Evaluating the Role of Telemedicine in Improving Rural Emergency Department Sepsis Care

项目摘要/摘要 脓毒症是一种危及生命的疾病，其发病率在过去十年中翻了一番，现在构成 占美国所有住院死亡人数的17%，每年的成本为240亿美元。早期、积极的紧急护理 拯救生命，但许多乡村医院对循证败血症护理指南的遵守程度较低。 因此，农村败血症患者的死亡率高出38%。以农村急诊科(ED)为基础 远程医疗已被提议用于标准化护理并支持乡村医院的当地临床医生，但其 有效性从未经过严格的测试。美国19%的人口生活在农村地区， 据估计，美国每年有5000例可预防的农村败血症死亡，迫切需要测试战略，以 改进循证脓毒症指南在农村中心的传播和实施。的目标是 这一职业发展奖是为申请者作为临床研究人员和健康人员的职业生涯做准备 服务研究者专注于农村急性护理干预措施的比较有效性研究。这个目标 将在农村远程保健研究中心的基础设施内通过(A)具体的 研究生课程，(B)导师关系咨询委员会，(C)精心挑选的会议和 (D)一项有指导的研究性研究。拟议研究的具体目标是：(1)衡量 基于ED的远程医疗使用、指南遵从性和临床结果之间的关联，(2)测量 远程医疗关系对接受远程医疗患者遵守指南的影响 可用但未使用，以及(3)描述远程医疗的使用如何以及为什么影响临床护理，决策- 使用定性方法制定和传播最佳做法。建议的指导性研究 该项目将通过对严重脓毒症患者进行观察性队列研究来实现这些目标 中西部大型远程医疗网络中关键通路医院4年来感染性休克的治疗 句号。我们的中心假设是，远程医疗将通过提高依从性来改善临床结果 国际脓毒症指南通过改变(1)患者层面的建议，(2)提供者层面的行为， (3)医院层面的实践。在这个职业发展奖结束时，候选人将- 准备成为一名在农村急性败血症护理方面具有专业知识的独立科学家，在 比较有效性研究方法和定性研究方法。我们的研究结果将作为 为今后研究了解传播战略(包括远程医疗)在以下方面的作用奠定基础 在农村保健环境中实施最佳做法，这将构成候选人第一个 R01提交。

Project Summary/Abstract Sepsis is a life-threatening condition that has doubled in incidence over the past decade, and now constitutes 17% of all in-hospital deaths in the US at an annual cost of $24 billion. Early, aggressive emergency care saves lives, yet many rural hospitals have low adherence to evidence-based sepsis care guidelines. Consequently rural sepsis patients have a 38% higher mortality rate. Rural emergency department (ED)-based telemedicine has been proposed to standardize care and support local clinicians in rural hospitals, but its effectiveness has never been rigorously tested. With 19% of the US population living in rural areas and an estimated 5,000 preventable rural sepsis deaths annually in the US, there is a critical need to test strategies to improve dissemination and implementation of evidence-based sepsis guidelines in rural centers. The goal of this Career Development Award is to prepare the applicant for a career as a clinical investigator and health services researcher focusing on comparative effectiveness research of rural acute care interventions. This goal will be accomplished within the infrastructure of the Rural Telehealth Research Center through (a) specific graduate coursework, (b) a Mentorship Advisory Committee, (c) carefully selected conferences and workshops, and (d) a mentored research study. The specific aims of the proposed study are (1) to measure the association between ED-based telemedicine use, guideline adherence, and clinical outcomes, (2) to measure the effect of a telemedicine relationship on guideline adherence among patients who have telemedicine available but not used, and (3) to describe how and why telemedicine use affects clinical care, decision- making, and dissemination of best practices, using qualitative methods. The proposed mentored research project will accomplish these aims through an observational cohort study of patients with severe sepsis or septic shock treated in critical access hospitals in a large Midwestern telemedicine network over a 4-year period. Our central hypothesis is that telemedicine will improve clinical outcomes through improved adherence with international sepsis guidelines by changing (1) patient-level recommendations, (2) provider-level behavior, and (3) hospital-level practices. At the end of this Career Development Award, the candidate will be well- prepared to become an independent scientist with expertise in rural acute sepsis care, with specific strength in comparative effectiveness research methods and qualitative methods. Our study findings will serve as the basis for future studies to understand the role of dissemination strategies (including telemedicine) on implementing best practices in rural health care settings, which will form the foundation of the candidate's first R01 submission.