CHANGE OF GRANTEE INSTITUTION K23 HL146890 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杰奎琳M克鲁斯，医学博士MS成为一个独立的 经过必要培训和经验的医生-研究者，以改善沟通和治疗 为危重病人做决策。克鲁斯博士将利用这个奖项，以建立在她现有的 在卫生服务和成果研究的基础上，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）增益 在复杂行为干预的临床试验中的知识和经验。这些技能将 扩展Kruser博士的研究重点，超越个人层面的干预，以解决复杂的，系统层面的 影响危及生命的疾病患者的治疗决策和临终关怀的因素， 特别是在慢性危重病中。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，涉及结构化教学法，以病人为导向的经验研究， 指导。Kruser博士的职业发展将由Jane L Holl MD MPH指导，Jane L Holl是一名医生， 在医疗保健中应用系统工程方法的经验，超过20年的持续校外 资金和优秀的导师记录这个奖项的共同导师都是临床试验方面的专家 和结果研究在重症监护（理查德G Wunderink，医学博士），并结束了生命的决策， 行为干预发展（Margaret Schwarze，MD MPP）。克鲁斯博士的职业发展将是 由西北大学的特殊制度环境的支持，包括（1）专用 来自肺部和重症监护医学科和医学系的资源，（2）强 医疗保健研究跨专业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关系 医学。美国每年有近40万人患上慢性危重病，大多数老年人 患有这种疾病的人活不过一年。研究表明，许多患有慢性危重病的老年人 疾病谁是接近生命的尽头接受不必要的照顾，不反映他们的目标，价值观， 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 系统工程的工具，以适应现有的个人层面的沟通工具，"最佳情况/最差情况" 案例，"以减少目标不一致的照顾老年人的风险，慢性危重病。具体目标1将 通过以下方式识别在沟通和治疗决策方面最具影响力的ICU系统故障： 失效模式、效应和危害性分析。接下来，Specific Aim 2将采用以用户为中心的设计工程 和模拟测试，以使"最佳情况/最差情况"适应复杂的ICU系统。第3章具体目标 通过两个地点的试点临床试验来测试新干预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.