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

描述(申请人提供)：创伤性脑损伤(TBI)是一岁以上儿童的头号杀手。2003年，《儿童重型创伤性脑损伤急诊医疗处理指南》发布。然而，这里没有任何战略来加强对这些指导方针的遵守。我们的项目目标是使用遵从性记分卡来检查遵从性和患者结果之间的关联，开发一个价值流图来说明影响遵从性的因素，并使用计算机模拟来创建遵从性的最佳实践蓝图。指导性假设是，组织因素预测，坚持预测结果，最佳实践蓝图将导致在严重的儿科脑损伤后坚持和有利的结果。具体目标1：开发一种国家依从性记分卡，以表征遵守儿科指南的国家差异，并使用该积分卡检查依从性与患者结局之间的关系。假设1：从5个儿科创伤中心和医疗保健成本和利用项目(HCUP)儿童住院患者数据库(KID)的图表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，描述所有地点内和所有地点之间遵守情况的可变性，并提供大规模的II类证据，证明坚持与更好的结果相关(出院与住院康复与长期设施或死亡，以及住院时间。具体目标#2：创建一个价值流图，该图可以容易地确定可补救的高优先级提供者和影响遵守儿科指南的组织因素，并检查这些因素是否因采用者状态而异(在目标#1中定义)。假设2：在采用者类别中，遵守的障碍很高，并构成提供商和组织因素。调查方法和焦点小组将显示，可补救的障碍和促进者概况因采用者身份而异。价值流图将基于TBI护理的活动流和通过图表抽象(目标1)、儿童数据以及调查和焦点小组结果(目标2)确定的结果来生成。价值流图将按采用者状态定义可补救和增值的TBI关怀流程。目标3：使用计算机模拟来开发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对依从性和有效性的参数估计(目标1)和价值流图的活动输入(目标2)来确定TBI护理过程对关键儿科指南指标和患者结果的影响。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护理下游手术的规模、方向和选择以及患者结果。然后，这些结果将有助于制定最佳实践蓝图，以便按采纳者状态进行遵守。调查结果将被广泛传播。将确定随机地点，以检查最佳实践蓝图对遵守儿科指南和患者结局的影响。

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.