Building a Learning Healthcare System to Understand and Improve Sepsis Outcomes in the VA TeleICU Network

背景：脓毒症是人体对感染的压倒性全身反应，发病人数超过100万 在美国每年都有患者，已知每年影响超过48,000名退伍军人。在过去的时间里 十年来，通过更好地了解有效的治疗方法，脓毒症的存活率继续提高 干预和预防。这在私营部门和退伍军人管理局的住院死亡率中都可以看到 从2008年的15%下降到2012年的10%。然而，尽管有这种改善，脓毒症患者可能 在30天内死亡风险增加100%，这取决于他/她所在的医院 退伍军人制度。 意义/影响：该提案专门针对高铁和高铁的三个优先领域而设计 服务-医疗信息学、医疗质量和安全以及虚拟医疗。通过独特的 结合这三个领域，我们计划解决在理解脓毒症方面的两个重要限制 退伍军人事务部；1)现有报告可能提供也可能不提供对 在被认为是类似的VA ICU中死于败血症的患者，以及2)在这些报告中有 已知或怀疑可改善结果的多种干预措施，其疗效水平各不相同 很少或根本没有提供任何信息。 创新：我们可以使用一种新的数据源(TeleICU)来直接识别与患者级别相关的因素 在败血症患者群体中有负面结果的情况下，量化高绩效和低绩效的实践 并随后利用这些信息改善对退伍军人管理局ICU中败血症患者的护理。 具体目标： 目的#1：评估脓毒症特异性阴性结局的危险因素和脓毒症类型 确定调整的最佳策略并计算经风险调整的ICU死亡率。 目标2：评估以前未监测的败血症护理要素(低血压、呼吸机)的发生率 管理和抗生素)及其对SA1a(以ICU死亡率为主要指标)结果的影响 结果)在VA败血症患者中。 目的#3：定性检查低血压、肺保护性通风和抗生素的治疗 在高绩效和低绩效场所对脓毒症患者进行治疗(基于适当调整的ICU死亡率 差饷)。评估将包括记录在案的方案、临床工作流程和TeleICU支持。 方法：我们将进行一项混合方法调查，合并来自TeleICU和 公司数据仓库首先识别在脓毒症治疗中高性能和低性能的ICU。我们会 然后对3个治疗脓毒症的高性能和低性能ICU进行民族志调查。 同时，我们将研究低血压的处理，肺保护性通风的使用，以及 ICU脓毒症患者抗菌药物的使用及疗效 下一步/实施：我们将开发实时临床决策支持，为当地临床医生提供 ICU中有关败血症患者的最新信息，提供有关败血症患者状态的信息和 他们对与改善结果相关的指标的遵守情况。我们预计这将有所改善 败血症患者的总体存活率和潜在的降低护理成本。

Background: Sepsis, the body’s overwhelming systemic response to infection, strikes more than 1 million patients annually in the United States and is known to impact over 48,000 Veterans every year. Over the past decade, sepsis survival has continued to improve through a better understanding of effective therapies, early intervention, and prophylaxis. This has been seen in the private sector and VA with inpatient mortality dropping from 15% in 2008 to 10% in 2012. However, despite this improvement, a patient with sepsis may have up to a 100% increased risk of death at 30 days depending on the hospital to which he/she is admitted in the VA system. Significance/Impact: This proposal is specifically designed to address three priority domains of the HSR&D Service - Healthcare Informatics, Quality and Safety of Health Care, and Virtual Care. Through the unique combination of these three domains we plan to address two significant limitations in understanding sepsis in the VA; 1) that existing reports may or may not provide insight into the distinguishing characteristics of the patients that died with sepsis in what are thought to be similar VA ICUs, and 2) in these reports there are multiple interventions known or suspected to improve outcomes with varying levels of efficacy about which little or no information is offered. Innovation: We can use a novel data source (TeleICU) to directly identify the patient level factors associated with negative outcomes in the septic patient population, quantify the practices of high and low performing units, and subsequently improve the care provided to septic patients in VA ICUs using this information. Specific Aims: Aim #1: Evaluate risk factors of negative outcomes for specificity to sepsis and within sepsis types to determine best strategies for adjustment and calculate risk-adjusted ICU mortality rates. Aim #2: Evaluate the incidence of previously unmonitored elements of sepsis care (hypotension, ventilator management, and antibiotics) and their impact on outcomes cited in SA1a (ICU mortality as primary outcome) in VA sepsis patients. Aim #3: Qualitatively examine the management of hypotension, lung protective ventilation, and antibiotic therapy in sepsis patients at high and low performing sites (based on appropriately adjusted ICU mortality rates). Evaluations will include documented protocols, clinical workflows, and TeleICU support. Methodology: We will conduct a mixed methods investigation by merging data from the TeleICU and Corporate Data Warehouse to first identify high and low performing ICUs in the treatment of sepsis. We will then perform an ethnographic investigation of 3 high and low performing ICUs in the treatment of sepsis. Simultaneously, we will examine the management of hypotension, the use of lung protective ventilation, and the use and efficacy of antibiotics in septic patients in the ICU. Next Steps/Implementation: We will develop real-time clinical decision support, to provide local clinicians with updates on septic patients in the ICU that provide information regarding the state of septic patients and their compliance with metrics that are associated with improved outcomes. We anticipate this will improve the overall survival of sepsis patients and potentially reduce the cost of care.