Change in Code Status Orders of Hospitalized Adults With COVID-19 Throughout the Pandemic: A Retrospective Cohort Study

Abstract

Aim: Our aim was to examine how code status orders for patients hospitalized with COVID-19 changed over time as the pandemic progressed and outcomes improved. Methods: This retrospective cohort study was performed at a single academic center in the United States. Adults admitted between March 1, 2020, and December 31, 2021, who tested positive for COVID-19, were included. The study period included four institutional hospitalization surges. Demographic and outcome data were collected and code status orders during admission were trended. Data were analyzed with multivariable analysis to identify predictors of code status. Results: A total of 3615 patients were included with full code (62.7%) being the most common final code status order followed by do-not-attempt-resuscitation (DNAR) (18.1%). Time of admission (per every six months) was an independent predictor of final full compared to DNAR/partial code status (p = 0.04). Limited resuscitation preference (DNAR or partial) decreased from over 20% in the first two surges to 10.8% and 15.6% of patients in the last two surges. Other independent predictors of final code status included body mass index (p < 0.05), Black versus White race (0.64, p = 0.01), time spent in the intensive care unit (4.28, p = <0.001), age (2.11, p = <0.001), and Charlson comorbidity index (1.05, p = <0.001). Conclusions: Over time, adults admitted to the hospital with COVID-19 were less likely to have a DNAR or partial code status order with persistent decrease occurring after March 2021. A trend toward decreased code status documentation as the pandemic progressed was observed.

Keywords: COVID-19; advanced care planning; cardiopulmonary arrest; do-not-attempt-resuscitation; resuscitation preferences.

FIG. 1.

Diagram of change in initial and last code status over time by pandemic surge (N = 3165). Transition frequencies of initial code status from first to fourth surge: DNAR 81 (12%) first (12%) to 112 (13%) second to 45 (6%) third to 86 (9%) fourth surge; full code 470 (70%) to 563 (66%) to 491 (71%) to 628 (66%); partial code 31 (5%) to 1–2% in second through fourth surge. Transition frequencies of last code status from first to fourth surge: DNAR 144 (21%) to 159 (19%) to 63 (9%) to 134 (14%); full code 407 (60%) to 518 (61%) to 474 (68%) to 587 (62%); partial code 31 (5%) to 1–2% second through fourth surge. The percentage without a code status order increased from 14% and 18% (N = 93 and 155) in the first two surges to 21% and 22% (N = 144 and 213) in final surges. DNAR, do-not-attempt-resuscitation.

FIG. 2.

Diagram of change in initial and last code status over time (bimonthly) from March 2020 through December 2021 (N = 3165).