CROSSING AN INVISIBLE QUALITY CHASM: FROM NICU TO AMBULATORY CARE

描述(由申请人提供)：护理过渡(移交)与错误和不良后果的风险增加相关。从住院环境过渡到门诊护理的风险可能特别高，因为过渡需要更长的时间，沟通可能很差，而且对患者护理的责任没有明确规定。住进重症监护病房的儿童和早产或患有复杂先天畸形的婴儿越来越多地存活到出院，患者往往需要大量的监测和护理协调。尽管成人向门诊护理过渡的研究 患者可能会告知婴儿和儿童的这一过程，但尚不清楚风险是否相同，或者解决这些问题的相同方法是否合适。我们的长期目标是通过开发一种有效的、广泛适用的流程来改善患有复杂疾病的儿科患者的健康，该流程将识别错误点并促进对这一过渡期间患者风险的了解，并以从高风险托儿所到门诊随访的过渡为范例，促进未来制定干预措施以减少这些错误的来源。我们的总体假设是，结合前瞻性和回溯性方法，将准确地识别从住院到门诊护理过渡过程中的多个高风险错误点，并将产生适当的未来改善计划。我们的具体目标是：1)使用医疗保健失败模式和效果分析(HFMEA)进行前瞻性风险评估，并确定从新生儿托儿所到门诊随访的护理过渡过程中可能发生的高影响错误点及其来源；以及2)使用回溯性方法，如提示自发报告、触发事件、选定的图表回顾和有针对性的问卷，以确定潜在和积极的错误，并证实和补充HFMEA的发现。改进后的模型将用于设计旨在确保最佳护理过渡的具体干预措施。我们的发现应该广泛推广到照顾有复杂卫生保健需求的儿童的组织，因为他们正在从高强度的住院护理过渡到门诊随访。相关性：该项目将通过整合前瞻性和回溯性风险评估来改善婴儿健康，以确定婴儿从重症监护托儿所向门诊随访过渡过程中的高风险点，并计划干预措施以减轻已确定的风险。

DESCRIPTION (provided by the applicant): Transitions in care (handoffs) are associated with increased risk for errors and adverse outcomes. The transition from the inpatient setting to ambulatory care may be particularly high-risk because the transition occurs over a longer period of time, communication may be poor, and the responsibility for the patient's care is not as clearly specified. Children admitted to intensive care units and infants born prematurely or with complex congenital abnormalities are surviving to discharge in growing numbers, and patients often require significant monitoring and coordination of care. Although studies of this transition to outpatient care in adult patients may inform the process in infants and children, it is not clear that the risks are the same or that the same approaches to resolving these problems will be appropriate. Our long term goal is to improve the health of pediatric patients with complex conditions by developing an efficient, widely applicable process that will identify error points and facilitate understanding of patient risk during this transition, and facilitate future development of interventions to mitigate these sources of error, using the transition from high-risk nurseries to outpatient follow up as the exemplar. Our overall hypothesis is that combining the prospective and retrospective approaches will accurately identify multiple high risk error points in the transition from inpatient to ambulatory care, and will result in appropriate plans for future improvement. Our specific aims are: 1) to conduct a prospective risk assessment using Health Care Failure Mode and Effect Analysis (HFMEA) and identify high impact error points and their origins that may occur in the care transition from the neonatal nurseries to ambulatory follow up; and 2) to use retrospective methods such as prompted spontaneous reporting, trigger events, selected chart reviews and targeted questionnaires to identify both latent and active errors and to corroborate and add to the findings from HFMEA. The refined model will be used to design specific interventions aimed at ensuring optimal transitions of care. Our findings should be broadly generalizable to organizations caring for children with complex health care needs as they transition from high intensity inpatient care to ambulatory follow up. Relevance: This project will improve infant health by integrating prospective and retrospective risk assessment to identify high risk points in the transition of infants from intensive care nurseries to ambulatory follow up and plans interventions to mitigate the identified risks.