The influence of ward capacity strain on outcomes among survivors of acute respiratory failure

项目总结/摘要 每年有超过100万美国人在急性呼吸衰竭（ARF）中幸存下来。这些ARF幸存者经常 在接下来的几个月里忍受与健康相关的生活质量，身体，心理和认知障碍 放电这种与ARF生存率相关的日益增长的公共卫生和发病率负担部分源于， 事实上，指导机械通气最佳实践的有力证据是无法比拟的， 在重症监护病房（ICU）住院后指导护理的类似证据。因为90%的ARF幸存者 从ICU到综合医院病房，在他们康复期间，以病房为基础的护理质量可能会大大提高， 影响患者的预后。然而，评估和改善病房系统做法所需的方法 ARF幸存者并不存在。候选人的临床流行病学硕士（MSCE）和F32 工作定义了“病房容量紧张”的概念，当对临床资源的需求超过 空房的这项工作确定了病房病人数量和工作人员的工作量，有助于病房的措施， 容量应变，并证明应变增加与ICU出院等待时间延长相关 次和30天的重症监护幸存者再次入院。这个职业发展奖建立 从这项工作，并寻求实现三个目标，共同促进候选人的长期目标， 制定和测试策略，通过减轻病房容量压力来改善ARF幸存者的结局， 其他系统级因素。具体来说，在这个奖项的候选人寻求衡量协会的病房 能力紧张与（1）住院结局和（2）住院后，以患者为中心的结局， ARF幸存者，和（3）确定护理过程，调解病房容量紧张之间的关系， 病人的结果，和病房级系统的做法，修改这种关系。为了实现这些目标， 候选人将进行回顾性队列研究（目标1），一项前瞻性纵向队列研究， 176名ARF幸存者（目标2），以及一项混合方法阳性偏差研究，招募了50名病房临床医生 照顾急性呼吸衰竭幸存者的人（目标3）。她在完成这三项任务时将获得的实践经验 使用不同方法的研究将通过精心挑选的教学课程和结构化的补充， 来自多个学科的高级调查员提供指导。这项工作将导致试点赠款和R21， 支持制定干预措施，以减轻病房容量紧张对ARF的不利影响 患者的结果，并R 01，以支持这种干预的随机对照试验。完成本 研究将建立在候选人过去的培训基础上，其中包括通过NHLBI T32获得的MSCE 支持和NHLBI F32支持的博士后奖学金，并将为她提供受保护的时间， 经验，以实现她的职业目标，成为一个领先的，独立资助的结果研究员 重点是利用系统级实践来改善ARF幸存者和其他关键 疾病。

Project Summary/Abstract More than 1 million Americans survive acute respiratory failure (ARF) each year. These ARF survivors often endure health-related quality of life, physical, psychological, and cognitive impairments in the months following discharge. This growing public health and morbidity burden associated with ARF survivorship stems, in part, from the fact that the robust evidence to guide best practices during mechanical ventilation is unmatched by similar evidence to guide care after the intensive care unit (ICU) stay. Because 90% of ARF survivors transition from ICUs to general hospital wards during their recoveries, the quality of ward-based care may strongly influence patients’ outcomes. However, the methods needed to assess and improve ward systems practices for ARF survivors do not exist. The candidate’s Master of Science in Clinical Epidemiology (MSCE) and F32 work defined the construct of “ward capacity strain,” which occurs when demand for clinical resources exceeds availability. This work identified measures of ward patient volume and staff workload that contribute to ward capacity strain, and demonstrated that increased strain was associated with prolonged ICU discharge wait times and 30-day hospital readmissions among critical care survivors. This Career Development Award builds from that work, and seeks to achieve three aims that, together, will promote the candidate’s long-term goal of developing and testing strategies to improve ARF survivor outcomes by mitigating ward capacity strain and other systems-level factors. Specifically, in this award the candidate seeks to measure associations of ward capacity strain with (1) in-hospital outcomes and (2) post-hospitalization, patient-centered outcomes among ARF survivors, and (3) identify care processes that mediate relationships between ward capacity strain and patient outcomes, and ward-level systems practices that modify such relationships. To complete these aims the candidate will perform a retrospective cohort study (Aim 1), a prospective longitudinal cohort study enrolling 176 ARF survivors (Aim 2), and a mixed-methods positive deviance study enrolling 50 ward-based clinicians who care for survivors of ARF (Aim 3). The hands-on experience she will acquire in completing these three studies using different methods will be complemented by carefully selected didactic coursework and structured mentoring by senior investigators from multiple disciplines. This work will lead to pilot grants and an R21 to support development of an intervention to mitigate the untoward effects of ward capacity strain on ARF patients’ outcomes, and to an R01 to support a randomized controlled trial of this intervention. Completing this research will build upon the candidate’s past training, which includes an MSCE obtained with NHLBI T32 support and an NHLBI F32-supported post-doctoral fellowship, and will provide her with the protected time and experience to achieve her career goal of becoming a leading, independently-funded outcomes researcher focused on leveraging systems-level practices to improve outcomes among survivors of ARF and other critical illnesses.