Building a Learning Healthcare System to Understand and Improve Sepsis Outcomes in the VA TeleICU Network

背景：脓毒症是人体对感染的压倒性全身反应， 每年在美国的患者，并已知每年影响超过48，000名退伍军人。过去 十年来，通过更好地了解有效的治疗方法， 干预和预防。这已经在私营部门和退伍军人管理局的住院死亡率中看到 从2008年的15%下降到2012年的10%。然而，尽管有这种改善，脓毒症患者可能 在30天内死亡风险增加100%，具体取决于他/她入住的医院 的VA系统。 重要性/影响：本提案专门针对HSR&D的三个优先领域 服务-医疗保健信息学、医疗保健质量和安全以及虚拟医疗。通过独特的 结合这三个领域，我们计划解决两个重要的局限性，在理解脓毒症， VA; 1）现有的报告可能会或可能不会提供洞察的区别特征， 在被认为是类似的VA ICU中死于败血症的患者，以及2）在这些报告中，有 已知或怀疑可改善结局的多种干预措施，其疗效水平各不相同， 很少或没有提供信息。 创新：我们可以使用一种新的数据源（TeleICU）来直接识别相关的患者水平因素。 脓毒症患者人群的负面结果，量化高性能和低性能的实践， 单位，并随后改善护理提供给脓毒症患者在VA ICU使用这些信息。 具体目标： 目的#1：评价脓毒症特异性阴性结局的风险因素，并在脓毒症类型中， 确定调整的最佳策略，并计算风险调整后的ICU死亡率。 目的#2：评价脓毒症护理中先前未监测要素（低血压、呼吸机）的发生率 管理和抗生素）及其对SA 1a中引用的结局的影响（ICU死亡率作为主要 结果）。 目的#3：定性检查低血压、肺保护性通气和抗生素的管理 在高性能和低性能部位的脓毒症患者中进行治疗（基于适当调整的ICU死亡率 费率）。评估将包括记录的方案、临床工作流程和远程ICU支持。 方法学：我们将通过合并来自TeleICU的数据和 企业数据仓库首先识别脓毒症治疗中的高性能和低性能ICU。我们将 然后对治疗脓毒症的3个高性能和低性能ICU进行人种学调查。 同时，我们将检查低血压的管理，肺保护性通气的使用， 抗生素在重症监护病房脓毒症患者中的使用和疗效。 下一步/实施：我们将开发实时临床决策支持，为当地临床医生提供 ICU中脓毒症患者的最新情况，提供有关脓毒症患者状态的信息， 他们对与改善结果相关的指标的遵守情况。我们预计这将改善 提高脓毒症患者的总体生存率，并可能降低护理成本。

Background: Sepsis, the body’s overwhelming systemic response to infection, strikes more than 1 million patients annually in the United States and is known to impact over 48,000 Veterans every year. Over the past decade, sepsis survival has continued to improve through a better understanding of effective therapies, early intervention, and prophylaxis. This has been seen in the private sector and VA with inpatient mortality dropping from 15% in 2008 to 10% in 2012. However, despite this improvement, a patient with sepsis may have up to a 100% increased risk of death at 30 days depending on the hospital to which he/she is admitted in the VA system. Significance/Impact: This proposal is specifically designed to address three priority domains of the HSR&D Service - Healthcare Informatics, Quality and Safety of Health Care, and Virtual Care. Through the unique combination of these three domains we plan to address two significant limitations in understanding sepsis in the VA; 1) that existing reports may or may not provide insight into the distinguishing characteristics of the patients that died with sepsis in what are thought to be similar VA ICUs, and 2) in these reports there are multiple interventions known or suspected to improve outcomes with varying levels of efficacy about which little or no information is offered. Innovation: We can use a novel data source (TeleICU) to directly identify the patient level factors associated with negative outcomes in the septic patient population, quantify the practices of high and low performing units, and subsequently improve the care provided to septic patients in VA ICUs using this information. Specific Aims: Aim #1: Evaluate risk factors of negative outcomes for specificity to sepsis and within sepsis types to determine best strategies for adjustment and calculate risk-adjusted ICU mortality rates. Aim #2: Evaluate the incidence of previously unmonitored elements of sepsis care (hypotension, ventilator management, and antibiotics) and their impact on outcomes cited in SA1a (ICU mortality as primary outcome) in VA sepsis patients. Aim #3: Qualitatively examine the management of hypotension, lung protective ventilation, and antibiotic therapy in sepsis patients at high and low performing sites (based on appropriately adjusted ICU mortality rates). Evaluations will include documented protocols, clinical workflows, and TeleICU support. Methodology: We will conduct a mixed methods investigation by merging data from the TeleICU and Corporate Data Warehouse to first identify high and low performing ICUs in the treatment of sepsis. We will then perform an ethnographic investigation of 3 high and low performing ICUs in the treatment of sepsis. Simultaneously, we will examine the management of hypotension, the use of lung protective ventilation, and the use and efficacy of antibiotics in septic patients in the ICU. Next Steps/Implementation: We will develop real-time clinical decision support, to provide local clinicians with updates on septic patients in the ICU that provide information regarding the state of septic patients and their compliance with metrics that are associated with improved outcomes. We anticipate this will improve the overall survival of sepsis patients and potentially reduce the cost of care.