Table 4.
Main factors that affect core cycle elements
| Edges (factors) | Representative quotes | Expert N=17 (%) | General N=19 (%) |
|---|---|---|---|
| Acquire | |||
| Hospital Factors | “Inevitably there’s quite wide variation in access to investigations, and we’re not in a general hospital by UK standards. I think our inability to have access to continuous EEG monitoring is a major issue, and I think that would change the way we go about things quite significantly”(Expert, Europe) “We have tried to do evoked potentials, but I don’t think that the technicians locally have the expertise.”(General, North America) |
17 (100) | 19 (100) |
| Time | “Usually, the first day after the event…we get an EEG. What we do is get a blood exam for neuron specific enolase. So this is the first day. Then we have a follow-up at 48 hours, or 72 hours, with another EEG, a clinical evaluation. We repeat second blood examination for neuron specific enolase and then somatosensory evoked potentials. This is done from 48 to 72 hours.” (General, Europe) | 16 (94) | 14 (74) |
| Physician Factors | “It [SSEPs] would probably be in about 50% of the patients, probably half would get it. It’s probably clinician dependent. Practice varies.” (Expert, North America) “I think there is a range of practice. Some people are more aggressive in their investigations. Some people are less aggressive in their investigations.” (General, Europe) “I’ve seen a wide variety of what I think of as worthless tests my partners are looking to guide management, but I don’t find them useful at all. Maybe I’m an under utilizer of those tests”(General, North America) “No. No, I’ve never ordered a serum enolase or whatever that thing is. I mean I don’t even know how to order that. I don’t even know what the timing on that is. I find brain MRIs to be worthless and disruptive. And, unfortunately, what happens with these tests, again this is one person’s experience”(General, North America) “So yeah, I think that a lot of doctors these days, I don’t want to be like, the kids these days, but yeah they look for technology. They look to technologic diagnostic solutions and biomarkers. And maybe that’s a function of training … there’s mission creep or imaging creep into all of neurology”(General, North America) |
9 (53) | 12 (63) |
| Interpret | |||
| Test Features | “When somebody presents a case to me and says: “The patient didn’t have a corneal, so I think they’re going to do poorly.” my next question is always: “How did you test the corneals?” And they tell me “a saline squirt.” Then, I put on my white coat, get on my Q-tip and say let’s go to the bedside and make sure. Technique is everything.”(Expert, North America) “So, we have an MRI in a gray zone patient. We have an MRI showing … diffusion restriction in the hippocampi, basal ganglia, and somehow widespread over parietal-occipital cortical area. That’s not a good outcome in a functional viewpoint, and we try to integrate that in that way. But it’s more a qualitative approach regarding imaging as opposed to the other tools.” (Expert, Europe) |
15 (88) | 18 (95) |
| Physician Factors | “You always get the raw data. It’s always a little bit subjective. I would have to say that you bring your own personality to interpreting it…”(Expert, North America) “The raw interpretation of an EEG by a clinical neurophysiologist I’ve found to be very variable…In our hospital, we have somebody who is internationally renowned, and even he openly admits that he will present the same EEG to himself and the different colleague. The variance is in the way that it’s reported, and the language that is used, can really bias you.” (General, Europe) “Yeah. It’s of course based on the experience and knowledge you have, and what is published. You never do it alone” (Expert, Europe) “Years of experience, attention to detail, coming in with an open mind and absolute candor with the family”(Expert, Europe) |
11 (65) | 11 (58) |
| Clinical Confounders | “Medications, obviously, as I alluded to. Multi organ dysfunction, or end organ dysfunction, so someone whose liver is not working well, their kidneys are not working well. We evaluate the diagnostic tests like EEG findings and clinical exam in the context of those things.”(Expert, North America) “In the first 24 hours, we don’t put a lot of stock in EEGs since they’re usually cold and usually on a decent amount of sedation”(Expert, North America) |
13 (76) | 14 (74) |
| Time and Trajectory | “So the EEG and seeing its progression over time is as good as watching the clinical exam improve over time. I feel that is a necessary step for recovery and would watch it for at least the first 24-36 hours to get a feeling for the trajectory. Seeing it recover more quickly than that is even more encouraging. But I would not give up hope unless I watched for 36-48 hours and had seen no improvement.”(Expert, North America) “I do find that in between days 3 to 5 you can have quite a significant change in the patient, either good or bad.” (General, Europe) “Any day that goes by with no improvement, I adjust my assessment accordingly, it gets worse with any day that goes by without any improvement, but I don’t have a hard cutoff.” (General, North America) |
14 (82) | 15 (79) |
| Formulate Prognosis | |||
| Hospital Factors | “We have a very strict protocol. If you don’t follow the protocol, I would be upset and I would tell the person that would have consequences…You have to have a very good explanation if you don’t follow a protocol that we have all agreed on”(Expert, Europe) “First of all, I think one issue I would like to stress, going back to the prognostication is that it’s a multidisciplinary approach. We’ll discuss all these cases together, intensivists,neurologists and colleagues from the neuro rehabilitation department.”(Expert, Europe) “One thing that shouldn’t affect, but definitely now and then does, is how full is your ICU? How many beds do you have? What else is going on? Unfortunately, that might influence at times.”(Expert, Europe) |
17 (100) | 19 (100) |
| Physician Factors | “Probably the experience, probably if you talk to all of the physicians, they are more pessimistic about this patient because they are used to how they treat with the outcome of this patient in the last, in the previous years maybe before 2000s. I don’t know. If you talk with a younger physician, they are more optimistic about the outcome of this patient.” (General, Europe) “Several of my colleagues will openly admit that they are much more optimistic, perhaps not the correct way perhaps, but they have a more positive outlook on most patients compared to others… I don’t know what their own personal background values are, but they openly admit that personal values are that, when they are in that situation, they might want more things to be done and tested than otherwise.” (General, Europe) “Well, there is always the bias of the last patient seen, right? And then you swear by the last patient seen, so they’ll keep doing that. So if the last patient that they saw, they predicted a poor outcome, they withdrew, and the patient died. That’s the vicious cycle.” (Expert, North America) “My approach is cautiousness.” (Expert, Europe) |
17 (100) | 19 (100) |
| Integration of Information | “You have to try a multimodal approach, combining several different aspects of the neurologic prognostication, I guess. Using a combination of the radiology, clinical, neurologic examination, lab values, the neurophysiology”(General, Europe) “I try not to interpret any of the prognostic data in a vacuum, so I try to interpret it within the whole context of how the patient is doing clinically. So, for instance, if someone is extremely ill, has may comorbid diagnoses at baseline, but has a reassuring head CT and a reassuring SSEP, but are doing poorly, have refractory ARDS, I’m not so optimistic about their prognosis because they’re ill from a separate, another organ standpoint”(General, North America) |
17 (100) | 16 (84) |
| Time | “We would personally never try to prognosticate before the 72 hours after cardiac arrest” (Expert, Europe) “I think that you’re always formulating their prognosis, right? Like I try and formulate the prognosis right away. Like I wouldn’t put a definitive prognosis right away, but sometimes you have a definitive prognosis right away.”(General, North America) |
17 (100) | 17 (89) |
| Patient Factors | “Well, we touched upon this already and patient wishes and families’ expression of patients’ wishes plays a very big part on how I predict the future, manage a patient.” (General, Europe) “I think younger, healthier bodies are more resilient and somewhat more likely to recover”(General, North America) |
17 (100) | 19 (100) |
For the Edge column: the sub-header node flows into the header node. For instance, under acquire there is hospital factors, so in the model, there is an arrow going from hospital factors to acquire.