In-Hospital Code Status Updates: Trends Over Time and the Impact of COVID-19
Abstract
Retrospective study comparing historical EMR code-status documentation with daily admission updates in ICU and ED patients, examining documentation accuracy and changes during COVID-19.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
9 of 16 cited sources checked · 5 supported · 0 flagged · accuracy not yet measured
- Premisecitation
Missing code status documentation can create care discrepancies, especially when the patient's actual preference differs.
“This may lead to discrepancies in care, particularly if the patient's preferred code status were different.9,10”
Quote in the paperSubstantial claim1 of 2 sources checked- cites [9] 9. Jain VG, Greco PJ, Kaelber DC. Code status reconciliation to improve identification and documentation of code status in electronic health records. Appl Clin Inform. 2017;8(1):226-234. doi:10.4338/ACI-2016-08-RA-0133. source
- cites [10] 10. Weinerman AS, Dhalla IA, Kiss A, et al. Frequency and clinical relevance of inconsistent code status documentation. J Hosp Med. 2015;10(8):491-496. doi:10.1002/jhm.2348. source
- Interpretationown data
The data indicate that the pandemic setting contributed to how patients made code status decisions.
“Although our study did not directly investigate these hypotheses, the data suggests that the pandemic context played a role in shaping patient choices.5”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [5] 5. Jacobson E, Troost JP, Epler K, et al. Change in code status orders of hospitalized adults with COVID-19 throughout the pandemic: A retrospective cohort study. J Palliat Med. 2023. doi:10.1089/jpm.2022.0578. source
- Rests on an assumption: Documented code status accurately reflects patients' actual preferences for resuscitation.
- Premisecitation
Even in the ED's aggressive care setting, routine code status conversations can make patients' status clearer before inpatient admission.
“Regular code status discussions, despite the ED's aggressive care nature, can enhance clarity on patients' code status prior to inpatient care.17,18”
Quote in the paperSubstantial claim1 of 2 sources checked- cites [17] 17. Miller DG, Vakkalanka JP, Swanson MB, et al. Is the emergency department an inappropriate venue for code status discussions? Am J Hosp Palliat Care. 2021;38(3):253-259. doi:10.1177/ 1049909120938332. source
- cites [18] 18. Lindner SA, Davoren JB, Vollmer A, et al. An electronic medical record intervention increased nursing home advance directive orders and documentation. J Am Geriatr Soc. 2007; 55(7):1001-1006. doi:10.1111/j.1532-5415.2007.01214.x. source
The Discussion (page unavailable) reports improved documentation of advance-directive discussions and greater concordance between resuscitation orders and patient preferences, supporting the general point about clearer code status. But the study concerns nursing-home admissions, not discussions in an emergency department before inpatient admission. The Intervention section also says the intervention did not actively target patient–clinician discussions. (LLM, conf=0.86)
Experimental — accuracy not yet measured
- Premisecitation
If a patient's code status is absent from the electronic record, the default is full code.
“When a patient's code status is not explicitly documented in electronic health care records (EHRs), the patient defaults to 'full code.'”
Quote in the paperSubstantial claim1 of 2 sources checked- cites [9] 9. Jain VG, Greco PJ, Kaelber DC. Code status reconciliation to improve identification and documentation of code status in electronic health records. Appl Clin Inform. 2017;8(1):226-234. doi:10.4338/ACI-2016-08-RA-0133. source
- cites [10] 10. Weinerman AS, Dhalla IA, Kiss A, et al. Frequency and clinical relevance of inconsistent code status documentation. J Hosp Med. 2015;10(8):491-496. doi:10.1002/jhm.2348. source
- Premisecitation
When documented code status does not match what patients want, resources such as ventilators may be overused for patients who would choose DNR, especially in crises like COVID-19.
