Additional authors: Samuel Snider, MD; Vishank Shah, MD; Casey Albin, MD; Amy Shapiro-Rosenbaum, PhD, FACRM; Shraddha Mainali, MD; Sahar Zafar, MD, MBBS
 

Introduction

Disorders of Consciousness (DoC) is a complex syndrome of impaired arousal and awareness after severe brain injury. Behavioral phenotypes of coma, vegetative state and minimally conscious state are included within the spectrum of consciousness disorders.¹ Patients require neurocritical care to provide evidence-based interventions to support neurological and functional recovery. DoC best practice has evolved exponentially over the last decade. National and international practice guidelines have been established to guide clinicians’ assessment of consciousness, diagnosis, prognosis and treatment interventions.^2,3 Regardless of available evidence-based guidelines, studies have shown there continues to be significant heterogeneity in how clinicians define, assess and treat individuals experiencing DoC.⁴ How do we close the gap between evidence dissemination to application at the bedside? Successful implementation of evidence into the clinical space requires a series of steps which include knowledge translation of information and clinical training to build capacity to apply evidence-based practice at the bedside.

The Curing Coma® Campaign recognizes the critical role of education in advancing knowledge and clinical management of coma and DoC.⁵ The Curing Coma® Campaign has identified the need to support evidence-based, accessible DoC-specific education and training for neurocritical care specialists. Recently, the Curing Coma® Education Module (EM) was launched to identify education and training needs for neurocritical care specialists and foster development of educational content that is accessible to support provision of evidence-based practice at the bedside. The first step for the EM was to identify clinicians’ current training tools, future educational priorities, preferences and modes of accessibility of neurocritical care clinicians. A pilot survey was completed as the initial step towards curating evidence-based, accessible educational content.

Methodology

A pilot survey was conducted by Curing Coma® EM members to investigate clinicians’ perceptions on education, content of education and preferred modalities to access educational curriculum. The survey consisted of seventeen questions, 11 multiple choice and 6 free text, related to respondents’ experience of DoC education within their clinical practice and query preferences of formats for educational content provision. Two questions focused on preferred educational format for families and caregivers experiencing DoC as the EM identifies family education as an important variable. IRB approval was obtained for the survey study. Once the survey was developed and consensus was achieved by members of the EM, the survey was distributed electronically through Curing Coma® and neurocritical care email contact lists. Survey responses were captured within RedCap® web application.

Results

Participants

Sixty-nine participants completed the survey. Forty-one (62.1%) were female and 23 (36.4%) were male. The three remaining did not identify gender or preferred not to respond. Forty-five (67.2%) of respondents were from North America. Nine respondents (13.4%) were from Asian countries, eight (11.9%) from Europe, four (6.0%) from South American countries and one respondent was from an African nation. Fifty-nine (88.1%) of respondents identified as medical professionals, which included nursing and physicians, eleven of which identified as neuro-intensivists. Six (9.0%) identified as allied healthcare professional, one (1.5%) as a family member or caregiver and one (1.5%) as other. Over half of the respondents (N=36, 54.5%) were between the ages of 18-45. Twenty-five (37.9%) were between the ages of 46-65 and three (4.5%) reported they were over the age of 65.

Educational Preferences

Twenty-eight (28.4%) of respondents reported utilizing a DoC-specific resource for education, 48 (71.6%) reported they did not. Educational tools or resources utilized included published guidelines, lectures and power points, textbooks, websites and staff experts. Participants reported their preferred format for accessing DoC-specific educational content was recorded webinars and lectures (N=43; 66.2%), in-person lectures (N=43; 66.2%), printed material (N=32; 41.5%), peer-reviewed literature (N=31; 47.7%), round table question and answer discussion format (N=19; 29.2%), clinical simulations and case studies (N=27; 41.5%), social media content (N=13; 20.0%) and online courses (N=38; 58.5%).

Participants also reported their preferences on length or duration of educational content. One-time training sessions of 30-60 min sessions (N=17; 26.2%) and monthly educational series (N=17; 26.2%) were the preferred length and frequency of DoC education by majority of respondents. Half-day to full-day seminar (N=11; 16.7%) and quarterly educational series (N=10; 15.4%) were also preferred by respondents. Annually offered content (N=6; 9.2%) and multi-day symposium were the least preferred frequency and length of educational content (N=1; 1.5%).

Open-ended, free text questions aimed to identify respondents’ educational priorities, mode of accessibility, barriers and challenges to obtaining and applying knowledge and educational content language preferences. A variety of education priority themes were recognized. The most common education domains listed as a priority included: assessment, diagnosis, prognosis and treatment. Modes to access education content were similar to preferred format responses but were overwhelmingly based within online platforms. Current barriers to DoC education and best-practice implementation included: general knowledge gaps, a lack of educational tools and resources to increase knowledge and perceived time pressures.

Recommended languages for educational content to be provided were English, Spanish, Portuguese, French and German. Participants reported they would apply education through implementation of best practice recommendations, educating families, training of colleagues and within research. Finally, one respondent outlined educational priorities and content development for families and caregivers that include medical terminology and definitions, roles of clinical team members, and the Rancho Los Amigos Cognitive Scale for traumatic brain injury. Mode of education dissemination included a multi-modal approach.

Discussion

This pilot survey, initiated by the Curing Coma® EM, supports there is a paucity of educational tools and resources applied by professionals serving the DoC population. Gaps exist in educational content and identify as priorities by providers which include assessment, diagnosis, prognosis and treatment interventions. Most respondents endorsed the use of web-based platforms to house educational content and to improve ease of accessibility versus in-person lecture of symposium formats. Furthermore, they endorsed education be available in multiple languages and with minimal associated costs. The results of this survey confirm the need for development and curation of available educational tools and resources for professionals focused on DoC care. The Curing Coma® EM has identified next steps to collate and develop coma and DoC-specific educational resources to support future access for neurocritical care teams that serve the DoC population. The EM is engaged in an environmental scan to capture current online DoC educational content supported by the Neurocritical Care Society, such as previous World Coma Day recordings.

The results of the pilot survey will inform domains for content collected based on priorities requested by survey respondents. EM members will work with Curing Coma® leadership and larger community to develop an online platform to house educational content. Collaboration is also required to adapt content into multiple languages to improve accessibility globally. A limitation of this pilot survey was the low number of responses. A secondary survey expanding questions related to educational needs, with wider distribution and interdisciplinary reach is needed to improve the strength of results and further guide development of DoC educational content. Furthermore, pilot survey questions did not seek to discern DoC educational priorities between adult and pediatric populations. Focus on pediatrics portends the need to investigate differences in educational needs unique to the pediatric population compared to adults. Finally, the pilot survey did attempt to reach and engage caregivers to identify caregiver education needs. Unfortunately, there were no caregivers that responded to the survey. Thus, future efforts also need to include caregivers and identifying their specific educational needs related to DoC. Investigation into the need for potential funding for educational development and affordability of access is required.

Conclusion

Coma and DoC are complex disorders that require clinical expertise to provide quality care and support accurate diagnosis, prognosis and treatment interventions. Through this pilot survey, the Curing Coma® EM has identified educational content preferences and formats for accessible education to be provided for clinicians to begin to build a cannon of content, accessible to neurocritical care practitioners to improve overall DoC patient care.