Redesigning Cardiac Surgery to Reduce Neurologic Injury

描述(由申请人提供)：Donald Likosky博士有两个主要的职业目标：(1)更好地了解和识别在心脏手术后导致神经损伤的临床护理的离散过程，以及(2)在心脏手术期间修改这些临床护理流程，以降低患者发生神经损伤的风险。在理解产生显性和细微神经损伤的机制方面已经取得了长足的进步。较少的工作集中于将这些调查结果落实到日常实践中，以创造持久的改善。这个为期5年的项目结合了结果研究和持续质量改进的使用，以重新设计心脏手术的流程，以降低患者发生神经损伤的风险。本研究的目标是确定和重新设计与神经损伤的主要原因(血栓/脂质栓子、脑低灌流和低血压以及气性栓子)相关的可修改的外科和灌注护理的临床策略和技术。目前的建议包括两项研究。第一项研究在新英格兰北部的三个医疗中心进行了密集的神经学和系统监测。在一项使用集中质量改进干预的队列研究设计中，这些医疗中心将确定并实施减少神经损伤的主要原因的策略。将收集血清并评估是否存在新的神经损伤，以确定这些干预措施是否会导致较少的组织水平和神经损伤。第二项研究使用队列研究设计，重点是质量改进干预，在新英格兰北部进行心脏手术的八个医疗中心内，只实施在第一项研究中被发现有效的策略。总而言之，这些研究可能会通过重新设计创造神经损伤的护理过程来实现心脏手术后神经损伤的可持续减少。心脏手术是美国最常见的手术之一，总的来说，神经损伤是这种手术最不利的后果之一。这项拟议的研究可能会通过重新设计心脏手术来预防神经损伤，对公共健康产生积极影响。

DESCRIPTION (provided by the applicant): Dr. Donald Likosky has two main career goals: (1) to understand and identify better the discrete processes of clinical care which produce neurologic injury subsequent to cardiac surgery, and (2) to modify these processes of clinical care during cardiac surgery to reduce a patient's risk of developing a neurologic injury. Great strides have been realized in understanding the mechanisms producing both overt and subtle neurologic injuries. Less work has focused on implementing these findings into daily practice to create lasting improvement. This 5-year project combines the use of outcomes research with continuous quality improvement to redesign processes of cardiac surgery to reduce a patient's risk of developing a neurologic injury. The goal of this research is to identify and redesign modifiable clinical strategies and techniques of surgical and perfusion care associated with the principal causes (thrombotic/lipid emboli, cerebral hypoperfusion & hypotension, and gaseous emboli) of neurologic injury. The current proposal comprises two studies. The first study utilizes intensive neurologic and systemic monitoring at three medical centers in northern New England. In a cohort study design using a focused quality improvement intervention, these medical centers will identify and implement strategies to reduce the principal causes of neurologic injury. Serum will be collected and presence of new neurologic injuries assessed to identify whether these interventions result in less tissue-level and neurologic injury. The second study uses a cohort study design with a focused quality improvement intervention to implement, within the eight medical centers in northern New England conducting cardiac surgery, only those strategies found effective in the first study. Together, these studies are likely to create sustainable reductions in neurologic injury after cardiac surgery by redesigning the processes of care creating them. Cardiac surgery is one of the most common operations performed in the United States, and neurologic injury, broadly speaking, one of the most adverse outcomes from this procedure. The proposed study will likely have a positive impact on public health, through the redesign of cardiac surgery to prevent neurologic injury.