“Misalignments between code status documentation and patients' actual desires can lead to overallocation of resources like ventilators to patients who would prefer DNR, particularly during crises like COVID-19 where resource allocation decisions are challenging and access to health care may be limited.[13][14][15]”
Quote in the paperSubstantial claim1 of 3 sources checked- cites [13] 13. Biller-Andorno N, Ferrario A, Joebges S, et al. AI support for ethical decision-making around resuscitation: proceed with care. J Med Ethics. 2022;48(3):175-183. doi:10.1136/medethics-2020- 106786. source
- cites [14] 14. Handfield R, Finkenstadt DJ, Schneller ES, et al. A commons for a supply chain in the post-COVID-19 era: The case for a re- formed strategic national stockpile. Milbank Q. 2020;98(4): 1058-1090. doi:10.1111/1468-0009.12485. source
The Background reports ventilator shortages during COVID-19 and difficulties distributing scarce medical supplies. It does not discuss code-status documentation, patients’ DNR preferences, or whether a mismatch between them causes ventilators to be overallocated. The copy provides no page numbers for these passages. (LLM, conf=0.84)
Experimental — accuracy not yet measured - cites [15] 15. Finkenstadt DJ, Handfield R. Blurry vision: Supply chain vis- ibility for personal protective equipment during COVID-19. J Purch Supply Manag. 2021;27(3):100689. doi:10.1016/j. pursup.2021.100689. source
- Findingown data
After the updates, the share of ICU days with no Not Specified patients fell from 100% to 41.6%.
“The proportion of days without NS patients decreased from 100% to 41.6%.”
Quote in the paperSubstantial claim - Findingown data
Adding daily code status updates at admission lowered the amount of missing code status documentation to a greater extent in the ICU than in the ED.
“Implementing daily updates upon admission was more effective in ICUs than in the ED in reducing missing code status documentation.”
- Also stated in: § Results · plain
“The ICU experienced a significant decrease in the number of patients with NS codes following code status updates, indicating the system's effectiveness.The proportion of days without NS patients decreased from 100% to 41.6%.However, the ED still had some NS coded patients before and after the update.T-tests confirmed the changes were more significant in the ICU than the ED.”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
For ICU patients whose prior records lacked a code, the new census showed 78% selecting full code, 13% DNR, 6% limited code, and 2% still without a code.
“Table 1 shows that, in the ICU, most patients with unknown code status under the old census chose full code (78%) in the new census, followed by DNR (13%).LC was the least favored (6%), and 2% remained without a code.”
Quote in the paperSubstantial claim - Findingown data
The ED continued to have patients with Not Specified code status both before and after the update.
“However, the ED still had some NS coded patients before and after the update.”
Quote in the paperNot a substantial claim - Findingown data
In the ICU, more patients with Not Specified status moved to full code at admission during COVID-19 than before it, a statistically significant difference.
“When compared to pre-COVID, a larger percentage of patients switched to FC and a smaller percentage switched to DNR from NS upon ICU admission during the COVID period.The differences are statistically significant.”
Quote in the paperSubstantial claim - Findingown data
In the ICU, fewer patients with Not Specified status moved to DNR at admission during COVID-19 than before it, a statistically significant difference.
“When compared to pre-COVID, a larger percentage of patients switched to FC and a smaller percentage switched to DNR from NS upon ICU admission during the COVID period.The differences are statistically significant.”
Quote in the paperSubstantial claim - Interpretationown data
By moving up to 13% of ICU patients from Not Specified to DNR, the updated system avoids resource mismatches for those patients.
“The new system effectively prevents resource mismatches for up to 13% of ICU patients through transitions from NS to DNR.”
Quote in the paperSubstantial claim- Rests on an assumption: When code status is left unspecified after admission, mismatches are common and can result in excessive care for patients who would have chosen limited or DNR status.
- Interpretationown data
The findings indicate that during a health crisis like a pandemic, patients' choices about code status, especially DNR, may change.
“However, our findings suggest that in the unique circumstances of a health care crisis such as a pandemic, patients' inclinations towards code status decisions, specifically DNR, may shift.”
