Implementation and Sustainment of Team-Based Practice Transformation to Improve Heart Failure Care and Outcomes

项目总结 心力衰竭(HF)是一种代价高昂且复杂的健康问题，影响着数百万美国人。心力衰竭的护理通常是 支离破碎，对质量、安全和以患者为中心的结果产生负面影响。结构化的跨专业人士 床边查房(SIBR)是一种护理模式，旨在将跨专业团队成员聚集在一起 患者和家属使用结构化的形式协作达成日常护理计划。SIBR模型是 其特点是四个核心组成部分：跨专业方法、利用四舍五入结构、 有意识地让患者和家人参与进来，并制定共享的日常护理计划。不断增长的 有证据表明，SIBR的实施与团队和患者结果的改善有关。假想的 SIBR的运作机制是，拥有可预测的结构会带来以下改进 沟通，减少护理方面的差距，更一致地利用循证方法。这些 改变被认为会导致患者预后的改善，如住院时间、再住院率、 以患者为中心的护理和安全/不良事件。尽管以下方面的结果经常得到改善 SIBR实现方面，对于忠诚度(遵守)SIBR模型在以下方面的作用存在证据差距 这种模式的工作方式和原因，以及如果保真度更高，结果可以进一步改善的程度。至 解决这一知识差距，这项建议利用了一个及时的机会来研究SIBR保真度和其 华盛顿大学医学院晚期心力衰竭患者与护理和预后的关系 中心，在那里，SIBR模式已经成为标准护理4年了。中心假设是更高的- 富达SIBR将带来更好的结果。为了验证这一假设，我将进行一项前瞻性队列研究 旨在实现三个具体目标的研究：(1)确定SIBR保真度与患者预后之间的关联，(2) 确定SIBR保真度预测启动和完成基于证据的 “先进的心力衰竭治疗路径”，以及(3)检查患者和家属的护理质量和安全体验 高保真和低保真SIBR的背景。这些目标将为最初的多站点R01奠定基础 研究实践中的SIBR和未来的R级拨款，以实施和评估优化的SIBR模型。穿过 这项工作，我将获得关于HF成果研究的正式培训，高级执行科学研究设计， 以病人为中心的临床研究方法。我将得到NHLBI资助的专家团队的指导 研究人员，Bryan Weiner(主要导师，实施科学)，Randall Curtis(沟通和 姑息治疗)、布伦达·齐尔勒(跨专业协作和临床路径)和凯文·奥布莱恩 (高级心力衰竭护理)。导师指导、课程安排和体验式学习的结合将使 我将成为一名独立调查员，使用科学严谨的方法来评估 以患者和家庭为中心的循证护理模式的实施和结果。

PROJECT SUMMARY Heart failure (HF) is a costly and complex health condition affecting millions of Americans. HF care is often fragmented which negatively affects quality, safety, and patient-centered outcomes. Structured Interprofessional Bedside Rounds (SIBR) is a model of care developed to bring interprofessional team members together with patients and families using a structured format to collaboratively arrive at a daily care plan. The SIBR model is characterized by four core components: an interprofessional approach, utilization of a rounding structure, intentional patient and family engagement, and development of a shared daily care plan. A growing body of evidence associates SIBR implementation with improvements in team and patient outcomes. The hypothesized mechanism through which SIBR operates is that having a predictable structure leads to improvements in communication, fewer gaps in care, and more consistent utilization of evidence-based approaches. These changes are thought to lead to improvements in patient outcomes such as, length of stay, readmission rates, patient-centeredness of care, and safety/adverse events. Despite frequent improvements in outcomes following SIBR implementation, an evidence gap exists as to the role that fidelity (adherence) to the SIBR model plays in how and why this model works and the extent to which outcomes can be further improved if fidelity is higher. To address this knowledge gap, this proposal leverages a timely opportunity to study SIBR fidelity and its relationship to care and outcomes among patients with advanced HF at the University of Washington Medical Center, where a SIBR model has been the standard of care for 4+ years. The central hypothesis is that higher- fidelity SIBR will be associated with better outcomes. To test this hypothesis, I will carry out a prospective cohort study to achieve three specific aims: (1) identify associations between SIBR fidelity and patient outcomes, (2) determine the extent to which SIBR fidelity predicts time to initiation and completion of an evidence-based “Advanced HF Work-Up Pathway”, and (3) examine patient and family experiences of care quality and safety in the context of higher- and lower- fidelity SIBR. These aims will lay the groundwork for an initial multi-site R01 to study SIBR in practice and a future R-level grant to implement and evaluate an optimized SIBR model. Through this work, I will obtain formal training in HF outcomes research, advanced implementation science study designs, and patient-oriented clinical research methods. I will be mentored by an expert team of NHLBI-funded researchers, Bryan Weiner (primary mentor, implementation science), Randall Curtis (communication and palliative care), Brenda Zierler (interprofessional collaboration and clinical pathways), and Kevin O'Brien (advanced heart failure care). The combination of mentorship, coursework, and experiential learning will position me to become an independent investigator using scientifically rigorous approaches to evaluate the implementation and outcomes of evidence-informed patient- and family-centered models of care.