Optimizing ED to ICU triage decisions for critically ill patients in respiratory distress

 描述(申请人提供)：拟议的研究和职业发展计划的目标是让首席调查员(PI)成为一名独立的临床调查员，使用多种研究方法直接提高危重患者的护理质量 急诊科(ED)和重症监护病房(ICU)之间的病人。为了过渡到她职业生涯的下一个阶段，并巩固她作为重症监护医生的优势以及她之前在临床研究和定量分析方面的培训，PI将通过个性化和课堂培训学习高级研究技能，包括多层次建模、定性和混合方法方法、决策分析和临床决策支持工具开发。ED患者在ICU入院前后的分诊决定对患者的预后以及ED和ICU资源的利用有着深远的影响。这一决定的差异超出了患者相关因素和床位可用性的解释。拟议的K23研究旨在通过了解ED-ICU界面上分诊决策的主观和客观因素之间的相互作用，改善获得适当ICU护理的机会，并开发创新的临床解决方案，以降低死亡率。这项建议的具体目标是(1)使用混合方法和多水平建模，在现有的多医院急诊急诊患者合并呼吸窘迫的数据集中检查当前ICU分诊实践的差异程度；(2)使用根据数据集分析开发的情景的半结构化医生访谈，确定影响疾病严重性和从ICU入院受益的可能性的主观评估的因素；以及3)开发和测试基于电子健康记录的临床决策支持工具的可行性，以减少ICU入院决定中潜在的有害差异。这些目标有可能1)在资源有限的情况下为具有某些特征的患者确定分诊决策的差异，2)提供对医生分诊实践影响最大的因素的洞察 以及他们对敏锐度和受益可能性的看法，以及3)使用临床决策支持工具确定干预的目标区域，以改善急诊-ICU界面的护理。

 DESCRIPTION (provided by applicant): The goal of the proposed research and career development plan is for the Principal Investigator (PI) to become an independent clinical investigator using multiple research methods to directly improve the quality of care for critically ill patients at the interface between the Emergency Department (ED) and Intensive Care Unit (ICU). To transition into the next phase of her career and build upon her strengths as a critical care physician and her prior training in clinical investigation and quantitative analysis, the PI wll learn advanced research skills through individualized and classroom training, including multi-level modeling, qualitative and mixed methods approaches, decision analysis, and clinical decision support tool development. Triage decisions around ICU admission for ED patients have profound implications for patient outcomes and utilization of ED and ICU resources. Variation in this decision exists beyond what is explained by patient-related factors and bed availability. The proposed K23 research seeks to improve access to appropriate ICU care and develop innovative clinical solutions to reduce mortality by understanding the interaction between subjective and objective factors on triage decision-making at the ED-ICU interface. The specific aims of this proposal are (1) Examine the extent of variation in current ICU triage practice in an existing multi-hospital dataset of critically ill ED patients with respiratory distress, using a mied methods approach and multi-level modeling, (2) Identify factors influencing subjective assessments of illness severity and likelihood to benefit from ICU admission, using semi-structured physician interviews with scenarios developed from dataset analysis, and 3) Develop and test the feasibility of an electronic health record-based clinical decision support tool to reduce potentially harmful variation in ICU admission decisions. These aims have the potential to 1) identify disparities in triage decisions for patients with certain characteristics when resources are limited, 2) provide insight into which factors most affect physician triage practices as well as their perceptions of acuity and likelihood to benefit, and 3) pinpoint target areas for intervention using clinical decision support tools to improve care at the ED-ICU interface.