Acute Pancreatitis Alert & Decision Support Improves Care & Cuts Length of Stay

 描述(由申请人提供)：这项研究的长期目标是开发一种便携式、可扩展的软件工具，以改善急性胰腺炎(AP)患者的治疗。在这份R21提案中要求提供资金，以支持使用第二代AP早期反应(TAPE)-临床决策支持(CDS)-工具的300名患者的研究。预期的结果是，使用版本2.0的Taper-CDS工具将导致AP患者更符合公认的临床指南，改善临床结果，并降低住院费用。急性胰腺炎是胃肠道相关住院的最常见原因。尽管存在公认的处理AP的临床指南，但对这些建议的遵从性普遍较差。我们的多学科质量改进(QI)团队开发了Taper-CDS-Tool 1.0，这是一个组合的早期自动寻呼警报系统，可以向急诊科(ED)临床医生发送有关可能患有AP的患者的文本页面，以及一个直观、简洁的基于Web的医疗点指南，其中包括7个早期管理建议。在我们的初步研究中，对223名患者在缩减CDS工具1.0前后的时间进行了比较，该工具与7项建议中的2项(液体复苏和风险分层)的实施增加了相关，住院时间(LOS)平均减少了2.1天，每次住院节省了3,874美元。虽然Tool 1.0显著改善了AP的结果并降低了成本，但AP治疗的7个最佳实践中有4个渗透率较差，这4个最佳实践中只有2个有显著改善。因此，我们改进了工具1.0来解决这些缺点，现在打算评估改进的Taper-CDS-Tool 2.0作为本提案的重点。Taper-CDS-Tool 2.0是一种可扩展的QI工具，旨在急诊室和住院期间广泛使用，以实现提高护理过程和质量以及改善结果的目标，特别是缩短医院损失。凭借我们的信息技术应用程序员的专业知识，我们专注于将Tool 2.0集成到电子病历(EMR)中，作为最佳实践警报(BPA)的单一来源，以便向用户“前馈”关键信息，以支持护理不同阶段的实时临床决策：1)有关AP诊断的警报通知，2)基于时间的严重性自动评估，3)基于时间的患者特定临床数据的自动显示，显示对治疗的反应，以及4)CDS工具的嵌入式链接，其中包含涵盖急诊和医院护理的指南和机构建议。BPA克服了工具1.0的局限性，将警报通知扩展到所有急诊和医院临床医生、实习生和护士，而不仅仅是急诊临床医生和实习生。我们预计，该项目的结果将展示一种有效的、可扩展的方法，通过与EMR基础设施的接口来实施临床指南，EMR基础设施已在全国范围内推广使用。从这项研究收集的数据将是设计验证性前瞻性随机对照试验的关键。从长远来看，我们的目标是利用这一平台技术和迭代改进战略来开发指南实施方法，以改善其他急性疾病的护理过程和结果。

 DESCRIPTION (provided by applicant): The long-term goal of this research is to develop a portable, scalable software tool to improve treatment for patients with acute pancreatitis (AP). Funds are requested in this R21 proposal to support a 300 patient study using the second generation of The AP Early Response (TAPER)-Clinical Decision Support (CDS)-Tool. The expected outcome is that use of version 2.0 of the TAPER-CDS-Tool will result in increased compliance with accepted clinical guidelines, improved clinical outcome, and lower hospitalization costs for AP patients. AP is the most common reason for gastrointestinal-related hospitalizations. Although accepted clinical guidelines for managing AP exist, compliance with these recommendations is generally poor. Our multidisciplinary quality improvement (QI) team developed the TAPER-CDS-Tool 1.0, which is a combined early automated paging-alert system, which text-pages emergency department (ED) clinicians about a patient with possible AP, and an intuitive, concise web-based point-of-care guide consisting of 7-early management recommendations. In our preliminary study comparing pre and post TAPER-CDS-Tool 1.0 periods involving 223 patients, this Tool associated with increased implementation of 2 of 7-recommendations (fluid resuscitation and risk stratification), and a mean decrease in hospital length-of-stay (LOS) by 2.1 days, associated with savings of $3,874/hospitalization. Although Tool 1.0 significantly improved outcomes and reduced cost of AP, 4 of 7 best practices for AP treatment had poor penetration and only 2 of these 4 improved significantly. Thus, we refined Tool 1.0 to address these shortcomings, and now intend to evaluate the refined TAPER-CDS- Tool 2.0 as the focus of this proposal. The TAPER-CDS-Tool 2.0 is a scalable QI tool intended for widespread use in the ED and during hospitalization to achieve the goals of increased process and quality of care and improved outcomes, specifically shortened hospital LOS. With the expertise of our Information Technology Application Programmer, we focused on integrating Tool 2.0 into the electronic medical record (EMR) as a single source of best practice alerts (BPA) to "feed forward" key information to users to support real-time clinical decision making at various stages of care: 1) alert notification about the diagnosis of AP, 2) a time-based automated assessment of severity, 3) a time-based automated display of patient specific clinical data showing the response to treatments and 4) an embedded link to the CDS-Tool, containing guideline and institutional recommendations encompassing ED and hospital care. The BPA overcomes limitations of Tool 1.0 by expanding the alert notification to all ED & hospital clinicians, trainees and nurses rather than just ED clinicians and trainees. We anticipate that results from this project will demonstrate an effective, scalable method for implementing clinical guidelines by interfacing with EMR infrastructures, which have been rolled-out for use nationally. Data gathered from this study will be pivotal to design a validating prospective RCT. In the long term, we aim to harness this platform technology and the iterative refinement strategy to develop guideline implementation methods to improve process of care and outcomes for other acute illnesses.