Implementation Science to Increase Use of Evidence Based Pediatric Brain Injury G

描述（由申请人提供）：创伤性脑损伤（TBI）是一岁以上儿童的主要杀手。2003年，出版了基于证据的严重小儿创伤性脑损伤急性医疗管理指南。然而，这里没有策略来增加对这些指导方针的遵守。我们的项目目标是使用依从性记分卡来检查依从性和患者结果之间的关联，开发一个价值流图，说明影响依从性的因素，并使用计算机模拟来创建依从性的最佳实践蓝图。指导性假设是，组织因素预测，坚持预测的结果和最佳实践蓝图将导致严重的儿科TBI后的坚持和有利的结果。 具体目标1：制定一个国家依从性记分卡，以表征国家依从性儿科指南的差异，并使用记分卡检查依从性和患者结局之间的关系。假设1：从5个儿科创伤中心的图表和医疗保健成本和利用项目（HCUP）儿童住院患者数据库（KID）中提取的数据将显示，在遵守儿科指南的程度上存在不必要的和可补救的变化。依从性评分卡将用于对研究中心采用者状态进行分类，描述所有研究中心内部和之间依从性的差异，并提供依从性与更好结局相关的大规模II类证据（出院回家vs.住院康复vs.长期住院或死亡，以及住院时间。 具体目标2：创建一个价值流图，可以很容易地识别影响儿科指南依从性的可补救的高优先级提供者和组织因素，并检查这些因素是否因采用者状态而异（在目标1中定义）。假设#2：在采用者类别中，坚持的障碍很高，并且构成了提供者和组织因素。调查方法和焦点小组将显示，可补救的障碍和促进者的概况因采用者的地位而异。将根据TBI护理的活动流程和通过图表摘要（目标1）、KID数据以及调查和焦点小组结果（目标2）确定的结果生成价值流图。价值流图将根据采用者状态定义可补救的和增值的TBI护理流程。 目标#3：使用计算机模拟来开发和传播遵守儿科指南的最佳实践蓝图。假设3：计算机模拟模型将根据回归模型（目标1）和价值流图（目标2）的活动输入的依从性和有效性参数估计值，确定TBI护理流程对关键儿科指南指标和患者结局的影响。迭代计算机模拟将展示儿科指南组成部分之间的关系，以及活动的相对变化如何影响TBI护理和患者结局下游操作的幅度，方向和选择。然后，这些结果将有助于为采用者状态的遵守提供最佳实践蓝图。调查结果将广为传播。将确定随机分配的研究中心，以检查最佳实践蓝图对儿科指南依从性和患者结局的影响。 公共卫生相关性：提高对严重创伤性脑损伤儿科指南依从性的策略尚不清楚。我们将使用实施科学方法，如价值流图和迭代计算机模拟，以开发和传播最佳实践蓝图，提高对儿科指南的遵守。

DESCRIPTION (provided by applicant): Traumatic brain injury (TBI) is the leading killer of children over one year of age. In 2003, the evidence based Guidelines for the Acute Medical Management of Severe Pediatric Traumatic Brain Injury was published. Yet, here are no strategies to increase adherence to these guidelines. Our project goal is to use an adherence scorecard to examine the association between adherence and patient outcomes, develop a value stream map illustrating factors impacting adherence, and use computer simulation to create a best practices blueprint for adherence. The guiding hypothesis is that organizational factors predict, adherence predicts outcomes and that a best practices blueprint will result in both adherence and favorable outcomes after severe pediatric TBI. Specific Aim # 1: To develop a national adherence scorecard that characterizes national variation in adherence to the Pediatric Guidelines, and to use the scorecard to examine the relationship between adherence and patient outcomes. Hypothesis # 1: Data abstracted from charts at 5 pediatric trauma centers and the Healthcare Cost and Utilization Project's (HCUP) child inpatient database (KID) will show that there is unwanted and remediable variability in the degree of adherence to the Pediatric Guidelines. The adherence score card will be used to classify study site adopter status, characterize variability in adherence within and between all sites, and provide large scale Class II evidence that adherence is associated with better outcomes (discharge to home vs. inpatient rehabilitation vs. long term facility or died, and hospital length of stay. Specific Aim # 2: To create a value stream map that readily identifies remediable high priority provider and organizational factors which impact adherence to the Pediatric Guidelines and examine whether these factors vary by adopter status (defined in Aim # 1). Hypothesis # 2: Barriers to adherence are high across adopter categories and constitute both provider and organizational factors. Survey methods and focus groups will show that remediable barrier and facilitator profiles vary by adopter status. Value stream maps will be generated based on the activity flows of TBI care and outcomes identified via chart abstraction (Aim #1), KID data, and survey and focus group outcomes (Aim # 2). Value stream maps will define remediable, and value added TBI care processes by adopter status. Aim # 3: To use computer simulation to develop and disseminate a best practices blueprint for adherence to the Pediatric Guidelines. Hypothesis # 3: Computer simulation models will determine the effect of TBI care processes on key Pediatric Guideline indicators and patient outcomes based on parameter estimates of adherence and effectiveness from regression models (Aim # 1) and activity inputs of value stream maps (Aim # 2). Iterative computer simulation will demonstrate the relationship among Pediatric Guideline components and how relative changes in activities impact the magnitude, direction and choice of operations downstream in TBI care and patient outcomes. These results will then contribute to a best practices blueprint for the adherence by adopter status. Findings will be widely disseminated. Sites to be randomized to examine the effect of the best practices blueprint on adherence to the Pediatric Guidelines and on patient outcomes will be identified. PUBLIC HEALTH RELEVANCE: Strategies to increase adherence to the Pediatric Guidelines for severe traumatic brain injury are not known. We will use implementation science methods, such as value stream maps and iterative computer simulation, to develop and disseminate a best practices blueprint that increases adherence to the Pediatric Guidelines.