ResCU II: Improving In-hospital Cardiac Arrest Care and Discovering Keys to Super-Survivorship

项目背景：至少从VHA指令2008-063开始，改善院内心脏骤停(IHCA)护理 一直是退伍军人事务部的重要优先事项。在监察长办公室关于 IHCA在2013年(13-00054-148年)，并在2015年再次重复，形成了VHA复苏质量 改善委员会(RQI-C)，由主管临床业务的卫生助理副副部长主持。在 个人层面，大量退伍军人临床医生的时间被投入到让每个临床医生重新认证他们的基础或 每两年进行一次高级心脏生命支持培训，以改善IHCA的护理。我们之前的Rescu-1 项目确定了IHCA在退伍军人管理局护理方面的关键差距：(1)记录有助于系统的IHCA关键因素 推动质量提高，临床医生决定预后和治疗的IHCA后往往 不可用；(2)1/3至2/3的退伍军人医院未充分利用IHCA护理方面的其他最佳做法，例如模拟代码 以及IHCA结束后的汇报。然而，RESCU-1也发现(3)一些退伍军人从IHCA中恢复得很好， 成为“超级幸存者”--但我们不知道超级幸存者的护理有何不同。 具体目标：以苏醒-1号S为基础，与退伍军人管理局复苏教育合作 倡议(Redi)，我们将：A1。评估新文档模板的实施情况，将其作为 高质量的努力。A2.开发和试验新的干预措施，以改善IHCA护理，重点放在邮编 汇报、模拟代码模拟培训和代码文档。A3.确定IHCA超级幸存者& 与他们的护理有关的“最佳做法”。 项目方法：目标1将通过对所有IHCA住院患者的回顾来实现 电子病历、研究--这些病历的辅助注释和多层次统计 模特儿。目标2将使用视频现场访问来确定障碍和使用已建立的框架的促进者 (CFIR和TDF)，然后合作试行和实施干预措施(可能从虚拟学习开始 协作)，以改进文档、模拟代码和IHCA后汇报。目标3号将做深半部- 对超级幸存者、他们的非正式照顾者和类似残疾的对照患者进行结构化访谈 谁在IHCA后没有恢复，以及他们的VA临床医生来确定可能有助于 超级求生能力。这些做法与超级生存能力的联系将在一项 IHCA幸存者的预期队列。所有这些都将整合起来，与合作伙伴共同制作和传播 “代码蓝色幸存者捆绑”，为进一步改善IHCA的VA护理奠定基础。 对退伍军人医疗保健的预期影响：当患者的心脏发生在医院内的心脏骤停时 由于电或肌肉问题，有效地停止跳动。IHCA是医疗急诊；退伍军人事务部 投入大量资源应对IHCA。在VA HSR&D的RESCU-1研究中，我们发现 许多患有IHCA的退伍军人的护理可以得到重要的改善。在这项拟议的资源- 2研究，我们将与退伍军人事务部全国努力合作，改善这些基本面。在目标1中，我们将评估 改进文件编制的努力，并找出文件编制方面的不足之处。在目标2中，我们将 通过更好的文档、更好的实践和更好的方式，确定改善IHCA护理的障碍和促进者 国际人道主义援助评估后汇报情况--并设计干预措施以改进其使用情况。但Rescu-1也显示出一些 退伍军人从IHCA继续成为超级幸存者，在心脏骤停后表现出显著的恢复。 在目标3中，我们将使用混合方法来发现导致超级生存的做法，并传播 在退伍军人事务部如此出色的护理的秘诀。

Project Background: Since at least VHA Directive 2008-063, improving in-hospital cardiac arrest (IHCA) care has been an important VA priority. This focus was renewed after the Office of the Inspector General report on IHCA in 2013 (13-00054-148), and repeated again in 2015 with the formation of VHA Resuscitation Quality Improvement Committee (RQI-C) by Assistant Deputy Undersecretary for Health for Clinical Operations. At the individual level, vast amounts of VA clinician time are devoted to having every clinician recertify their Basic or Advanced Cardiac Life Support training every two years to improve the care of IHCA. Our previous ResCU-1 project identified critical gaps in VA care of IHCA: (1) documentation of key IHCA factors that help systems drive quality improvement, and clinicians determine prognosis and treatment after IHCA were often unavailable; (2) 1/3rd to 2/3rd of VA hospitals underutilized other best practices in IHCA care, e.g. mock codes and post-IHCA debriefing. Yet, ResCU-1 also found (3) some Veterans had remarkable recovery from IHCA, becoming “super-survivors”—but we do not know how the care of super-survivors differed. Specific Aims: Building on ResCU-1's foundations and in partnership with the VA Resuscitation Education Initiative (REdI), we will: A1. Assess implementation of a new documentation template as a model for quality efforts. A2. Develop & pilot new interventions to improve IHCA care, focusing on post-code debriefing, mock code simulation training, and code documentation. A3. Identify IHCA super-survivors & `best practices' associated with their care. Project Methods: Aim 1 will be accomplished by retrospective review of all IHCA hospitalizations' electronic medical records, research-assistant annotation of those records, and multi-level statistical modeling. Aim 2 will use video-site-visits to identify barriers and facilitators using established frameworks (CFIR and TDF), and then partner to pilot and implement interventions (likely beginning with virtual learning collaborative) to improve documentation, mock codes, and post-IHCA debriefing. Aim 3 will do deep semi- structured interviews with super-survivors, their informal caregivers and control patients of similar disability who did not recover after IHCA, and their VA clinicians to identify candidate practices that may contribute to super-survivorship. The association of those practices with super-survivorship will then be tested in a prospective cohort of IHCA survivors. All will be integrated to produce and disseminate with partners a `Code Blue Survivor Bundle' to form the basis of further improvements in VA care of IHCA. Anticipated Impact on Veteran's Healthcare: An in-hospital cardiac arrest occurs when a patient's heart stops beating effectively, either due to electrical or muscular problems. IHCA is a medical emergency; VA devotes great resources to responding to IHCAs. In VA HSR&D's ResCU-1 study, we discovered that important improvements can be made to the care of many Veterans who suffer IHCA. In this proposed ResCU- 2 study, we will partner with VA national efforts to improve these fundamentals. In Aim 1, we will evaluate efforts to improve documentation, and identify where documentation remains inadequate. In Aim 2, we will identify barriers and facilitators to improving IHCA care via better documentation, better practice and better post-IHCA debriefing—and design interventions to improve their use. But ResCU-1 also showed that a few Veterans go on from IHCA to become super-survivors, showing remarkable recovery after their cardiac arrest. In Aim 3, we will use mixed methods to discover practices that lead to super-survivorship, and disseminate the secrets to such excellent care throughout VA.