A Systems Approach to Align ICU Care with Patient Treatment Goals

摘要 这个职业发展奖的支持将帮助Jacqueline M Kruser，MD MS成为一名独立的 医生-研究人员，具有改善沟通和治疗所需的培训和经验 危重病人的决策。Kruser博士将利用这一奖项在她现有的基础上 保健服务和成果研究基金会，以实现两个职业发展目标：(1)发展 在医疗保健中应用系统工程原理和方法的专业知识，以及(2)收获 在进行复杂行为干预的临床试验方面的知识和经验。这些技能将 将Kruser博士的研究重点从个人层面的干预扩展到复杂的系统层面 影响危及生命的疾病患者的治疗决策和临终关怀的因素 尤其是在慢性危重疾病中。Kruser博士将通过5年的职业生涯实现这些职业目标 发展计划，包括结构化教学、以患者为导向的体验式研究和强化 辅导。克鲁斯博士的职业发展将由简·L·霍尔医学博士指导，她是一名 在医疗保健中应用系统工程方法的经验，有20多年的持续校外工作经验 资金，以及杰出的导师记录。该奖项的共同导师是临床试验专家。 重症监护和结局研究(理查德·G·温德因克，医学博士)，以及临终决策和 行为干预发展(玛格丽特·施瓦茨，医学硕士)。克鲁瑟博士的职业发展将是 由西北大学特殊的制度环境支持，包括(1)致力于 来自肺和重症监护医学司和医学部的资源，(2)强大 跨专业医疗研究中心的研究基础设施(由霍尔博士指导)，以及(3) 麦考密克工程学院和范伯格学院之间建立的卓有成效的合作 医学部。在美国，每年有近40万人患上慢性危重疾病，大多数老年人 这种情况下将无法存活超过一年。研究表明，许多患有慢性危重病的老年人 生命接近尾声的疾病接受不必要的护理，这些护理不能反映他们的目标、价值观或 偏好，指的是“目标不协调”的关怀。因此，该奖项的总体研究目标是应用 系统工程的工具，以适应现有的个人级别的沟通工具，“最佳情况/最坏情况” 案例：“减少有慢性危重疾病风险的老年人的目标不协调的护理。具体目标1将 通过以下方式确定通信和治疗决策中影响最大的ICU系统故障 故障模式、影响和危害性分析。接下来，《特定目标2》将采用以用户为中心的设计工程 以及模拟测试，使最好/最坏情况适应复杂的ICU系统。最后，具体目标3将 通过两个地点的先导性临床试验，测试新干预措施的可行性和可接受性。

ABSTRACT The support of this career development award will help Jacqueline M Kruser, MD MS become an independent physician-investigator with the training and experience necessary to improve communication and treatment decision making for patients with critical illness. Dr. Kruser will use this award to build on her existing foundation in health services and outcomes research to achieve two career development goals: (1) Develop expertise in the application of systems engineering principles and methods in healthcare, and (2) Gain knowledge and experience in the conduct of clinical trials of complex behavioral interventions. These skills will expand Dr. Kruser's research focus beyond individual-level interventions to address the complex, system-level factors that influence treatment decision making and end-of-life care for patients with life-threatening illness, specifically in chronic critical illness. Dr. Kruser will achieve these career objectives through a 5-year career development plan that involves structured didactics, patient-oriented experiential research, and intensive mentoring. Dr. Kruser's career development will be mentored by Jane L Holl MD MPH, a physician with experience in applying systems engineering methods in healthcare, with over 20 years of sustained extramural funding, and an outstanding record of mentorship. The co-mentors of this award are experts in clinical trials and outcomes research in critical care (Richard G Wunderink, MD), and end-of-life decision making and behavioral intervention development (Margaret Schwarze, MD MPP). Dr. Kruser's career development will be supported by the exceptional institutional environment of Northwestern University, including the (1) Dedicated resources from the Division of Pulmonary and Critical Care Medicine and Department of Medicine, (2) Strong research infrastructure of the interprofessional Center for Healthcare Studies (directed by Dr. Holl), and (3) Established, productive collaborations between the McCormick School of Engineering and the Feinberg School of Medicine. Nearly 400,000 people in the US develop chronic critical illness each year, and most older adults with this condition will not survive beyond one year. Studies suggest that many older adults with chronic critical illness who are near the end of life receive unwanted care that does not reflect their goals, values, or preferences, referred to as “goal-discordant” care. Thus, the overall research objective of this award is to apply the tools of systems engineering to adapt an existing individual-level communication tool, “Best Case/Worst Case,” to reduce goal-discordant care in older adults at risk for chronic critical illness. Specific Aim 1 will identify the most impactful ICU system failures in communication and treatment decision-making through a Failure Mode, Effects, and Criticality Analysis. Next, Specific Aim 2 will use user-centered design engineering and simulation testing to adapt “Best Case/Worst Case” to the complex ICU system. Finally, Specific Aim 3 will test the feasibility and acceptability of the novel intervention through a two-site, pilot clinical trial.