Implementation Science to Increase Use of Evidence Based Pediatric Brain Injury G

描述（由申请人提供）：创伤性脑损伤（TBI）是一岁以上儿童的主要杀手。2003年，以证据为基础的《儿童严重创伤性脑损伤急性医疗管理指南》出版。然而，这里没有策略来增加对这些指导方针的遵守。我们的项目目标是使用依从性记分卡来检查依从性与患者结果之间的关系，开发一个价值流图来说明影响依从性的因素，并使用计算机模拟来创建依从性的最佳实践蓝图。指导假设是组织因素预测，依从性预测结果，最佳实践蓝图将导致严重儿童TBI后的依从性和良好结果。具体目标1：开发一种全国性的依从性记分卡，以表征各国对《儿科指南》依从性的差异，并使用记分卡检查依从性与患者预后之间的关系。假设# 1：从5个儿科创伤中心的图表和医疗成本和利用项目（HCUP）的儿童住院患者数据库（KID）中提取的数据将显示，在遵守儿科指南的程度上存在不必要的和可补救的差异。依从性记分卡将用于对研究地点采用者的状态进行分类，描述所有地点内部和之间依从性的可变性，并提供大规模的II类证据，证明依从性与更好的结果（出院回家、住院康复、长期设施或死亡）和住院时间有关。具体目标2：创建一个价值流图，容易识别影响儿科指南遵守的可补救的高优先级提供者和组织因素，并检查这些因素是否因采用者状态而变化（在目标1中定义）。假设2：在采用者类别中，遵守障碍很高，并构成提供者和组织因素。调查方法和焦点小组将显示，可补救的障碍和推动者概况因采用者状态而异。价值流图将根据TBI护理的活动流程和通过图表抽象（目标1）、KID数据以及调查和焦点小组结果（目标2）确定的结果生成。价值流图将根据采用者的状态定义可补救的和增值的TBI护理过程。目标3：使用计算机模拟来制定和传播遵守儿科指南的最佳实践蓝图。假设# 3：计算机模拟模型将根据回归模型（目标# 1）和价值流图（目标# 2）的活动输入对依从性和有效性的参数估计，确定TBI护理过程对关键儿科指南指标和患者结局的影响。迭代计算机模拟将展示儿科指南组成部分之间的关系，以及活动的相对变化如何影响TBI护理和患者预后的下游手术的大小、方向和选择。然后，这些结果将为采用者状态的遵守提供最佳实践蓝图。调查结果将广为散发。将确定随机抽查的地点，以检查最佳实践蓝图对遵守《儿科指南》和患者预后的影响。

DESCRIPTION (provided by applicant): Traumatic brain injury (TBI) is the leading killer of children over one year of age. In 2003, the evidence based Guidelines for the Acute Medical Management of Severe Pediatric Traumatic Brain Injury was published. Yet, here are no strategies to increase adherence to these guidelines. Our project goal is to use an adherence scorecard to examine the association between adherence and patient outcomes, develop a value stream map illustrating factors impacting adherence, and use computer simulation to create a best practices blueprint for adherence. The guiding hypothesis is that organizational factors predict, adherence predicts outcomes and that a best practices blueprint will result in both adherence and favorable outcomes after severe pediatric TBI. Specific Aim # 1: To develop a national adherence scorecard that characterizes national variation in adherence to the Pediatric Guidelines, and to use the scorecard to examine the relationship between adherence and patient outcomes. Hypothesis # 1: Data abstracted from charts at 5 pediatric trauma centers and the Healthcare Cost and Utilization Project's (HCUP) child inpatient database (KID) will show that there is unwanted and remediable variability in the degree of adherence to the Pediatric Guidelines. The adherence score card will be used to classify study site adopter status, characterize variability in adherence within and between all sites, and provide large scale Class II evidence that adherence is associated with better outcomes (discharge to home vs. inpatient rehabilitation vs. long term facility or died, and hospital length of stay. Specific Aim # 2: To create a value stream map that readily identifies remediable high priority provider and organizational factors which impact adherence to the Pediatric Guidelines and examine whether these factors vary by adopter status (defined in Aim # 1). Hypothesis # 2: Barriers to adherence are high across adopter categories and constitute both provider and organizational factors. Survey methods and focus groups will show that remediable barrier and facilitator profiles vary by adopter status. Value stream maps will be generated based on the activity flows of TBI care and outcomes identified via chart abstraction (Aim #1), KID data, and survey and focus group outcomes (Aim # 2). Value stream maps will define remediable, and value added TBI care processes by adopter status. Aim # 3: To use computer simulation to develop and disseminate a best practices blueprint for adherence to the Pediatric Guidelines. Hypothesis # 3: Computer simulation models will determine the effect of TBI care processes on key Pediatric Guideline indicators and patient outcomes based on parameter estimates of adherence and effectiveness from regression models (Aim # 1) and activity inputs of value stream maps (Aim # 2). Iterative computer simulation will demonstrate the relationship among Pediatric Guideline components and how relative changes in activities impact the magnitude, direction and choice of operations downstream in TBI care and patient outcomes. These results will then contribute to a best practices blueprint for the adherence by adopter status. Findings will be widely disseminated. Sites to be randomized to examine the effect of the best practices blueprint on adherence to the Pediatric Guidelines and on patient outcomes will be identified. PUBLIC HEALTH RELEVANCE: Strategies to increase adherence to the Pediatric Guidelines for severe traumatic brain injury are not known. We will use implementation science methods, such as value stream maps and iterative computer simulation, to develop and disseminate a best practices blueprint that increases adherence to the Pediatric Guidelines.