Redesigning Cardiac Surgery to Reduce Neurologic Injury

描述（由申请人提供）：Donald Likosky博士有两个主要职业目标：（1）更好地理解和识别心脏手术后产生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过程，以降低患者发生神经损伤的风险。在理解产生显性和隐性神经损伤的机制方面已经取得了很大的进展。较少的工作集中在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年的项目将结果研究与持续质量改进相结合，重新设计心脏手术流程，以降低患者发生神经损伤的风险。本研究的目的是确定和重新设计与神经损伤的主要原因（血栓/脂质栓塞，脑灌注不足和低血压，气体栓塞）相关的手术和灌注护理的可修改的临床策略和技术。目前的建议包括两项研究。第一项研究在北方新英格兰的三个医疗中心进行了密集的神经和系统监测。在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主要原因的策略。将采集血清，并评估是否存在新的神经损伤，以确定这些干预措施是否导致组织水平和神经损伤较少。第二项研究采用队列研究设计，在北方新英格兰进行心脏手术的八个医疗中心内，仅实施在第一项研究中发现有效的那些策略。总之，这些研究很可能通过重新设计护理过程来持续减少心脏手术后的神经损伤。心脏手术是美国最常见的手术之一，而神经损伤，广义上说，是该手术最不利的结果之一。这项拟议中的研究可能会对公共卫生产生积极影响，通过重新设计心脏手术来防止神经损伤。

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.