Quote in the paperSubstantial claim- Rests on an assumption: Documented code status accurately reflects patients' actual preferences for resuscitation.
- Study design and conductown data
Detailed patient characteristics and demographic data were not available to the study.
“Additionally, we did not have access to detailed patient characteristics and demographic information.”
Quote in the paperSubstantial claim - Study design and conductown data
The ICU data showed a large standard deviation, reflecting substantial variation in patients' code status decisions.
“Notably, the high standard deviation observed in the ICU data indicates a wide variation in patient decisions regarding code status.”
Quote in the paperNot a substantial claim - Study design and conductown data
The study did not have patient-level records connecting each patient to post-admission code status changes.
“While we had access to the number of patients in each code status category daily, we lacked patient-level data linking individual patients to changes in status post-admission.”
Quote in the paperSubstantial claim - Study design and conductown data
The study lacked individual-level records for patients who were first in the ED and later in the ICU.
“In addition, we did not have individual-level data on patients seen first in ED and then in ICU.”
Quote in the paperNot a substantial claim - Interpretationown data
The pandemic shifted patient preferences in the direction of full code status.
“The COVID-19 pandemic's influence on shifting patient preferences towards full code status underscores the need for adaptable documentation practices.”
Quote in the paperSubstantial claim- Rests on an assumption: Documented code status accurately reflects patients' actual preferences for resuscitation.
- Interpretationown data
Having active discussions about code status in the hospital was linked to a marked drop in patients whose code was unknown.
“In this exploratory study, we found that active code status discussions in the hospital was associated with a notable reduction in patients with unknown codes.”
Quote in the paperSubstantial claim - Interpretationown data
The effect of code status updates in the ED may be small.
“However, updating code status in the ED may have limited impact.”
Quote in the paperSubstantial claim - Study design and conductown data
Without detailed patient characteristics and demographics, the study cannot fully explain why patient decisions varied or what drove code status changes during hospitalization.
“The absence of this information restricts our ability to understand fully the reasons behind the variability in patient decisions and the factors influencing changes in code status during hospitalization.”
Quote in the paperSubstantial claim
- Classified as probably not a substantial claim. 4
- May combine two claims. 10
- The quote only partly states this claim. 1
Probably not a substantial claim: may not pass S3 (load-bearing).
InterpretationcitationThe present result agrees with another study that found declining selection of limited resuscitation options over the pandemic.
“This finding is in line with another study that also saw fewer people choosing limited resuscitation options as the pandemic went on.5”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [5] 5. Jacobson E, Troost JP, Epler K, et al. Change in code status orders of hospitalized adults with COVID-19 throughout the pandemic: A retrospective cohort study. J Palliat Med. 2023. doi:10.1089/jpm.2022.0578. source
Probably not a substantial claim: may not pass S2 (checkable).
PremisecitationThe code status recorded for a patient is essential for guiding resuscitation in hospitals.
“This information, recorded in the patient's code status, is crucial for resuscitation management in hospitals.7”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [7] 7. Bhatia HL, Patel NR, Choma NN, et al. Code status and re- suscitation options in the electronic health record. Resuscitation. 2015;87:14-20. doi:10.1016/j.resuscitation.2014.10.022. source
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationPrior work suggests that discussing code status early in admission may relate to preference changes, with many patients moving from full code to DNR.
“Some studies have suggested that early code status discussions during hospital admission may be associated with changes in patient preferences, with a significant proportion switching from full code to DNR. 12”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [12] 12. El-Jawahri A, Lau-Min K, Nipp RD, et al. Processes of code status transitions in hospitalized patients with advanced cancer. Cancer. 2017;123(24):4895-4902. doi:10.1002/cncr.30969. source
The Results report that 26.3% of patients transitioned from full-code to DNR orders during hospitalization. But 48.7% of those patients already preferred DNR before admission, so their order changes did not represent changes in preference. The Discussion recommends prompt admission discussions; it does not establish that early discussions were associated with preference changes. (LLM, conf=0.88)
Experimental — accuracy not yet measured
May combine two claims.
