A human factors intervention to reduce risk in primary care of The elderly

描述（由申请人提供）：证据表明，门诊护理是不安全的，对老年患者更不安全。但人们对安全问题的根源知之甚少。这使得AHRQ推出了门诊护理患者安全主动风险评估FOA，根据该评估，我们获得了一笔赠款，用于识别老年人初级保健中的危险。我们招募了所有15家诊所（8家城市诊所，7家农村诊所，9家使用电子健康记录（EHR），6家未使用EHR），对数据的主动危害分析表明，几乎所有危害都是一个最严重的危害：医生正在经历信息混乱。信息混乱是同时存在的（a）信息过载，（B）信息欠载，（c）信息的不确定性，以及（d）对某些信息缺乏意识。在人因工程（HFE）中，这种情况已经被研究过，证据表明它会导致两种不必要的结果：糟糕的情况意识（SA）和高脑力工作负荷（MWL）。SA被定义为一个人对他或她的情况的认识和理解。当一个人的心理能力被超过时，就会出现高MWL。低SA和高MWL最终都会损害记忆、问题识别、决策和决策执行，因此对安全性有明显的负面影响。提供更好SA的干预措施将降低MWL并改善初级保健医生（PCP）的表现（问题识别，决策）。提高SA的方法是在正确的时间为人们提供正确的信息。因此，我们的风险知情干预将测试SA干预，以改善PCP性能，从而提高老年人（75岁以上）初级保健的安全性。干预涉及一名RN，我们称之为“护理协调员”，他（a）在计划访视前5个工作日从其他提供者处收集离散患者数据，如问题列表、药物、测试和程序，（B）在PCP首次访视前的计划时间与PCP会面，以便在PCP能够集中精力和交谈时向其提供正确的信息。我们采用随机设计，涉及4个不相关的诊所，16名初级保健医生和1,536名老年患者，随机分配到干预或护理。我们将评估对PCP SA和MWL、患者感知的PCP SA、患者临床结局和投资回报的影响。我们将评估干预障碍和促进者，并通过理论驱动的计划广泛分享结果。这项研究具有重要意义和创新性，因为我们正在（a）测试初级保健干预措施，这是研究不足的;（B）对老年患者进行干预，这是一个优先人群;（c）使用风险知情的安全干预措施;（d）关注信息混乱;（e）涉及经验丰富的多学科团队，由人为因素工程师和初级保健临床医生组成。 公共卫生相关性：该研究旨在测试老年人初级保健安全的干预措施。潜在的好处是更安全，更有效的护理，以及更有效的护理。这将导致更好的病人临床过程和结果的措施和更有效的诊所运作。

DESCRIPTION (provided by applicant): Evidence demonstrates that ambulatory care is unsafe, and more unsafe with elderly patients. But little is known about what underlies the safety problems. That led AHRQ to launch the Ambulatory Care Patient Safety Proactive Risk Assessment FOA, under which we were awarded a grant to identify hazards in the primary care of the elderly. We have enrolled all 15 clinics (eight urban, seven rural, nine using electronic health records [EHRs] and six not using EHRs), and proactive hazard analysis of the data show that underlying nearly all of the hazards is one most serious hazard: physicians are experiencing information chaos. Information chaos is simultaneous (a) information overload, (b) information underload, (c) uncertainty about information, and (d) lack of awareness of some information. In human factors engineering (HFE) this situation has been studied, and evidence shows it contributes to two unwanted outcomes: poor situation awareness (SA) and high mental workload (MWL). SA is defined as a person's awareness and understanding of his or her situation. High MWL occurs when a person's mental capacity is exceeded. Both poor SA and high MWL ultimately impair memory, problem identification, decisionmaking, and decision execution and therefore have clear, negative impacts on safety. An intervention that provides better SA will reduce MWL and improve performance for the primary care physician (PCP) (problem identification, decisionmaking). The way to improve SA is to provide people with the right information at the right time. Thus our risk-informed intervention will test a SA intervention to improve PCP performance and thus safety of primary care of the elderly (aged 75+). The intervention involves a RN we call a "care coordinator" who (a) collects discrete patient data such as problem lists, medications, and tests and procedures from other providers 5 business days before a scheduled visit and (b) meets with the PCP at a scheduled time before the PCP's first visit to provide him/her with the right information at a time when the PCP can focus and talk. We use a randomized design involving four unrelated clinics, 16 primary care physicians, and 1,536 elderly patients randomly assigned to the intervention or care as usual. We will evaluate the impact on PCP SA and MWL, patient-perceived PCP SA, patient clinical outcomes, and return on investment. We will evaluate intervention barriers and facilitators and share the results widely with a theory-driven plan. This study is significant and innovative because we are (a) testing an intervention in primary care, which is understudied; (b) intervening for elderly patients, a priority population; (c) using a risk-informed safety intervention; (d) focusing on information chaos; and (e) involving a highly experienced multidisciplinary team of human factors engineers and primary care clinicians. PUBLIC HEALTH RELEVANCE: The study seeks to test an intervention for the safety of primary care of the elderly. The potential benefits are safer and more effective care, as well as more efficient care. This should result in better patient clinical process and outcomes measures and more efficient clinic operations.