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

项目摘要 心力衰竭（HF）是一种昂贵且复杂的健康状况，影响着数百万美国人。HF护理通常 分散，对质量、安全性和以患者为中心的结局产生负面影响。结构化跨专业人员 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， 患者和家庭使用结构化格式来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：专业间办法，利用舍入结构， 患者和家属的有意参与，以及制定共同的日常护理计划。越来越多的 证据将SIBR的实施与团队和患者结局的改善联系起来。假设的 SIBR运作的机制是，具有可预测的结构会导致 沟通，减少护理差距，更一致地利用循证方法。这些 这些变化被认为会导致患者结果的改善，例如住院时间，再入院率， 以患者为中心的护理和安全性/不良事件。尽管在以下情况下， 在SIBR实施过程中，对于SIBR模型的忠实性（遵守）在 这一模式如何以及为何发挥作用，以及如果保真度更高，结果可以在多大程度上得到进一步改善。到 为了解决这一知识差距，该提案利用了一个及时的机会来研究SIBR的保真度及其 华盛顿大学医学院晚期心力衰竭患者的护理与预后的关系 中心，在那里，SIBR模型已经成为4年以上的护理标准。核心假设是，更高- 保真度SIBR将与更好的结果相关联。为了验证这一假设，我将进行一个前瞻性队列研究， 研究实现三个具体目标：（1）确定SIBR保真度和患者结局之间的关联，（2） 确定SIBR保真度在多大程度上预测循证医学的启动和完成时间 “高级HF工作路径”，以及（3）检查患者和家庭在护理质量和安全方面的经验， 更高和更低保真度的SIBR的背景。这些目标将为最初的多站点R 01奠定基础， 在实践中研究SIBR和未来的R级赠款，以实施和评估优化的SIBR模型。通过 通过这项工作，我将获得HF结局研究，高级实施科学研究设计， 以病人为中心的临床研究方法。我将由一个由NHLBI资助的专家小组指导， 研究人员，布赖恩韦纳（主要导师，实施科学），兰德尔柯蒂斯（通信和 姑息治疗），布伦达齐勒（跨专业合作和临床路径），和凯文奥布莱恩 （Advanced Heart Failure Care）。导师制，课程和体验式学习的结合将定位 我想成为一名独立的调查员，使用科学严谨的方法来评估 以病人和家庭为中心的循证护理模式的实施和成果。

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.