PremisecitationAccurate code status documentation has been linked to better care, lower costs, shorter ICU stays, fewer readmissions, and greater patient satisfaction.
“Proper code status documentation is associated with improved patient care, reduced health care costs, shortened ICU stays, lower readmission rates, and increased patient satisfaction.8”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [8] 8. Briedé S, van Goor HMR, de Hond TAP, et al. Code status documentation at admission in COVID-19 patients: A de- scriptive cohort study. BMJ Open. 2021;11(11):e050268. doi: 10.1136/bmjopen-2021-050268. source
The Introduction (page not provided) says code status discussions have been shown to reduce ICU length of stay, ICU readmissions and healthcare costs, and can help align care with patients’ wishes. It says these discussions do so without impacting patient satisfaction—not that they increase it. The reported benefits concern discussions rather than documentation alone. (LLM, conf=0.90)
Experimental — accuracy not yet measured
May combine two claims.
Findingown dataAfter the COVID mitigation date, the ICU pattern of more full code and less DNR from Not Specified status remained, but the differences were no longer statistically significant.
“This difference persisted in the COVID-mitigation period as well, but the percentage differences were no longer statistically significant.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataAfter the update, 75% of ED patients still had no code; of those who selected one, 24% chose full code and only 1% chose DNR or limited code.
“In the ED, a large percentage of patients (75%) still lacked a code after the update.Among those who chose a code, full code was the most common (24%), with minimal selections of DNR or LC (1%).”
Quote in the paperSubstantial claimMay combine two claims. The quote only partly states this claim.
Findingown dataIn the ED, more patients with Not Specified status moved to full code both during and after COVID-19 than before it, with significant differences.
“In the ED, both during and post-COVID, a larger percentage of patients switched to both FC and DNR from NS, implying a larger percentage of total patients switched out of NS code status.In all cases, the differences were significant.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataAt the study hospital, the average share of patients with unspecified code status fell below 1% in the ICU and by about half in the ED.
“The code status documentation within the focal hospital saw an average decrease in unspecified patients to less than 1% in the ICU and about half in the ED.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataIn the ED, more patients with Not Specified status moved to DNR both during and after COVID-19 than before it, with significant differences.
“In the ED, both during and post-COVID, a larger percentage of patients switched to both FC and DNR from NS, implying a larger percentage of total patients switched out of NS code status.In all cases, the differences were significant.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataAbout 37% of ICU admissions and 16% of ED admissions that had no prior code status chose a specific code after talking with clinicians.
“Approximately 37% of admitted ICU patients and 16% of admitted ED patients without a prior code status elected a specific code after consulting with medical staff.”
Quote in the paperSubstantial claimMay combine two claims.
PremisecitationPost-admission code status updates and documentation increase accuracy and support informed decisions.
“Updating and documenting code status after admission not only improves accuracy but also enhances informed decisionmaking.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [11] 11. Gehlbach TG, Shinkunas LA, Forman-Hoffman VL, et al. Code status orders and goals of care in the medical ICU. Chest. 2011; 139(4):802-809. doi:10.1378/chest.10-1798. source
May combine two claims.
Interpretationown dataThat earlier study included only COVID-19 inpatients, while the current data cover all ICU and ED patients.
“However, they only studied patients hospitalized with COVID-19 while our data set consists of all patients in the ICU and ED.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
InterpretationcitationThe present results agree with an earlier study of palliative care embedded in the ED, which found clinical and financial gains from early goal-concordant discussions there.
“Our findings align with those from a study of an ED-embedded palliative care service, which observed meaningful clinical and financial benefits, including a 10fold surge in consultations, from early discussions about goal-concordant care in the ED.16”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [16] 16. Wang DH, Heidt R. Emergency department embedded palliative care service creates value for health systems. J Palliat Med. 2023;26(5):646-652. 10.1089/jpm.2022.0245. source
The paper relies on this without support.
