunnybrook Health Sciences Centre in Toronto, about her team's recent publication in the Journal of Hospital Medicine (JHM) ."
This "point prevalence" study from three academic medical centers found that 65% of inpatients had at least one code status documentation inconsistency, and 20% were clinically relevant.
What is your background and how did you become interested in evaluating inconsistencies in code status in the medical record?
Weinerman: "I did my IM residency at University of Toronto, and during my last year I had the opportunity to do an administrative position as a chief resident, which helped me get a good understanding of the administrative side of medical centers. Also during my residency, I was surrounded by mentors in quality improvement at the University, and the Hospital gave me many opportunities to do QI research. This specific topic was interesting to me, as I have seen and continue to see the daily inefficiencies of documentation and the ramifications of documentation inconsistencies. So this topic really blends my administrative and QI backgrounds into interesting research that can be translated into real quality improvement projects."
How should hospitalists "streamline" code status documentation to avoid the risk of having inconsistencies?
Weinerman: "The ideal solution is reducing the overall number of places that documentation can occur and ensuring that appropriate documentation can accurately 'flow' to other critical places in the medical record. For the day-to-day hospitalist, it is important to make sure code status is documented in the place you need to see it, should a cardiac arrest occur. In the absence of a better solution, we should at least be consistent from patient to patient and always document it in the same place within our practices."
Were there any unexpected findings in your study?
Weinerman: "There were no real surprises in the findings. The one finding that 'lingers' as disturbing is that we found an independent association with clinically relevant inconsistencies among the elderly and among those receiving comfort measures. These patients are more likely to have pre-expressed wishes of DNR, which can make inconsistencies more likely to happen."
Where does this take you with respect to future research efforts?
Weinerman: "These findings are probably generalizable beyond code status (allergies, diet, medications, etc.), so our next research efforts will use QI methods to reduce the risk of documentation discrepancies and identify the 'source of truth' and create compatible information sources for multiple domains of care, including code status."
Adina Weinerman, MD, is a clinical associate in the Division of Internal Medicine at Sunnybrook Health Sciences Centre in Toronto. Her research interests are in the area of quality improvement and patient safety. She will be completing her Masters of Health Administration from University of Toronto's Institute of Health Policy, Management and Evaluation (IHPME) in June 2015.
Danielle Scheurer, MD, is a clinical hospitalist and the Medical Director of Quality and Safety at the Medical University of South Carolina in Charleston, S.C., and is an assistant professor of Medicine there. She also serves as the web editor and physician adviser for the Society of Hospital Medicine.
A version of this article originally appeared at The Hospital Leader blog, the official blog of the Society of Hospital Medicine (SHM), which features bloggers who provide insights and expertise on the most compelling issues in the specialty of hospital medicine. Visit to read some of the latest perspectives in hospital medicine.