Optimizing Critical Care for Patients with Acute Respiratory Failure: A Mixed-Methods Study

背景：重症监护是医院护理中最耗费资源和最昂贵的组成部分之一。 各退伍军人医院在使用重症监护治疗急性呼吸道疾病患者方面存在很大差异 失败(ARF)，表明在何时以及如何最好地使用重症监护病房(ICU)方面存在知识差距。 此外，对不需要重症监护的患者过度使用ICU也会导致医疗成本上升 并可能造成伤害。 意义：首先，这项建议将有助于澄清ICU床位供应是否影响ICU床位的使用。这 对整个VHA的医疗保健服务具有重要影响，因为这将表明减少ICU床位 供应可能有助于在不牺牲护理质量的情况下防止不必要的ICU使用，从而改善整体 重症监护的价值。其次，它将确定可修改的组织因素和关怀流程，使 在ICU外提供高质量和高效率的护理。第三，它将带动医院的发展-- 为患有ARF的退伍军人量身定做护理和指导分诊策略的水平干预。 创新：在这项研究中，弗拉纳斯博士创建了一个新的数据集，它结合了来自 VHA内100家地理位置不同的医院。这一建议在人的应用上也是创新的。 以设计为中心的思想，开发可扩展的干预措施，以提高退伍军人管理局危重护理的价值。 具体目标：1)评估ICU床位供应与ICU入院的相关性，以及ICU的相关性 入院与结果；2)使用积极偏离方法来确定组织因素和护理 与ARF患者的高价值护理相关的流程；3)使用以人为中心的设计思想 开发和试行一种干预措施，以指导ICU的使用并提高ICU护理的价值。 方法：目标1和目标2将使用解释性顺序混合方法来评价组织 与高价值ICU护理相关的因素和护理流程。在目标1a中，弗拉纳斯医生将以病人的身份进行 多变量回归分析检验ICU床位供应增加与 ICU入院几率增加。检验ICU入院并不独立相关的假设 随着结果的改善(目标1b)，弗拉纳斯博士将使用倾向评分技术来评估这种联系 ICU使用率与结果，包括死亡率和出院回家。在《目标2》中，弗拉纳斯博士将使用积极的 异常法识别ICU使用率高/低，以及高于/低于平均风险调整后的医院30- 急性肾功能衰竭患者的日死亡率。使用有目的的抽样，她将进行医学人种学和半 对大约12家选定医院的关键利益相关者进行了结构化访谈。她将使用快速定性 探询方法来描述与目标1中观察到的结果相关的过程。她还将利用 实施研究综合框架，以确定可修改和 可在医疗保健设置中推广。在《目标3》中，弗拉纳斯博士将组建一个利益相关者工作组，并使用 以人为本的设计思想，为指导分诊的干预措施的发展提供信息 ARF患者的决定。她将在波特兰退伍军人医院试行这种干预措施，以评估其 可接受性/可行性，并为未来的多中心试验生成初步数据。 下一步：这项工作将导致提交多个IIR提案，包括混合效力-- 在多个退伍军人事务部实施精细化干预的群集化随机对照试验。

Background: Critical care is one of the most resource-intensive and costly components of hospital care. Substantial variability exists across VA hospitals in the use of critical care for patients with acute respiratory failure (ARF), suggesting a knowledge gap about when and how to best use the intensive care unit (ICU). Furthermore, overuse of the ICU for patients who do not need critical care contributes to rising healthcare costs and may cause harm. Significance: First, this proposal will help clarify whether ICU bed supply influences ICU bed utilization. This has important implications for healthcare delivery across the VHA, as it would indicate that decreasing ICU bed supply may help prevent unnecessary ICU use without sacrificing quality of care, thereby improving the overall value of critical care. Second, it will identify modifiable organizational factors and care processes that enable the provision of high-quality and efficient care outside the ICU. Third, it will lead to the development of a hospital- level intervention that will tailor care and guide triage strategies for Veterans with ARF. Innovation: For this study, Dr. Vranas has created a novel dataset that combines highly-granular data from over 100 geographically diverse hospitals within the VHA. This proposal is also innovative in its application of Human- Centered Design Thinking to develop scalable interventions to improve the value of critical care at VA. Specific Aims: 1) Evaluate the association of ICU bed supply with ICU admission, and the association of ICU admission with outcomes; 2) Use a positive-deviance approach to identify organizational factors and care processes associated with high-value care of patients with ARF; 3) Use Human-Centered Design Thinking to develop and pilot test an intervention that will guide ICU utilization and improve the value of ICU care. Methods: Aims 1 and 2 will use an explanatory sequential mixed methods approach to evaluate organizational factors and care processes associated with high value ICU care. In Aim 1a, Dr. Vranas will perform patient-level multivariable regression analyses to test the hypothesis that increased ICU bed supply is associated with increased odds of ICU admission. To test the hypothesis that ICU admission is not independently associated with improved outcomes (Aim 1b), Dr. Vranas will use propensity score techniques to evaluate the association of ICU utilization with outcomes including mortality and discharge to home. In Aim 2, Dr. Vranas will use a positive deviance approach to identify hospitals with high/low ICU utilization, and above/below average risk-adjusted 30- day mortality for patients with ARF. Using purposive sampling, she will conduct medical ethnography and semi- structured interviews of key stakeholders at approximately 12 select hospitals. She will use Rapid Qualitative Inquiry methods to characterize processes associated with outcomes observed in Aim 1. She will also utilize the Consolidated Framework for Implementation Research to identify common domains that are modifiable and generalizable across healthcare settings. In Aim 3, Dr. Vranas will assemble a stakeholder taskforce and use Human-Centered Design Thinking to inform the development of an intervention designed to guide triage decisions for patients with ARF. She will pilot this intervention at the Portland VA hospital to evaluate its acceptability/feasibility, and to generate preliminary data for a future multicenter trial. Next Steps: This work will lead to the submission of multiple IIR proposals, including a hybrid effectiveness- implementation clustered randomized controlled trial of the refined intervention across multiple VA sites.