An Alternative Approach to Understanding the Drivers of High-Performance End-of-life Care Delivery in the Intensive Care Unit

项目摘要/摘要 这项研究提案的总体目标是促进候选人作为一名 独立资助的外科科学家，专注于以生物伦理为导向的健康服务、结果和 质量改进研究。这位候选人和她的导师还设计了一套完善的培训计划 由研究方法论和生物伦理学方面的定期指导和正式教学课程组成。使用 这份NRSA个人奖学金申请，候选人将专注于职业发展，而 通过研究临终关怀的交付，培养定量和定性研究方法的技能 西北纪念医院(NMH)重症监护病房(ICU)的EOL护理。 在美国，大量成年人在生命即将结束时被送往重症监护室。大约20到30岁 他们中有10%的人死于ICU服务，更多的人接受的护理与他们的意愿不符。宽 在提供EOL护理的方式上存在差异。练习模式中的范围不能用 患者和单位级别的特征。EOL护理不是标准化的，质量措施需要验证。 此外，确定潜在的、单位级别的结构、流程和文化对患者的生命周期有影响 经验是未实现的改进机会。NMH有五个不同的ICU在运作 彼此独立。我们假设，在这些ICU中，过程中存在差异，并且 提供EOL护理服务的结果。我们将使用混合方法来确定潜在的单位水平差异 这可以归因于特定ICU的结构、流程和文化。从电子健康记录中 (EHR)，我们将找到有关EOL质量指标的可测量和可记录的数据。然后通过一个积极的-偏离的 框架，包括人种学案例研究和对ICU临床医生的半结构化访谈，我们的目标是 是发现与特定EOL关怀领域的高绩效相关的实践模式。建议数 该项目具有创新性，因为它是第一次测量EOL护理的领域，同时也研究 这些患者接受护理的环境。复杂影响因素的系统分析 EOL护理服务的提供将引导我们走向单元级别的干预，以改善未来ICU患者的护理。

PROJECT SUMMARY/ABSTRACT The overall goal of this research proposal is to facilitate the candidate's development as an independently-funded surgeon scientist with a focus on bioethics-oriented health services, outcomes, and quality improvement research. The candidate and her mentors have also designed a robust training plan consisting of regular mentorship and formal didactic coursework in research methodologies and bioethics. With this proposed NRSA individual fellowship application, the candidate will focus on career development while also building skills in both quantitative and qualitative research methods by studying the delivery of end-of-life (EOL) care in intensive care units (ICU) at Northwestern Memorial Hospital (NMH). A large number of adults in the United States are admitted to ICUs near their end of life. About 20 to 30 percent of them die using ICU services and many more receive care that is discordant to their wishes. Wide discrepancies exist in how EOL care is delivered. The range in practice patterns cannot be explained by patient and unit-level characteristics. EOL care is not standardized and quality measures require validation. Furthermore, identifying latent, unit-level structures, processes, and culture that impact patients' EOL experiences are unrealized opportunities for improvement. NMH has five different ICUs that operate independently of each other. We hypothesize that amongst these ICUs there is variability in the process and outcomes of EOL care delivery. We will use a mixed-methods approach to identify latent unit level differences that can be attributed to the structure, process, and culture of a given ICU. From the electronic health record (EHR), we will find measurable and recordable data on EOL quality metrics. Then through a positive-deviant framework, involving an ethnographic case study and semi-structured interviews of the ICU clinicians, our goal is to uncover practice patterns associated with high-performance on specific EOL care domains. The proposed project is innovative because it is the first time measuring domains of EOL care while also studying the environments from which these patients receive care. The systematic analysis of the complex influences on EOL care delivery will lead us towards unit level interventions to improve ICU patient care in the future.