Establishing and Implementing Pneumonia Diagnosis in ED Older Adults: A Mixed Methods Approach

项目摘要/摘要 在阅读此应用程序的时间内，20名老年人(年龄≥65岁)将在2010年死于肺炎 美国。每年有超过500,000名老年人在急诊科接受治疗 肺炎。不幸的是，急诊科医生无法准确诊断老年人肺炎，因为 不典型症状、胸部X光不准确、合并症、肺部临床预测规则失败 在较年轻的成年人中建立，以及现有生物标志物的准确性较差。急诊医生无法 老年人肺炎的诊断会导致延误诊断、治疗不足、感染加重、 较长的住院时间(6.6天对5.4天)和死亡率。 肺炎可由细菌和病毒病原体单独或组合引起。细菌 肺炎本身就会导致不良后果，并面临刚才所述的诊断挑战。这个 病毒性肺炎的存在使诊断进一步复杂化。所有成年人的细菌和病毒混合感染增加 死亡几率降低2.1，预计对老年人的有害影响更大。不幸的是，当病毒传播时 检测到细菌来源我们目前的诊断方法无法可靠地识别细菌来源 混合感染。这可能会导致不适当的护理，并突出了确保快速、准确的重要性 细菌性肺炎和病毒性肺炎的诊断。 不幸的是，可用的检查(血清、成像)和患者表现(症状、检查和病史) 对老年ED患者肺炎的诊断是不可靠的。我们之前的研究结果显示，新奇的测试 可提高肺炎(抗菌肽和单核细胞分布)的诊断准确性 宽度[MDW])。AMP是先天免疫系统的一部分，对细菌和病毒只需几分钟就能做出反应。 单核细胞分布宽度测量白细胞大小的分布，并在ED脓毒症中增加。 该项目寻求在以往研究的基础上提高肺炎的诊断准确率。 老年ED患者的长期目标是改善临床护理，降低发病率和 与肺炎相关的死亡率。目标#1考察了新测试(AMP和MDW)的潜力，以 单独诊断肺炎，并结合患者表现/症状和现有诊断 学习。这一目标将考虑由细菌病原体、病毒病原体和联合病原体引起的肺炎 以创建和确定诊断路径的准确性。Aim#2将采用团队概念 在理论领域框架的指导下进行映射，以邀请急诊医生确定促进者 以及在急诊医学中实施诊断途径的障碍，以便为未来的研究提供信息。目标#3 引导AIM#1诊断路径。如果成功，这项提议将产生一条诊断途径 老年ED患者的肺炎，并为成功验证和 这一诊断途径的实施研究。

PROJECT SUMMARY/ABSTRACT In the time it takes to read this application, 20 older adults (age≥65 years) will die of pneumonia in the United States. Annually over 500,000 older adults received treatment in emergency departments (ED) for pneumonia. Unfortunately, ED physicians cannot accurately diagnose pneumonia in older adults because of atypical symptoms, chest x-ray inaccuracy, comorbidities, failure of pulmonary clinical prediction rules established with younger adults, and poor accuracy of available biomarkers. Emergency physician’s inability to diagnose pneumonia in older adults leads to delayed diagnosis, inadequate treatment, worsening infection, longer lengths of stay (6.6 days vs. 5.4), and mortality. Pneumonia can be caused by bacterial and viral pathogens alone or in combination. Bacterial pneumonia alone causes the adverse outcomes and faces the diagnostic challenges just described. The presence of viral pneumonia further complicates diagnosis. Bacterial and viral co-infection in all adults increase odds of death by 2.1 with expected greater deleterious effects on older adults. Unfortunately, when viral sources are detected our current diagnostic approach fails to reliably identify bacterial sources in the event of co-infections. This can lead to inappropriate care and highlights the importance of ensuring fast, accurate diagnosis of both bacterial and viral pneumonia. Unfortunately, available tests (serum, imaging) and patient presentation (symptoms, exam, and history) are unreliable for diagnosing pneumonia in older adult ED patients. Our previous results reveal that novel tests may improve diagnostic accuracy of pneumonia (antimicrobial peptides [AMPs] and monocyte distribution width [MDW]). AMPs are a part of the innate immune system and respond in minutes to bacteria and viruses. Monocyte distribution width measures the distribution of size of leukocytes and increases in ED sepsis. This project seeks to build on previous investigations to improve the diagnostic accuracy of pneumonia in older adult ED patients with the long-term goal of improving clinical care and decreasing the morbidity and mortality associated with pneumonia. Aim #1 examines the potential for novel tests (AMPs and MDW) to diagnose pneumonia alone and in combination with patient presentation/symptoms and existing diagnostic studies. This aim will consider pneumonia caused by bacterial pathogens, viral pathogens and the combination separately to create and determine the accuracy of a diagnostic pathway. Aim #2 will employ group concept mapping guided by the Theoretical Domains Framework to engage emergency physicians to identify facilitators and barriers to implementation of a diagnostic pathway in emergency medicine to inform future studies. Aim #3 pilots the Aim #1 diagnostic pathway. If successful, this proposal will produce a diagnostic pathway for pneumonia in older adult ED patients and provide the groundwork for a successful validation and implementation study of this diagnostic pathway.