PROJECT SUMMARY – Improving care after cardiac arrest by informing surrogate decision makers Survival and neurological recovery after cardiac arrest are highly variable, driven in part by inconsistent hospital care following successful resuscitation. Significant variability in delivery of evidence based, guideline concordant care has been associated with differences in overall outcome from cardiac arrest. When guidelines are followed, survival with good neurologic recovery is improved. However, adherence to guidelines regarding delayed decision to withdraw life support has been highly variable across US hospitals. Reasons attributed to early withdrawal of life sustaining therapy include poor knowledge of national and international guidelines, requests from family for early outcome predications, and incomplete family comprehension of critical care. In order to encourage utilization of guideline concordant delayed neuro-prognostication and concomitant withdrawal of life-sustaining therapy (>72 hours after resuscitation) we propose a novel approach; to educate and inform surrogate decision makers on neuro-prognostic uncertainty and guideline concordant care. The research proposed in this career development award is intended to create a novel intervention that will encourage improved guideline adherence on neuro-prognostication and delayed WLST as well as to support the continued development of Dr. Sarah Perman, an early investigator committed to improving outcomes from out-of-hospital cardiac arrest. Aim 1 will utilize qualitative methodology to interview key stakeholders in decision making for comatose post-cardiac arrest patients (physicians, nurses, surrogate decision makers) to identify knowledge gaps and determine barriers to guideline concordant post-cardiac arrest care. Aim 2 will allow us to develop and refine educational tools to address neuro-prognostic uncertainty and guideline concordant post-arrest care. Utilizing a panel of cardiac arrest experts and stakeholder focus groups we will perform an iterative process to refine the tools and address potential barriers to implementation. Finally, in Aim 3 we will pilot test our educational tools in an equivalent time-samples quasi-experiment where we implement the tools in the University of Colorado Hospital Emergency Department for surrogate decision makers of resuscitated out of hospital cardiac arrest patients to explore feasibility and acceptability for widespread implementation. The results of the pilot trial will further inform the design of a multi-center pragmatic clinical trial to implement the educational tool in order to encourage guideline concordant post-cardiac arrest care including delayed neuro-prognostication and delayed withdrawal of life-sustaining therapy. Overall, we hypothesize that informing surrogate decision makers on guideline concordant care, will result in delayed decisions to withdraw life-sustaining therapy and allow the post-arrest patient adequate timing for appropriate neuro-prognostication and awakening, thus improving outcomes from out-of-hospital cardiac arrest. This will be the subject of a future R01 proposal by the applicant.

PROJECT NARRATIVE Better outcomes are observed in cardiac arrest patients who receive guideline concordant therapy, however, guideline adherence is poor. This intervention will empower surrogates to engage in guideline concordant decision making for post-arrest patients to allow adequate time to awakening and improved outcomes.