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Electronic Screening of Dictated Reports to Identify Patients with Do-Not-Resuscitate Status

Affiliations of the authors: Departments of Biomedical Informatics & Emergency Medicine, Vanderbilt University, Nashville, TN (DA); Division of Medical Ethics (EK, JAJ), Department of Medical Informatics (PJH), Division of Pulmonary Medicine (NCD), LDS Hospital, University of Utah, Salt Lake City, UT

Correspondence and reprints: Dominik Aronsky, MD, PhD, Department of Biomedical Informatics, Eskind Biomedical Library, Vanderbilt University Medical Center, 2209 Garland Avenue, Nashville, TN 37232-8340; e-mail: <dominik.aronsky{at}vanderbilt.edu>.

Received for publication: 12/18/03; accepted for publication: 05/10/04.

Objective: Do-not-resuscitate (DNR) orders and advance directives are increasingly prevalent and may affect medical interventions and outcomes. Simple, automated techniques to identify patients with DNR orders do not currently exist but could help avoid costly and time-consuming chart review. This study hypothesized that a decision to withhold cardiopulmonary resuscitation would be included in a patient's dictated reports. The authors developed and validated a simple computerized search method, which screens dictated reports to detect patients with DNR status.

Methods A list of concepts related to DNR order documentation was developed using emergency department, hospital admission, consult, and hospital discharge reports of 665 consecutive, hospitalized pneumonia patients during a four-year period (1995–1999). The list was validated in an independent group of 190 consecutive inpatients with pneumonia during a five-month period (1999–2000). The reference standard for the presence of DNR orders was manual chart review of all study patients. Sensitivity, specificity, predictive values, and nonerror rates were calculated for individual and combined concepts.

Results The list of concepts included: DNR, Do Not Attempt to Resuscitate (DNAR), DNI, NCR, advanced directive, living will, power of attorney, Cardiopulmonary Resuscitation (CPR), defibrillation, arrest, resuscitate, code, and comfort care. As determined by manual chart review, a DNR order was written for 32.6% of patients in the derivation and for 31.6% in the validation group. Dictated reports included DNR order–related information for 74.5% of patients in the derivation and 73% in the validation group. If mentioned in the dictated report, the combined keyword search had a sensitivity of 74.2% in the derivation group (70.0% in the validation group), a specificity of 91.5% (81.5%), a positive predictive value of 80.9% (63.6%), a negative predictive value of 88.0% (85.5%), and a nonerror rate of 85.9% (77.9%). DNR and resuscitate were the most frequently used and power of attorney and advanced directives the least frequently used terms.

Conclusion Dictated hospital reports frequently contained DNR order–related information for patients with a written DNR order. Using an uncomplicated keyword search, electronic screening of dictated reports yielded good accuracy for identifying patients with DNR order information.

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