Improving Clinical Decisions for Critically Ill Traumatic Brain Injury Patients

 描述(由申请人提供)：Susanne Muehlschleel博士是马萨诸塞大学医学院(UMMS)的重症监护神经学家，他的目标是成为一名独立调查员，拥有患者结局预测、共享决策和决策科学方面的专业知识，以改善灾难性脑损伤患者及其家人的临床决策。中至重度创伤性脑损伤(MsTBI)仍然是创伤后死亡的主要原因，主要原因是放弃治疗。Muehlschleel博士将解决msTBI患者继续或退出治疗(“护理目标”)的生死决定，并为这些危重患者的医疗代理开发一种决策辅助。Muehlschleel博士的职业发展计划汇集了来自三个领先机构的杰出研究人员团队，包括密歇根大学、新英格兰大学和匹兹堡大学。Muehlschleel博士已经在msTBI患者中获得了初步结果，证实重症监护病房(ICU)并发症与较差的短期功能患者结局和死亡率相关，也导致临床医生较差的主观预后。作为一名神经ICU医生，Muehlschlegel博士根据她作为神经ICU医生的独特临床地位与msTBI患者家属的日常互动，敏锐地意识到需要改善预后及其在医生和家人之间的沟通，同时也包括患者的价值观和偏好。在Goldberg博士、Col博士、Shutter博士和Mazor博士的指导下，Muehlschleel博士建议：(1a)在msTBI患者和焦点小组中的医生的医疗保健代理中确定护理目标决策的关键心理社会因素；(1b)在前瞻性收集的基于医院的msTBI患者队列中制定新的结果预测评分，包括ICU并发症和先前验证的入院预测因素，并在内部验证她的结果；(2)通过合并来自AIMS 1a和1b的结果，以及基于住院变量的众所周知和有效的msTBI结果预测“影响分数”，为msTBI患者的护理目标决策创建决策辅助原型；以及(3)在神经ICU的可行性试验中对决策辅助进行试点测试。这项提案的总体目标是开发一种护理目标决策辅助工具，通过确保代理人收到基于证据的预测、了解预测结果和风险，同时还考虑患者的偏好和价值观，可能改善msTBI患者的健康结果。这一定义明确、有指导、以患者为导向的研究提案将汇集用于决策辅助和结果预测规则推导的尖端定性和定量方法，以及一个在结果研究、共享决策制定和msTBI患者的神经危重护理方面拥有专业知识的团队。这项提议，与高级统计、定性和决策科学课程的结构化教学课程相结合，将为Dr。 Muehlschleel拥有对她在共享决策科学前沿的神经ICU研究中发展独立职业生涯所必需的技能和指导。

 DESCRIPTION (provided by applicant): Dr. Susanne Muehlschlegel is a Critical Care Neurologist at the University of Massachusetts Medical School (UMMS) whose goal is to become an independent investigator with expertise in patient outcome prediction, shared decision making, and decision-science to improve clinical decision making for patients with catastrophic brain injuries and their families. Moderate to severe traumatic brain injury (msTBI) remains the leading cause of death after trauma which mostly follows withdrawal of care. Dr. Muehlschlegel will tackle the life-or-death decision about continuation or withdrawal of care ("goals-of-care") in msTBI patients and develop a decision aid for health care proxies of these critically ill patients. Dr. Muehlschlegel's career development plan brings together an outstanding team of investigators from three leading institutions, including the UMMS, University of New England, and University of Pittsburgh. Dr. Muehlschlegel has already obtained preliminary results in msTBI patients confirming that intensive care unit (ICU) complications are associated with worse short-term functional patient outcomes and mortality, and also lead to worse subjective prognostication by clinicians. Based on her daily interactions with families of msTBI patients in her unique clinical position as a neuroICU physician, Dr. Muehlschlegel is acutely aware of the need to improve prognostication and its communication between physicians and families while also including patient's values and preferences. Under the mentorship of Drs. Goldberg, Col, Shutter and Mazor, Dr. Muehlschlegel proposes to: (1a) identify key psychosocial factors of goals-of-care decisions in health care proxies of msTBI patients and physicians in focus groups and structured interviews; (1b) develop a new outcome prediction score for msTBI patients including ICU complications and previously validated admission predictors in a prospectively collected hospital-based cohort of patients with msTBI and to validate her findings internally; (2) create a decision aid prototype for goals-of- care decisions in msTBI patients by incorporating results from Aims 1a and 1b, and the well known and validated msTBI outcome prediction "IMPACT score" based on hospital admission variables; and (3) to pilot test the decision aid in a feasibility trial in the neuroICU. The overal goal of this proposal is to develop a goals- of-care decision aid that may improve health outcomes for msTBI patients by ensuring proxies receive evidence-based prognostication, understand projected outcomes and risks, while also addressing patient's preferences and values. This well-defined mentored patient-oriented research proposal will bring together cutting-edge qualitative and quantitative methods for decision aid and outcome prediction rule derivation, and a team with expertise in outcomes research, shared decision making, and neurocritical care of msTBI patients. This proposal, in concert with a structured didactic curriculum of advanced statistical, qualitative, and decision- science coursework, will provide Dr. Muehlschlegel with the skills and mentorship that are essential for her to develop an independent career in neuroICU research at the cutting edge of shared decision making science.