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

项目摘要/摘要-探索神经预测中的制度变异性 心脏骤停幸存者 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。院内和院外心脏骤停患者的数据 人们已经表现出对基于证据的心脏骤停后指南的不同应用，包括 对延迟神经预测的建议，定义为至少在自发恢复后72小时 发行量。提供商没有采纳这些建议的原因包括对以下方面的了解不足 目前的指南、对患者术后神经功能恢复不良的看法和代孕决定 制造者希望能及早做出预测。为此，我们的研究团队正在进行工作，以实现 支持这类进程的决策援助。这项拨款建议的目的是在实施前进行研究，以 了解早期使用率不同的医院的组织文化和工作流程 “不复苏”(DNR)命令。这项工作将揭示执行工作的潜在障碍和促进者 以指导方针为基础的决策辅助，并将允许更好地欣赏实践的神经- 以更普遍的方式预测心脏骤停后患者的预后。要全面支持这一点 为了完成这项研究任务，我们在R03提案中提出了以下具体目标。第一个研究目标是探索 在美国多中心院内心脏骤停登记中，医院使用早期柔红霉素的可变性。 这一分析将提供对机构在将DNR作为 神经学预测实践的潜在替代者。在这项研究提案的目标2中，我们计划 对早期DNR使用率不同的机构进行定性案例研究，包括一些 报告高利用率的中心和报告低利用率的其他中心。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，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，以了解 潜在的促进者和执行支持家庭决策的决策援助的障碍 为心跳骤停昏迷的幸存者。我们的总体目标是改进指南的实践 心跳骤停昏迷幸存者的和谐决策将鼓励延迟的神经- 预测，并留出足够的时间从心脏骤停中苏醒。通过从心脏骤停中学习 不同做法的机构的利益相关者，我们的研究团队将能够适应我们的实施 促进更好地采用决策辅助工具的战略。这项建议的结果将为今后的工作提供指导 在改善心脏骤停昏迷幸存者的决策质量和改善神经学方面 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.