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

项目总结/摘要 在阅读本申请的时间内，20名老年人（年龄≥65岁）将死于肺炎。 美国的每年有超过500，000名老年人在急诊科（艾德）接受治疗， 肺炎不幸的是，艾德医生不能准确诊断老年人的肺炎，因为 不典型症状，胸部X线不准确，合并症，肺部临床预测规则失败 建立与年轻的成年人，和可用的生物标志物的准确性差。急诊医生无法 诊断老年人肺炎导致诊断延迟，治疗不足，感染恶化， 住院时间更长（6.6天vs. 5.4天）和死亡率。 肺炎可以由细菌和病毒病原体单独或组合引起。细菌 肺炎单独引起不良结果并面临刚才描述的诊断挑战。的 病毒性肺炎的存在使诊断更加复杂。所有成人中细菌和病毒合并感染增加 死亡几率降低2.1，对老年人的有害影响更大。不幸的是，当病毒 我们目前的诊断方法无法可靠地识别细菌来源， 合并感染。这可能导致不适当的护理，并强调了确保快速、准确 诊断为细菌性和病毒性肺炎。 不幸的是，可用的测试（血清，成像）和患者的表现（症状，检查和历史） 对于诊断老年艾德患者的肺炎不可靠。我们之前的研究结果表明， 可以提高肺炎的诊断准确性（抗菌肽[AMP]和单核细胞分布 宽度[MDW]）。AMP是先天免疫系统的一部分，在几分钟内对细菌和病毒作出反应。 单核细胞分布宽度测量白细胞大小的分布和艾德脓毒症中的增加。 该项目旨在建立在以前的调查，以提高肺炎的诊断准确性 老年艾德患者的长期目标是改善临床护理和降低发病率， 与肺炎相关的死亡率。目的#1检查新测试（AMP和MDW）的潜力， 单独诊断肺炎，并结合患者表现/症状和现有诊断 问题研究本目将考虑细菌性病原体、病毒性病原体及两者联合引起的肺炎 分别创建和确定诊断路径的准确性。目标#2将采用组概念 在理论领域框架的指导下进行映射，以使急诊医生参与识别促进者 以及在急诊医学中实施诊断途径以告知未来研究的障碍。目标3 引导Aim #1诊断路径。如果成功的话，这一提议将为以下方面提供一条诊断途径： 老年艾德患者肺炎，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.