CHANGE OF GRANTEE INSTITUTION K23 HL146890 A Systems Approach to Align ICU Care with Patient Treatment Goals

摘要 该职业发展奖的支持将帮助 Jacqueline M Kruser, MD MS 成为一名独立的 具有改善沟通和治疗所需的培训和经验的医师研究员 为重症患者做出决策。 Kruser 博士将利用该奖项在她现有的基础上再接再厉 卫生服务和成果研究的基础，以实现两个职业发展目标：(1) 发展 在医疗保健领域应用系统工程原理和方法的专业知识，以及（2）获得 进行复杂行为干预临床试验的知识和经验。这些技能将 将 Kruser 博士的研究重点扩展到个人层面的干预措施之外，以解决复杂的系统层面的问题 影响危及生命疾病患者的治疗决策和临终关怀的因素， 特别是慢性危重疾病。 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，涉及结构化教学、以患者为导向的体验式研究和强化 指导。 Kruser 博士的职业发展将由 Jane L Holl MD MPH 指导，她是一位拥有 在医疗保健领域应用系统工程方法的经验，拥有 20 多年持续的校外经验 资金和出色的指导记录。该奖项的联合导师均为临床试验领域的专家 重症监护领域的结果研究（Richard G Wunderink，医学博士）以及临终决策和 行为干预发展（Margaret Schwarze，MD MPP）。 Kruser 博士的职业发展将是 得到西北大学卓越的制度环境的支持，包括（1） 肺科和重症医学科和医学部的资源，（2）强 跨专业医疗保健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了富有成效的合作 医学。美国每年有近 40 万人患有慢性危重疾病，其中大多数老年人 患有这种情况的人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 临近生命尽头的疾病患者接受了不必要的护理，而这些护理并不反映他们的目标、价值观或 偏好，称为“目标不一致”护理。因此，该奖项的总体研究目标是应用 系统工程工具，以适应现有的个人级沟通工具，“最好情况/最坏情况” Case”，以减少对有慢性危重疾病风险的老年人的目标不一致的护理。具体目标 1 将 通过以下方式确定沟通和治疗决策中影响最大的 ICU 系统故障： 失效模式、影响和严重性分析。接下来，Specific Aim 2将采用以用户为中心的设计工程 以及模拟测试，以适应复杂的 ICU 系统的“最佳情况/最坏情况”。最后，具体目标 3 将 通过两地试点临床试验来测试新型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.