Improving Appropriate Neurologic Prognostication after Cardiac Arrest. A Stepped Wedge Cluster Randomized Controlled Trial.
Predictions about neurologic prognosis that are based on early clinical findings after out-of-hospital cardiac arrest (OHCA) are often inaccurate and may lead to premature decisions to withdraw life-sustaining treatments (LST) in patients who might otherwise survive with good neurologic outcomes.



To improve adherence to recommendations for appropriate neurologic prognostication after OHCA and reduce deaths from premature decisions to withdraw LST.



This was a pragmatic stepped wedge cluster randomized controlled trial evaluating a multifaceted quality intervention (education, pathways, local champions, audit-feedback). The primary outcome was appropriate neurologic prognostication, defined as (1a) no early withdrawal of LST (WLST) (within 72 h) based on estimates of poor neurologic prognosis and (1b) no WLST between 72 hours and 7 days in absence of clinical predictors of poor neurologic prognosis or (2) surviving beyond 7 days. Secondary outcomes were deaths from early WLST and survival with good neurologic outcome.



Between June 1, 2011, and June 30, 2014, a total of 905 patients with OHCA were enrolled from ICUs of 18 Ontario hospitals. Rates of appropriate neurologic prognostication increased after the intervention (68% vs. 74% patients; odds ratio [OR], 1.79; 95% confidence interval [CI], 1.01-3.19; P = 0.05). However, rates of survival to hospital discharge (46% vs. 50%; OR, 1.71; 95% CI, 0.97-3.01; P = 0.06) and survival with good neurologic outcome remained similar (38% vs. 43%; OR, 1.43; 95% CI, 0.84-2.86; P = 0.19).



A multicenter quality intervention improved rates of appropriate neurologic prognostication after OHCA but did not increase survival with good neurologic outcome. Clinical trial registered with www.clinicaltrials.gov (NCT 01472458).
1 Department of Critical Care Medicine and.|6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|2 Interdepartmental Division of Critical Care.|3 Department of Medicine.|4 Institute for Health Policy, Management and Evaluation.|5 Institute of Clinical and Evaluative Sciences, Toronto, Ontario, Canada.
Damon C
DC
Scales
2 Interdepartmental Division of Critical Care.|3 Department of Medicine.|4 Institute for Health Policy, Management and Evaluation.|7 Department of Medicine, University Health Network, Toronto, Ontario, Canada.
Eyal
E
Golan
1 Department of Critical Care Medicine and.|2 Interdepartmental Division of Critical Care.
Ruxandra
R
Pinto
8 Department of Emergency Medicine, Faculty of Medicine, Queen's University, Kingston, Ontario, Canada.
Steven C
SC
Brooks
1 Department of Critical Care Medicine and.|6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|2 Interdepartmental Division of Critical Care.
Martin
M
Chapman
6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|9 Lawrence S. Bloomberg Faculty of Nursing, and.
Craig M
CM
Dale
10 Department of Neurology and Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada; and.
Draga
D
Jichici
1 Department of Critical Care Medicine and.|6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|2 Interdepartmental Division of Critical Care.|3 Department of Medicine.|4 Institute for Health Policy, Management and Evaluation.
Gordon D
GD
Rubenfeld
3 Department of Medicine.|4 Institute for Health Policy, Management and Evaluation.|12 Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.|11 Rescu, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
Laurie J
LJ
Morrison
D000368:Aged; D016887:Cardiopulmonary Resuscitation; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D009422:Nervous System Diseases / Q000175:diagnosis / Q000209:etiology*; D058687:Out-of-Hospital Cardiac Arrest / Q000150:complications* / Q000401:mortality / Q000628:therapy; D011379:Prognosis; D058996:Quality Improvement; D012307:Risk Factors; D028761:Withholding Treatment / Q000592:standards
cardiac arrest; cluster randomized trial; critical care; knowledge translation; neurologic prognosis