Transfusion Recommendations Implemented in the PICU (TRIP)

项目总结/摘要 红细胞（RBC）输注通常在儿科重症监护室（PICU）中进行， 增加氧气输送的目标;然而，RBC的储存可能会限制预防或逆转 氧气债RBC输注与PICU发病率增加独立相关， 死亡率，并因感染性和非感染性严重危害而给患者带来额外风险， 输血制定了循证指南，将输血限制在最有可能 效益自由输血的做法仍然存在;然而，每年将近25万儿童 因输血而有伤害风险而被送入PICU。对于血流动力学， 血红蛋白（Hb）>7 g/dL的稳定患者，证据可靠，而临床判断 当Hb为5-7 g/dL或在Hb > 7 g/dL的血流动力学不稳定患者中推荐。 实施输血指南和干预措施的障碍和促进因素的定性研究 摸底调查为制定一套旨在解决具体问题的执行战略提供了信息， 在PICU常规采用输血指南的背景障碍。一系列的策略， 由实施研究综合框架（CFIR）提供的信息包括建立共识， 识别和授权冠军，教育提供者，使用综合计算机化临床决策 支持（CCDS）工具，并向提供者提供基于量化指标的反馈。 拟议的试点研究旨在解决在实施和评价《公约》方面存在的两个关键差距， 在执行多中心2型混合型之前，必须在各机构之间捆绑实施 有效性和实施试验，以正式评估实施包。其中包括需要 对于1）具有不必要RBC输血风险的患者的经验证的电子队列表征和2） 优化和整合CCDS工具，预计这些工具将带来最大的运营挑战 在一项多中心研究中。因此，我们提出以下具体目标： 具体目标1。为处于以下风险的PICU患者的动态队列创建并验证可计算表型 不必要的输血，包括符合基于阈值和/或基于临床判断的CCDS的儿童 工具 具体目标2。部署和评估计算机化临床决策支持（CCDS）工具的实施 作为输血实施包的一个组成部分。使用定制的 RE-AIM临床信息学评价实施框架的版本将进一步促进 工具的优化。

Project Summary/Abstract Red blood cell (RBC) transfusions are commonly administered in the pediatric intensive care unit (PICU) with the goal of increasing oxygen delivery; however, storage of RBCs may limit efficacy to prevent or reverse oxygen debt. RBC transfusions have been independently associated with increased PICU morbidity and mortality and impart additional risk to patients due to infectious and non-infectious serious hazards of transfusion. Evidence-based guidelines were developed to restrict transfusion to those patients most likely to benefit. Liberal transfusion practices persist; however, placing nearly one quarter million children annually admitted to the PICU at risk for harm from transfusions. Threshold-based guidelines exist for hemodynamically stable patients with a hemoglobin (Hb) >7 g/dL where evidence is robust, whereas clinical judgement is recommended when Hb is 5-7 g/dL or in hemodynamically unstable patients with a Hb > 7 g/dL. Qualitative study of barriers and facilitators to implementation of the transfusion guidelines and intervention mapping informed the development of a bundle of implementation strategies directed at addressing specific contextual barriers to routine adoption of the transfusion guidelines in the PICU. The bundle of strategies, informed by the Consolidated Framework for Implementation Research (CFIR) includes building consensus, identifying, and empowering champions, educating providers, use of integrated computerized clinical decision support (CCDS) tools, and providing quantitative metric-based feedback to providers. The proposed pilot study aims to address two critical gaps in operationalization and evaluation of the implementation bundle across institutions that are necessary prior to execution of a multi-center type 2 hybrid effectiveness and implementation trial to formally evaluate the implementation bundle. These include the need for 1) validated, electronic cohort characterization of patients at-risk for unnecessary RBC transfusion and 2) optimization and integration of CCDS tools, which are anticipated to pose the greatest operational challenges in a multi-site study. Thus, we propose the following specific aims: Specific Aim 1. Create and validate a computable phenotype for a dynamic cohort of PICU patients at-risk for unnecessary transfusion, including children eligible for threshold-based and/or clinical judgment-based CCDS tools Specific Aim 2. Deploy and assess implementation of Computerized Clinical Decision Support (CCDS) tools as one component of the transfusion implementation bundle. Evaluation of the CCDS tools using a customized version of the RE-AIM evaluative implementation framework for clinical informatics will facilitate further optimization of the tools.