Identifying optimal care structures and processes in long term acute care hospitals

描述(由申请人提供)： 许多危重患者在最初的急性疾病发作中幸存下来，但后来发展为持续性器官衰竭，需要延长生命支持，这是一种被称为慢性危重疾病的综合征。越来越多的慢性危重病患者在长期急性护理医院(LTAC)接受护理，LTAC是专门用于护理这些高风险、高成本患者的设施。在我们之前的工作中，我们证明了LTAC在慢性危重疾病的护理中发挥着重要作用，与传统的重症监护病房(ICU)相比，可以以更低的成本产生类似的结果。然而，我们的工作也显示了不同LTAC患者存活率的巨大差异，长期死亡率的显著差异并不能用病例组合的差异来解释。这项工作肯定了长期护理中心在美国卫生系统中的重要地位，但也强调了迫切需要研究如何最好地组织和管理长期护理中心内的护理，以优化对慢性危重病患者的护理。类似的护理环境 例如ICU和疗养院有丰富的证据基础来指导它们的组织和管理，但到目前为止还没有关于LTAC的数据。在这个项目中，我们将通过确定与LTAC绩效相关的关键临床和组织因素来解决这一基本知识差距。我们的中心假设是，客观的临床和组织因素将区分高绩效的LTAC和低绩效的LTAC。在一个新的分级风险-调整模型的基础上，我们将首先对风险最低的五个美国LTAC进行实地考察-调整死亡率，以及五个风险最高的LTAC-调整死亡率。在这些实地考察期间，我们将进行深入的民族志研究 以及半结构化访谈，以确定与积极结果相关的临床和组织因素。其次，我们将对美国所有LTAC的医生和护士经理进行量化调查，将调查与患者水平的结果数据联系起来，并从经验上定义LTAC临床和组织的“最佳实践”。通过将LTAC评估的范式从是否有效转移到它们如何以及在哪里工作最好，该项目将是对定义有效LTAC的因素以及对慢性危重疾病的有效护理的第一次严格检查。最终，这些结果将为临床医生、医院管理人员和政策制定者提供有关如何最有效和高效地使用LTAC的即时、可操作的数据，从而提高慢性危重疾病患者的存活率。

DESCRIPTION (provided by applicant): Many critically ill patients survive their initial episode of acute illness but go on to develop persistent organ failures necessitating prolonged life support, a syndrome known as chronic critical illness. Increasingly, patients with chronic critical illness receive care in long---termacute care hospitals (LTACs), specialized facilities for the care of these high---risk, high---cost patients. In our prior work we demonstrated that LTACs play an important role in the care of chronic critical illness, producing similar outcomes at lower costs compared to traditional intensive care units (ICUs). Yet our work also demonstrated wide variation in survival across LTACs, with significant differences in long---term mortality that are not explained by differences in case---mix. This work affirmed the essential position of LTACs in the US health system, but also highlighted a pressing need for research on how to best organize and manage care within LTACs in order to optimize care for patients with chronic critical illness. Analogous care settings such as ICUs and nursing homes have a rich evidence base informing their organization and management, but to date no such data exist for LTACs. In this project we will address this fundamental knowledge gap by identifying the key clinical and organizational factors associated with LTAC performance. Our central hypothesis is that objective clinical and organizational factors will distinguish high performing LTACs from low performing ones. Building off a novel hierarchical risk---adjustment model for measuring LTAC---specific mortality, we will first perform site visits at five US LTACs with the lowest risk---adjusted mortality and five LTACs with highest risk--- adjusted mortality. During these site visits we will conduct in---depth ethnography and semi---structured interviews to identify the clinical and organizational factors associated with positive outcomes. Second, we will develop and field a quantitative survey of physician and nurse managers at all US LTACs, linking the survey back to patient---level outcomes data and empirically defining LTAC clinical and organizational "best practices". By shifting the paradigm of LTAC evaluation away from whether they work to how and where they work best, this project will be the first rigorous examination of the factors that define effective LTACs, as well as effective care for chronic critical illness. Ultimately, these results will provide clinicins, hospital administrators and policy makers with immediate, actionable data about how to use LTACs most effectively and efficiently, leading to improved survival for patients with chronic critical illness.