A Sepsis Transition Program to Reduce Morbidity and Mortality in High Risk Individuals

项目总结 败血症幸存者和医疗保健系统承受着高死亡率、发病率和使用率的负担 因败血症住院治疗。虽然败血症后的许多并发症是由可预防的原因造成的，但医疗保健 系统缺乏有效的策略来提供针对特定缺陷的循证护理建议 败血症幸存者所经历的。迫切需要确定以下方面的成功实施战略 败血症后护理以改善患者预后。我们工作的首要目标是减少医院 住进急性脓毒症护理机构的患者的再入院和出院后死亡率。这个 这项研究的目的是评估实施证据的有效性和成本效益- 基于脓毒症过渡和恢复(STAR)计划，开发关于BEST的概括性知识 败血症后护理的实践。为了实现这一目标，我们将：1)将基于EHR的数据与风险预测联系起来 在护理点识别败血症后死亡率和再入院高危患者的算法； 2)实施循证的败血症后护理建议，针对高危败血症幸存者， 并使用主动的护士导航流程进行交付。STAR计划的重点是18岁的成年人 以及年纪较大的人因败血症住院。STAR计划的有效性是使用阶梯楔子进行评估的， 整群随机对照研究设计。来自不同地理区域的八家急救医院 北卡罗来纳州西部和中部将被随机分成交错序列(即步骤1至8) 从日常护理过渡到明星团队任务。两种干预条件是：ARM 1)通常 医院及其提供者无法获得与干预相关的败血症后护理支持的护理； 和ARM 2)STAR计划干预，其中位于中心位置的护士导航器促进应用 败血症后护理的四个循证核心组成部分(即药物审查、新的损害、 患者在出院前和出院后90天内的合并症和姑息治疗)。使用 8个医院地点和4400名潜在符合条件的患者，这项研究将正式检验这一假设 方案实施优于常规护理，显著降低合并死亡率或 90天后再次入院。我们进一步假设，STAR将拥有较低的医疗保健和社会保障 费用比平时的护理要高。我们将使用实施研究过程综合框架来 指导实施规划、组织、实施和影响评估，将这一复杂干预措施纳入 大型、多样化的医疗保健系统。我们将应用聚焦的民族志来获得一个密集和细致入微的 了解护士导航员在实施STAR项目中的重要作用。建议数 该项目将吸引具有相当高发病率和死亡率的异质人口，并在 提供循证的败血症后护理。成果将推动传播和实施研究 可以改善败血症带来的巨大长期医疗负担的方法。

PROJECT SUMMARY Sepsis survivors and healthcare systems are burdened by high mortality, morbidity, and utilization following hospitalization for sepsis. While many complications post-sepsis result from preventable causes, healthcare systems lack efficient strategies to deliver evidence-based care recommendations targeted to specific deficits experienced by sepsis survivors. There is urgent need to determine successful implementation strategies for post-sepsis care to improve patient outcomes. The overarching goal of our work is to reduce hospital readmissions and post-discharge mortality for patients admitted to an acute care facility for sepsis. The objective of this study is to evaluate the effectiveness and cost-effectiveness of implementing an evidence- based Sepsis Transition And Recovery (STAR) program to develop broadly generalizable knowledge on best practices for post-sepsis care. To achieve this objective, we will: 1) link EHR based data to risk prediction algorithms to identify at the point of care patients who are high risk for post-sepsis mortality and readmission; and 2) implement evidence-based post-sepsis care recommendations, directed to high-risk sepsis survivors, and delivered using a proactive, nurse navigation process. The STAR program will focus on adults aged 18 and older hospitalized for sepsis. Effectiveness of the STAR program is assessed using a stepped-wedge, cluster randomized controlled study design. Eight acute care hospitals from diverse geographic regions of western and central North Carolina will be randomized to a staggered sequence (i.e., steps 1 to 8) of transitioning from Usual Care to STAR group assignment. The two intervention conditions are: Arm 1) Usual care in which hospitals and their providers have no access to intervention-related post-sepsis care support; and Arm 2) STAR program intervention in which a centrally located nurse navigator facilitates the application of four evidence-based core components of post-sepsis care (i.e., review of medications, new impairments, comorbidities, and palliative care), to patients prior to and during the 90 days after hospital discharge. With eight hospital sites and 4400 potentially eligible patients, this study will formally test the hypothesis that STAR program implementation is superior to usual care with respect to significantly lower rate of combined death or hospital readmission, at 90 days. We further hypothesize that STAR will have lower healthcare and societal costs than usual care. We will use the Consolidated Framework for Implementation Research processes to guide implementation planning, organization, conduct, and impact evaluation of this complex intervention into a large, diverse healthcare system. We will apply focused ethnography to obtain an intensive and nuanced understanding of the nurse navigator’s important role in the execution of the STAR program. The proposed project will engage a heterogeneous population with substantial morbidity and mortality and gaps in the delivery of evidence-based post-sepsis care. Results will advance dissemination and implementation research methods that can improve the immense long-term healthcare burden of sepsis.