Exploring Institutional Variability in Neuro-prognostication for Survivors of Cardiac Arrest

项目摘要/摘要-探索神经预测中的机构变异性 心脏骤停的幸存者 心脏骤停后的生存率和神经功能恢复情况差异很大，部分原因是不一致的 成功复苏后的医院护理。来自院内外心脏骤停患者的数据 人群显示出对基于证据的心脏骤停后指南的不同应用，包括 建议延迟神经传导阻滞，定义为自发性恢复后至少72小时 流通供应商没有采纳这些建议的原因包括缺乏对以下方面的了解： 目前的指南，对逮捕后患者神经恢复不良的看法和替代决定 制造商希望尽早做出预测。为此，我们的研究团队正在开展工作， 决策支持，以支持这些进程。该拨款提案的目的是实施前研究， 了解医院的组织文化和工作流程，这些医院的早期使用率各不相同。 “不要复苏”（DNR）命令。这项工作将发现执行工作的潜在障碍和促进因素 的指导方针为基础的决策援助，并将允许更好地了解神经的做法， 以一种更普遍的方式为心脏骤停后的患者提供指导。为了支持这一整体 研究使命，我们在R 03提案中提出了以下具体目标。第一个研究目标是探索 在美国多中心住院心脏骤停登记研究中，不同医院使用早期DNR的差异。 这项分析将提供如何可变机构在他们的应用程序中的DNR作为一个理解， 潜在的替代品的做法，神经系统的精确性。在本研究建议的目标2中，我们计划 对早期DNR利用率不同的机构进行定性案例研究， 报告利用率高的中心和报告利用率低的其他中心。中心将有目的地针对， 有不同的特点，包括农村与城市，学术与非学术和低与 大量心脏骤停患者。我们将采访医生、护士和社会工作者， 实施决策辅助以支持家庭决策的潜在促进因素和障碍 心脏骤停后昏迷的幸存者我们的总体目标是改进指导方针的实践， 为心脏骤停的昏迷幸存者做出一致的决定，这将鼓励延迟的神经功能恢复， 并留出足够的时间从心脏骤停中醒来。通过从心脏骤停中学习 利益相关者在机构的做法不同，我们的研究团队将能够适应我们的实施 战略，以促进更好地采用决策援助。该提案的结果将为今后的工作提供参考， 在提高心脏骤停昏迷幸存者的决策质量和改善神经功能方面， 心脏骤停幸存者的结局。

PROJECT SUMMARY/ABSTRACT – Exploring Institutional Variability in Neuro-prognostication for Survivors of Cardiac Arrest Survival and neurological recovery after cardiac arrest are highly variable, driven in part by inconsistent hospital care following successful resuscitation. Data from both in- and out-of-hospital cardiac arrest patient populations have shown variable application of evidence based post-cardiac arrest guidelines, including recommendations for delayed neuro-prognostication, defined as at least 72 hours after return of spontaneous circulation. Reasons for lack of provider adoption of these recommendations have included poor knowledge of the current guidelines, perceptions of poor neurologic recovery for post-arrest patients and surrogate decision makers wishes for early prognostication. To that end, our research team has ongoing work to implement a decision aid to support such processes. The purpose of this grant proposal is pre-implementation research to learn about the organizational culture and workflow at hospitals that have variable rates of utilization of early “Do Not Resuscitate” (DNR) orders. This work will uncover potential barriers and facilitators to implementation of a guideline based decision aid and will allow for a better appreciation of the practice of neuro- prognostication for post-cardiac arrest patients in a more generalizable fashion. To support this overall research mission, we propose the following specific aims in this R03 proposal. The first study aim will explore the variability in utilization of early DNR by hospital in a US multi-center registry of in-hospital cardiac arrest. This analysis will provide understanding of how variable institutions are in their application of DNR as a potential surrogate for the practice of neurological prognostication. In Aim 2 of this research proposal, we plan to conduct a qualitative case study of institutions with variable rates of utilization of early DNR, with some centers reporting high utilization and others reporting low utilization. Centers will be purposively targeted that have different characteristics, including rural versus urban, academic versus non-academic and low versus high volume of cardiac arrest patients. We will interview physicians, nurses and social workers to learn about potential facilitators and barriers to the implementation of a decision aid to support families in making decisions for comatose survivors of cardiac arrest. Our overall objective is to improve the practice of guideline concordant decision making for comatose survivors of cardiac arrest that will encourage delayed neuro- prognostication and allow for sufficient time to awaken from cardiac arrest. By learning from cardiac arrest stakeholders at institutions that practice differently, our study team will be able to adapt our implementation strategy to promote better adoption of the decision aid. Results of this proposal will inform future work aimed at improving the quality of decisions made for comatose survivors of cardiac arrest and to improve neurologic outcomes for cardiac arrest survivors.