Establishing and Implementing Pneumonia Diagnosis in ED Older Adults: A Mixed Methods Approach

在急诊科老年人中建立和实施肺炎诊断：混合方法

• 批准号: 10705136
• 负责人: Katherine Hunold Buck
• 金额: $ 23.42万
• 依托单位: OHIO STATE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-09-15 至 2027-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10705136
• 关键词: Accident and Emergency department; Address; Adoption; Adult; Adverse effects; Antibiotics; Bacteria; Bacterial Infections; Bacterial Pneumonia; Biological Markers; COVID-19 impact; Caring; Cessation of life; Clinical; Communities; Defensins; Development; Diagnosis; Diagnostic; Diagnostic tests; Early Diagnosis; Elderly; Emergency Department Physician; Emergency Department patient; Emergency Medicine; Emergency department visit; Ensure; Event; Face; Female; Future; Genes; Geriatrics; Goals; Guidelines; Health; Human; Image; Infection; Innate Immune System; Investigation; Length of Stay; Leukocytes; Life; Maps; Measures; Methodology; Methods; Mission; Modeling; Morbidity - disease rate; Natural Immunity; Outcome; Participant; Pathway interactions; Patient Care; Patient-Focused Outcomes; Patients; Physicians; Pneumonia; Proteins; Qualifying; Recommendation; Recording of previous events; Research Priority; Rural; Sepsis; Serum; Source; Subgroup; Symptoms; Testing; Theoretical Domains framework; Thinking; Thoracic Radiography; Time; United States; Validation; Viral; Viral Pneumonia; Virus; Virus Diseases; Width; Work; accurate diagnosis; adverse outcome; alpha-Defensins; antimicrobial peptide; clinical care; clinical diagnostics; clinical predictors; co-infection; comorbidity; concept mapping; diagnostic accuracy; diagnostic criteria; diagnostic strategy; experience; future implementation; human old age (65+); implementation barriers; implementation science; implementation study; implementation trial; improved; lung failure; male; monocyte; mortality; novel; novel diagnostics; novel marker; pathogen; pathogenic bacteria; pathogenic virus; predictive modeling; prevent; prospective; tool; usability; validation studies; young adult

PROJECT SUMMARY/ABSTRACT In the time it takes to read this application, 20 older adults (age≥65 years) will die of pneumonia in the United States. Annually over 500,000 older adults received treatment in emergency departments (ED) for pneumonia. Unfortunately, ED physicians cannot accurately diagnose pneumonia in older adults because of atypical symptoms, chest x-ray inaccuracy, comorbidities, failure of pulmonary clinical prediction rules established with younger adults, and poor accuracy of available biomarkers. Emergency physician’s inability to diagnose pneumonia in older adults leads to delayed diagnosis, inadequate treatment, worsening infection, longer lengths of stay (6.6 days vs. 5.4), and mortality. Pneumonia can be caused by bacterial and viral pathogens alone or in combination. Bacterial pneumonia alone causes the adverse outcomes and faces the diagnostic challenges just described. The presence of viral pneumonia further complicates diagnosis. Bacterial and viral co-infection in all adults increase odds of death by 2.1 with expected greater deleterious effects on older adults. Unfortunately, when viral sources are detected our current diagnostic approach fails to reliably identify bacterial sources in the event of co-infections. This can lead to inappropriate care and highlights the importance of ensuring fast, accurate diagnosis of both bacterial and viral pneumonia. Unfortunately, available tests (serum, imaging) and patient presentation (symptoms, exam, and history) are unreliable for diagnosing pneumonia in older adult ED patients. Our previous results reveal that novel tests may improve diagnostic accuracy of pneumonia (antimicrobial peptides [AMPs] and monocyte distribution width [MDW]). AMPs are a part of the innate immune system and respond in minutes to bacteria and viruses. Monocyte distribution width measures the distribution of size of leukocytes and increases in ED sepsis. This project seeks to build on previous investigations to improve the diagnostic accuracy of pneumonia in older adult ED patients with the long-term goal of improving clinical care and decreasing the morbidity and mortality associated with pneumonia. Aim #1 examines the potential for novel tests (AMPs and MDW) to diagnose pneumonia alone and in combination with patient presentation/symptoms and existing diagnostic studies. This aim will consider pneumonia caused by bacterial pathogens, viral pathogens and the combination separately to create and determine the accuracy of a diagnostic pathway. Aim #2 will employ group concept mapping guided by the Theoretical Domains Framework to engage emergency physicians to identify facilitators and barriers to implementation of a diagnostic pathway in emergency medicine to inform future studies. Aim #3 pilots the Aim #1 diagnostic pathway. If successful, this proposal will produce a diagnostic pathway for pneumonia in older adult ED patients and provide the groundwork for a successful validation and implementation study of this diagnostic pathway.

项目概要/摘要 在阅读本申请的时间内，20 名老年人（年龄≥65 岁）将死于肺炎 美国。每年有超过 500,000 名老年人在急诊科 (ED) 接受治疗 肺炎。不幸的是，急诊科医生无法准确诊断老年人的肺炎，因为 非典型症状、胸部 X 线检查不准确、合并症、肺部临床预测规则失败 与年轻人一起建立，并且现有生物标志物的准确性较差。急诊科医生无能力 诊断老年人肺炎会导致诊断延迟、治疗不充分、感染恶化， 住院时间更长（6.6 天 vs. 5.4 天）和死亡率。 肺炎可由细菌和病毒病原体单独或组合引起。细菌 仅肺炎就会导致不良后果，并面临刚才描述的诊断挑战。这 病毒性肺炎的存在使诊断进一步复杂化。所有成年人的细菌和病毒双重感染都会增加 死亡几率降低 2.1，预计对老年人的有害影响更大。不幸的是，当病毒 检测到来源 我们当前的诊断方法无法可靠地识别细菌来源 合并感染。这可能会导致护理不当，并凸显了确保快速、准确的重要性 细菌性和病毒性肺炎的诊断。 不幸的是，可用的测试（血清、成像）和患者表现（症状、检查和病史） 对于诊断老年 ED 患者的肺炎并不可靠。我们之前的结果表明，新颖的测试 可以提高肺炎的诊断准确性（抗菌肽 [AMP] 和单核细胞分布 宽度[MDW]）。 AMP 是先天免疫系统的一部分，可在几分钟内对细菌和病毒做出反应。 单核细胞分布宽度测量白细胞大小的分布和 ED 脓毒症的增加。 该项目旨在以之前的研究为基础，提高肺炎的诊断准确性 老年 ED 患者的长期目标是改善临床护理并降低发病率和 与肺炎相关的死亡率。目标 #1 检查新颖测试（AMP 和 MDW）的潜力 单独诊断肺炎并结合患者表现/症状和现有诊断 研究。该目标将考虑由细菌病原体、病毒病原体及其组合引起的肺炎 分别创建和确定诊断途径的准确性。目标 #2 将采用团体概念 在理论领域框架的指导下绘制地图，让急诊医生参与识别促进者 以及实施急诊医学诊断途径的障碍，为未来的研究提供信息。目标#3 试点目标#1 诊断途径。如果成功，该提案将为以下问题提供一条诊断途径： 老年 ED 患者肺炎，并为成功验证和提供基础 该诊断途径的实施研究。