Improving Care after cardiac arrest by informing surrogate decision makers

项目摘要-通过通知代理决策者改善心脏骤停后的护理 心脏骤停后的存活率和神经恢复是高度可变的，部分原因是不一致 成功复苏后的医院护理。在以证据为基础的指南的交付方面存在重大差异 协调的护理与心脏骤停的总体结局的差异有关。When指南 神经功能恢复良好的患者存活率提高。然而，遵守关于以下方面的指南 推迟停止生命支持的决定在美国各医院都存在很大的差异。原因归因于 早期停止生命维持治疗包括对国家和国际指南了解不足， 家庭对早期结局预测的要求，以及家庭对危重护理的不完全理解。在……里面 为了鼓励使用符合延迟神经预测和伴随的指南 停止生命维持治疗(复苏72小时后)我们提出了一种新的方法；教育 并告知代理决策者神经预后的不确定性和指南一致性护理。这个 这项职业发展奖中提出的研究旨在创造一种新的干预方式，将 鼓励改善神经预测和延迟WLST的指导方针，并支持 萨拉·佩尔曼博士的持续发展，她是一名早期研究员，致力于改善 院外心脏骤停。目标1将利用定性方法采访关键利益相关者 心脏骤停后昏迷患者(医生、护士、替代决策者)的决策 确定知识差距并确定与指南相一致的心脏骤停后护理的障碍。目标2将 允许我们开发和改进教育工具，以解决神经预测的不确定性和指南 和谐的逮捕后护理。利用心脏骤停专家小组和利益相关者焦点小组，我们将 执行迭代过程以改进工具并解决实施的潜在障碍。最后，在AIM中 3我们将在一个等价的时间样本准实验中对我们的教育工具进行试点测试，在那里我们实施 科罗拉多大学医院急诊科为代理决策者提供的工具 探讨院外心脏骤停患者复苏推广的可行性和可接受性 实施。先导试验的结果将进一步指导多中心实用临床的设计 尝试实施教育工具，以鼓励与指南一致的心脏骤停后护理 包括延迟神经预测和延迟停止生命维持治疗。总体而言，我们 假设通知代理决策者有关指南一致性护理的信息将导致延迟 决定停止生命维持治疗，并允许患者有足够的时间进行适当的 神经预测和唤醒，从而改善院外心脏骤停的预后。这将是 成为申请者未来R01提案的主题。

PROJECT SUMMARY – Improving care after cardiac arrest by informing surrogate decision makers Survival and neurological recovery after cardiac arrest are highly variable, driven in part by inconsistent hospital care following successful resuscitation. Significant variability in delivery of evidence based, guideline concordant care has been associated with differences in overall outcome from cardiac arrest. When guidelines are followed, survival with good neurologic recovery is improved. However, adherence to guidelines regarding delayed decision to withdraw life support has been highly variable across US hospitals. Reasons attributed to early withdrawal of life sustaining therapy include poor knowledge of national and international guidelines, requests from family for early outcome predications, and incomplete family comprehension of critical care. In order to encourage utilization of guideline concordant delayed neuro-prognostication and concomitant withdrawal of life-sustaining therapy (>72 hours after resuscitation) we propose a novel approach; to educate and inform surrogate decision makers on neuro-prognostic uncertainty and guideline concordant care. The research proposed in this career development award is intended to create a novel intervention that will encourage improved guideline adherence on neuro-prognostication and delayed WLST as well as to support the continued development of Dr. Sarah Perman, an early investigator committed to improving outcomes from out-of-hospital cardiac arrest. Aim 1 will utilize qualitative methodology to interview key stakeholders in decision making for comatose post-cardiac arrest patients (physicians, nurses, surrogate decision makers) to identify knowledge gaps and determine barriers to guideline concordant post-cardiac arrest care. Aim 2 will allow us to develop and refine educational tools to address neuro-prognostic uncertainty and guideline concordant post-arrest care. Utilizing a panel of cardiac arrest experts and stakeholder focus groups we will perform an iterative process to refine the tools and address potential barriers to implementation. Finally, in Aim 3 we will pilot test our educational tools in an equivalent time-samples quasi-experiment where we implement the tools in the University of Colorado Hospital Emergency Department for surrogate decision makers of resuscitated out of hospital cardiac arrest patients to explore feasibility and acceptability for widespread implementation. The results of the pilot trial will further inform the design of a multi-center pragmatic clinical trial to implement the educational tool in order to encourage guideline concordant post-cardiac arrest care including delayed neuro-prognostication and delayed withdrawal of life-sustaining therapy. Overall, we hypothesize that informing surrogate decision makers on guideline concordant care, will result in delayed decisions to withdraw life-sustaining therapy and allow the post-arrest patient adequate timing for appropriate neuro-prognostication and awakening, thus improving outcomes from out-of-hospital cardiac arrest. This will be the subject of a future R01 proposal by the applicant.