ICU Discharge: A Critical Juncture for Survivors of Acute Respiratory Failure

描述(由申请者提供)：一名医学博士研究生正准备进入她的临床流行病学博士论文阶段，正在申请这笔培训补助金。候选人渴望成为重症监护结果研究领域的一名领先的独立内科医生兼科学家。在她的博士学位期间，她将100%的时间投入到这项研究中。她在论文阶段的实践培训，加上精心挑选的教学课程，旨在使她成为使用先进的统计方法来确定重症监护暴露与结果之间的关联的专家，以及使用定性方法来深入探索机制和产生新的假设。这种双重培训方法将使她为未来关于危重病人护理过渡期间医患沟通的研究做好最佳准备。在整个奖项过程中，她将得到卫生服务研究、危重护理、生物统计学、生物伦理学和定性方法方面的资深专家的指导。这一职业发展奖的研究部分将在三个免费项目中进行，以提高对ICU出院情况如何影响急性呼吸衰竭(ARF)患者及其代理人的结局的了解。在项目1中，候选人将使用国家ICU患者数据库检查ICU人口普查对ARF患者医疗结局的影响。首先，她将评估ICU人口普查对需要机械通气的ARF患者从拔管到ICU出院时间的影响。然后，她将研究ICU人口普查与住院死亡和ICU重新住院之间的关系，调查拔管和ICU出院之间的时间是否作为人口普查和负面结果之间的影响修饰符。在项目2中，她将前瞻性地收集数据，以检查患有ARF需要机械通气的患者及其代理人的心理和信任结果。她将在ICU出院后一个月对患者和代理人进行电话采访，并进行有效的调查，评估焦虑、抑郁和信任结果。因此，这项研究将对需要机械通气的ARF患者及其代理人的出院时间周围以前未探索的风险提出有效的衡量标准。它将建立一个概念模型的基础，该模型将用作未来定性研究的基础，该研究检查医疗团队与患者和代理人在ICU出院时的对话内容，以确定患者和代理人认为最有帮助的沟通元素。最终目标是通过未来针对床位分配决策和医疗团队与患者和代理人之间的沟通的干预研究来改善这一脆弱的患者和代孕者的结局。 公共卫生相关性：ICU出院的时间和环境可能是急性呼吸衰竭患者及其代理人存活下来的长期结果的关键决定因素。使用定量和调查方法，这项研究将确定围绕ICU出院的情况，预示着不良的临床结果，从而阐明干预措施的目标，以改善对这一弱势群体患者及其代理人的护理。

DESCRIPTION (provided by applicant): This training grant is being sought by an MD-PhD student preparing to enter the dissertation phase of her PhD in clinical epidemiology. The candidate aspires to become a leading independent physician-scientist in the field of critical care outcomes research. She will devote 100% of her time to this research for the duration of her PhD. Her hands-on training during her dissertation phase, coupled with carefully selected didactic courses, are designed to make her expert in the use of advanced statistical methods to define associations between critical care exposures and outcomes as well as in the use of qualitative methods to deeply explore mechanisms and generate new hypotheses. This dual training approach will optimally prepare her for future studies on doctor-patient communication during transitions of care for critically ill patients. Throughout this award, she will be mentored by senior experts in health services research, critical care, biostatistics, bioethics, and qualitative methods. The research portion of this career development award will proceed in three complimentary projects to improve understanding of how the circumstances surrounding ICU discharge affect the outcomes for acute respiratory failure (ARF) patients and their surrogates. In project 1, the candidate will examine the effect of ICU census on the medical outcomes of ARF patients using a national database of ICU patients. First, she will evaluate the effect of ICU census on the time between extubation and ICU discharge for ARF patients requiring mechanical ventilation. She will then examine the relationship between ICU census and in-hospital death and ICU readmission, investigating whether time between extubation and ICU discharge acts as an effect modifier between census and negative outcomes. In project 2, she will prospectively collect data to examine psychological and trust outcomes patients who suffered an episode of ARF requiring mechanical ventilation and their surrogates. She will conduct telephone interviews with patients and surrogates one month following ICU discharge and administer validated surveys that assess anxiety, depression, and trust outcomes. This research will therefore produce valid measures of the previously unexplored risks surrounding the time of discharge to ARF patients requiring mechanical ventilation and their surrogates. It will build the foundations of a conceptual model that will be used as the basis for future qualitative studies that examine the content of conversations between the health care team and patients and surrogates at the time of ICU discharge to determine which communication elements patients and surrogates find most helpful. The ultimate goal is to improve outcomes in this vulnerable group of patients and surrogates with future intervention studies targeting bed allocation decisions and communication between the health care team and patients and surrogates. PUBLIC HEALTH RELEVANCE: The timing and circumstances of discharge from the ICU may be critical determinants of longer-term outcomes for patients surviving an episode of acute respiratory failure and their surrogates. Using quantitative and survey methods, this research will identify circumstances surrounding ICU discharges that portend adverse clinical outcomes, thereby elucidating targets for interventions to improve care for this vulnerable group of patients and their surrogates.