Adherence to Clinical Practice Guidelines in the Emergency Department

描述（由申请人提供）：美国急诊科（ed）是医疗保健系统的重要组成部分，因为它们：(1)是唯一提供24小时急性护理的场所；(2)是住院治疗最常见的接入点；(3)发挥医疗保障网络的作用在美国，急诊科护理对于几乎所有住院和死亡的主要原因的急性管理至关重要，2-4。此外，在急诊科提供的护理已被证明对死亡率有显著影响，5-9并且一旦在急诊科开始，在住院期间更有可能维持循证护理，10。尽管急诊科提供的护理质量很重要，但人们对急诊科的护理质量或护理质量的障碍知之甚少。急性冠状动脉综合征（ACS）、急性ST段抬高型心肌梗死（AMI）、社区获得性肺炎（CAP）、急性缺血性卒中（AIS）和严重脓毒症和感染性休克（SS）是研究急诊科护理质量的5个理想疾病过程，因为它们都是住院的常见原因，其中3个与显著发病率相关。死亡率和医疗费用，2-3是在急诊科最初治疗的，3都有基于急诊科的临床实践指南（cpg），影响患者的结果。54-58我们计划研究与这5种疾病相关的医生对CPGs的依从性，以提供第一个关于ED护理质量和ED护理质量障碍的全面和比较研究。第一个假设是，ED中CPGs的依从性偏离了先验定义为95%的标准阈值，并且ED中CPGs的依从性因疾病特定CPGs而异。第二个假设是患者、提供者和环境因素与ED CPGs的不良依从性显著相关。因此，具体目的包括：(1)进行一项多中心回顾性研究，以估计ACS、AMI、CAP、AIS和SS ED患者的依从性偏离标准阈值和疾病特异性CPGs之间的依从性差异；(2)进行定性研究，以确定提供者的知识、态度和对ACS、AMI、CAP、AIS和SS的CPGs坚持ED的感知障碍；(3)开展多中心回顾性研究，评估ACS、AMI、CAP、AIS和SS患者、提供者和环境因素与CPGs ED依从性之间的关系。

DESCRIPTION (provided by applicant): United States emergency departments (EDs) are a vital component of the health care system because they: (1) are the only site that provides 24-hour acute care; (2) are the most frequent access point for inpatient care; and (3) function as the health care safety net.1 ED care is critical for the acute management of almost every major cause of hospital admission and death in the United States, 2-4. Moreover, care provided in the ED has been shown to have a significant impact on mortality, 5-9 and once started in the ED, evidence-based care is more likely to be maintained during hospitalization,10. Despite the importance of quality of care provided in the ED, little is known about ED quality of care or barriers to quality of care in the ED. Acute coronary syndrome (ACS), acute ST elevation myocardial infarction (AMI), community-acquired pneumonia (CAP), acute ischemic stroke (AIS), and severe sepsis and septic shock (SS) are 5 ideal disease processes to study ED quality of care given that they are all common reasons for hospital admission,3 are associated with significant morbidity, mortality, and health care costs,2-3 are initially treated in the ED,3 nd all have ED based clinical practice guidelines (CPGs) that impact patient outcomes.54-58 We plan to study physician adherence to CPGs related to these 5 diseases in order to provide the first comprehensive and comparative study on ED quality of care and barriers to ED quality of care. The first hypothesis is that adherence to CPGs in the ED deviates from a criterion threshold defined a priori as 95% and adherence to CPGs in the ED varies between disease specific CPGs. The second hypothesis is that patient, provider, and environmental factors are significantly associated with poor adherence to ED CPGs. The Specific Aims therefore include: (1) to perform a multi-center retrospective study to estimate adherence deviation from a criterion threshold and adherence variation between disease specific CPGs among ED patients with ACS, AMI, CAP, AIS, and SS; (2) to perform a qualitative study to identify provider knowledge, attitudes, and perceived barriers to ED adherence of CPGs for ACS, AMI, CAP, AIS, and SS; and (3) to perform a multi-center retrospective study to estimate associations between patient, provider, and environmental factors and ED adherence of CPGs for ACS, AMI, CAP, AIS and SS.