When code status is left unspecified after admission, mismatches are common and can result in excessive care for patients who would have chosen limited or DNR status.
“Code status mismatches often occur when code status remains unspecified after admission, leading to potentially excessive care for patients who would prefer a limited or DNR code.”
The paper relies on this without support.
Documented code status accurately reflects patients' actual preferences for resuscitation.
“We also investigated if the COVID-19 pandemic affected patients' code status preferences (Table 2).”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Abstract overstates transitions from unspecified status to DNR
MajorThe abstract says around 20% chose DNR, but Table 1 reports 13.4% for the ICU and 1.81% for the ED among patients whose old status was unspecified.
“Around 20% of patients without a specific code status chose DNR under the new system.”
“| ICU | 78.78 [13.44] | 13.4 [13] | 5.68 [9.23] | 2.14 [3.2] | | ED | 23.67 [8.14] | 1.81 [2.2] | .1 [.58] | 74.41 [8.28] |”
Funding statement conflicts with acknowledgement
MinorThe acknowledgements expressly thank two organizations for financial support, while the funding declaration says the authors received none for the research, authorship, or publication.
“The author(s) received no financial support for the research, authorship, and/or publication of this article.”
“We appreciate the financial support of the Business Management Department at the Poole College of Management and the Supply Chain Resource Cooperative at the NC State University.”
Reported days without unspecified ICU patients move opposite to the claimed improvement
MinorIf 100% of days initially had no patients with unspecified status, the ICU initially had none on any day. That cannot coexist with the stated decrease in such patients after updates.
“The proportion of days without NS patients decreased from 100% to 41.6%.”
“The ICU experienced a significant decrease in the number of patients with NS codes following code status updates, indicating the system's effectiveness.”
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Sorted by citations
Physicians’ opinion of patients’ CPR decision: Secondary analysis from a pilot RCT
Ji, S., Pisciotti, A., Patel, M., et al. (2025) · Resuscitation Plus · doi:10.1016/j.resplu.2025.100967
“23 Patients without confirmed code status pick no resuscitation as frequently as 20% when asked, 23,24 and communication interventions—which improve patient knowledge—lead to lower preference for CPR. 3 As code status discussions take less than five minutes on average, 18 it is clear that the added…”
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- Authors
- Sahebi-Fakhrabad, A., Kemahlioglu-Ziya, E., Handfield, R., Wood, S., Patel, M. D., Page, C. P., & Chang, L.
- Affiliations
- North Carolina State University (US)
- Department of Business Management, Poole College of Management, NC State University, Raleigh, NC, USA
- University of North Carolina at Chapel Hill (US)
- Asheville Pulmonary and Critical Care Associates, Asheville, NC, USA
- Venue
- American Journal of Hospice and Palliative Medicine®
- Publisher
- SAGE Publications
- Published
- 2023-12-18
- Volume
- 41
- Issue
- 11
- Pages
- 1363-1367
- ISSN
- 1049-9091 (ISSN-L)
- 1938-2715
- OpenAlex
- W4389954178
- Cited by
- 2
- References
- 21
- Citations by year
- 2025: 2
- FWCI
- 0.51
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- American Journal of Hospice and Palliative Medicine® (publishedVersion)
- PubMed (publishedVersion)
- Funders
- North Carolina State University
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
- Health Sciences › Health Professions › General Health Professions › Ethics in medical practice
- Keywords
- do-not-resuscitate orders, patient preferences, COVID-19 pandemic, intensive care unit, emergency department, trauma hospital, end-of-life decisions, patient education
- MeSH terms
- COVID-19, Adult, Aged, Documentation, Emergency Service, Hospital, Female, Humans, Intensive Care Units, Male, Middle Aged, Retrospective Studies, Resuscitation Orders, Patient Preference, Electronic Health Records
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