Elucidating Non-Routine Events Arising from Interhospital Transfers

2021年，退伍军人经历了300多万急诊科就诊，其中近三分之一 处于非VA设置中。非退伍军人紧急护理是社区护理的最大贡献者，具有 估计每个月的成本为5亿美元。医院间的转移用于遣返退伍军人 急症护理或提供无障碍的专科护理(例如，心脏病)，如果这种技术服务不是 在最初的医院提供。然而，这种转移对退伍军人及其家人来说是沉重的负担，而且 与恶化的临床结果有关。人因工程领域运用系统科学 通过对“非常规”的评估，检查可能导致次优临床结果的因素。 活动。“这些是与已确定的护理标准或意外事件的次优偏差 通过对工作人员、临床医生和患者的有效调查。 在这一试点应用中，我们试图通过非常规事件(NRES)的应用来推进NRES的研究 从退伍军人事务部和非退伍军人事务部的医院间转送。我们将使用经过验证的NRES调查 连同转账文件一起研究转账，以寻找NRES的证据。最后，为了使NRE自动化 收集数据，我们寻求训练一门光学字符识别和自然语言处理的信息学 Cool，“Mirror EHR”，从扫描的医疗记录中为退伍军人提取NRE组件的数据 有医院间转院经验。 在高可靠性原则的指导下，我们的创新试点方案直接针对多个Ord 和HSR&D优先领域，包括获得护理、质量和安全以及医疗保健信息学，通过使用 卫生系统工程研究医院间传输和寻址数据的交叉方法 质量以及如何整合非VA数据。这项工作涉及《使命法》的一项主要立法优先事项 解决非退伍军人管理局紧急护理的质量和安全问题。具体目标是：1)考核非常规 退伍军人医院间转移引起的事件；2)确定医院临床转移中的NRES 在经历医院间转移的退伍军人中的文件；以及3)证明 镜像EHR信息学工具，以收集作为NRES指标的数据并对其进行分类。 该团队是唯一有资格实现这些目标的团队，拥有系统科学、人为因素等方面的专业知识 工程学、生物医学信息学、实施科学、定性方法和以急性医院为基础 护理(急诊和医院药物)。退伍军人事务部田纳西山谷医疗中心的制度环境 系统和范德比尔特大学医学中心是杰出的，包括老年学研究、教育 和临床中心(GRECC)，一个VA质量学者的网站，一个创新的定性研究中心； 相关研究领域的全国排名的研究生课程；以及国家CTSA协调中心。 该应用程序将进行必要的试点工作，以评估NRE数据收集的可行性 使用经过验证的NRE调查，从退伍军人事务部和非退伍军人事务部进行医院间转院。这是一个高度的 旨在改进安全科学和生物医学信息学方法的创新建议 以医院间转院的形式经历护理过渡的退伍军人的质量和安全。应该 这项工作被证明是可行的，我们计划使用这些试点数据来准备一个更大的功绩奖申请来评估 NRES在医院间转院中的作用，并制定干预措施，以减轻其对退伍军人的潜在伤害。

Veterans experienced more than 3 million emergency department visits in 2021 and nearly one-third of these are in non-VA settings. Non-VA emergency care is the single largest contributor to community care with an estimated $500 million in monthly costs. Interhospital transfers are used either to repatriate Veterans during acute episodes of care or to provide access specialty care (e.g., cardiology) should such skilled services not be available at the initial hospital. However, such transfers are burdensome for Veterans and their families, and are associated with worsened clinical outcomes. The field of Human Factors Engineering uses system science to examine what may contribute to suboptimal clinical outcomes through the evaluation of “Non-Routine Events.” These are sub-optimal deviations from the standards of care or unexpected events that are identified through validated surveys of staff, clinicians, and patients. In this pilot application, we seek to advance the study of Non-Routine Events (NREs) through their application to interhospital transfers from VA and non-VA emergency departments. We will use validated surveys of NREs along with transfer documentation to study transfers for evidence of NREs. Finally, in order to automate NRE data collection, we seek to train an optical character recognition and natural language processing informatics cool, “MIRROR EHR,” to extract data of NRE components from scanned medical records for Veterans who experienced interhospital transfers. Guided by the principles of high reliability, our innovative pilot proposal directly addresses multiple ORD-wide and HSR&D priority areas including Access to Care, Quality & Safety, and Healthcare Informatics by using cross-cutting methods of Health Systems Engineering to study interhospital transfers and addressing data quality and how to integrate non-VA data. This work addresses a major legislative priority of the MISSION Act to address the quality and safety of non-VA emergency care. The Specific Aims are: 1) Examine Non-Routine Events arising from interhospital transfers of Veterans; 2) Identify NREs in transferring hospital clinical documentation amongst Veterans experiencing interhospital transfer; and 3) Demonstrate the feasibility of the MIRROR EHR informatics tool to collect and categorize data that are indicators of NREs. The team is uniquely qualified to accomplish these Aims, with expertise in systems science, human factors engineering, biomedical informatics, implementation science, qualitative methods, and acute hospital-based care (emergency and hospital medicine). The institutional environment at the VA Tennessee Valley Healthcare System and Vanderbilt University Medical Center is outstanding, including the Geriatric Research, Education and Clinical Center (GRECC), a site for VA Quality Scholars, an innovative qualitative research center; nationally ranked graduate programs in the relevant fields of study; and the national CTSA coordinating center. This application will conduct necessary pilot work to evaluate the feasibility of NRE data collection arising from interhospital transfers from both VA and non-VA settings using validated NRE surveys. This is a highly innovative proposal to advance the methods of safety science and biomedical informatics designed to improve the quality and safety for Veterans experiencing care transitions in the form of interhospital transfers. Should this work prove feasible, we plan to use these pilot data to prepare a larger Merit award application to evaluate NREs in interhospital transfers and to develop interventions to mitigate their potential harm of Veterans.