Strategies to Enhance Pneumonia Care via Intermediate Intensive Care (STEP IN)

摘要 每年有近100万美国人因肺炎住院，肺炎是最常见的感染 在美国被处死。最近的数据表明，住进重症监护病房(ICU)可以降低 肺炎患者，即使他们不需要生命支持。这引发了增加ICU的呼声 用于肺炎患者，可能会增加ICU资源的压力。部分是为了缓解ICU的压力，使用 美国医院对肺炎患者的“中间护理”(IMC)从8%增加到21% 在过去的20年里。然而，令人惊讶的是，人们对IMC床知之甚少。IMC可能是一种具有成本效益的方式 为肺炎患者提供护理，但也可能只会增加成本，而不会改善结果 该提案的目标是描述占主导地位的组织表型、护理实践和 与肺炎患者有效实施IMC相关的背景因素和策略 在美国医院的大量和有代表性的样本中。我们建议使用混合方法，即 将索赔数据的计量经济分析、调查和实地考察结合起来，以实现以下目标： 目的1.通过联系住院患者的数据，我们将对IMC使用的表型进行经验性评估和分类 肺炎患者在IMC接受护理，同一家医院的领导人调查发现 这些国际货币基金组织的环境、人员配置和组织特征。 目的2.研究IMC表型对肺炎患者预后的影响。这些分析 在这一目标中也将有助于定义一组具有主导地位的高绩效医院 为肺炎患者提供有效IMC的IMC表型。 目标3.我们将在与IMC相关的肺炎预后最佳的地点定义最佳实践，方法是 对以IMC表型为主的顶级、中级和低绩效医院进行实地考察。 通过实地考察、对主要线人的采访、观察和文件收集，我们将收集有关以下方面的数据 每个机构的资源，审查中间护理政策和方案，以 确定背景因素 以及与有效的IMC交付相关的战略。 这个项目将填补我们对肺炎医院护理的理解上的一个巨大的知识空白 病人。Step-In将提供美国肺炎IMC的第一张全面图片，确定 与减少肺炎死亡相关的护理模式。利用这个基础，我们还将确定 候选最佳实践，以改善IMC中肺炎的护理，并定义 在哪里传播这种做法。建议的Step In工作将直接导致Step In 2的最终结果 对这些最佳做法进行了实施试验，并组织了这项工作，以加快向快速翻译的转变。

Abstract Nearly one million Americans are hospitalized every year with pneumonia, the most common infection leading to death in the US. Recent data suggest that admission to an intensive care unit (ICU) can reduce mortality for patients with pneumonia, even when they do not require life support. This has prompted calls to increase ICU use for patients with pneumonia, potentially stressing ICU resources. In part to relieve ICU strain, use of “intermediate care” (IMC) for pneumonia patients in US hospitals has tripled from 8% to 21% of admissions over the last 2 decades. Yet remarkably little is known about IMC beds. IMCs may be a cost-effective way to providing care for pneumonia patients, but may also serve to only increase costs without improving outcomes The goal of this proposal is to characterize the dominant organizational phenotypes, care practices, and contextual factors and strategies associated with effective IMC implementation for individuals with pneumonia in a large and representative sample of US hospitals. We propose using a mixed-methods approach that combines econometric analysis of claims data, surveys, and site visits to address the following aims: Aim 1. We will empirically evaluate and classify the phenotypes of IMC use by linking data from hospitalized patients with pneumonia receiving care in IMCs with surveys of leaders within the same hospitals that capture the environment, staffing, and organizational features of those IMCs. Aim 2. We will determine the effect of IMC phenotype on outcomes of patients with pneumonia. The analyses in this aim will also be instrumental in defining a group of high-performing hospitals with the dominant phenotype of IMC that deliver effective IMC to patients with pneumonia. Aim 3. We will define optimal practices at sites with the best pneumonia outcomes associated with IMC by performing site visits to the top-, mid-, and low-performing hospitals with the dominant phenotype of IMC. Through site tours, interviews of key informants, observations, and document collection, we will collect data on each institution's resources, review intermediate care policies and protocols to identify the contextual factors and strategies associated with effective IMC delivery. This project will fill a large knowledge gap in our understanding of provision of hospital care for pneumonia patients. STEP-IN will provide the first comprehensive picture of IMC for pneumonia in the US, identifying models of care associated with reduced deaths from pneumonia. Using this foundation, we will identify also candidate best practices to improve care for pneumonia in IMC, and define the organizational contexts across which to disseminate such practices. The proposed work of STEP IN will lead directly in STEP IN 2 to definitive implementation trials of such best practices, and is organized to expedite that move to rapid translation.