Optimizing Critical Care for Patients with Acute Respiratory Failure: A Mixed-Methods Study

优化急性呼吸衰竭患者的重症监护：一项混合方法研究

基本信息

批准号：
10689697
负责人：
Kelly C. Vranas
金额：
--
依托单位：
PORTLAND VA MEDICAL CENTER
依托单位国家：
美国
项目类别：
财政年份：
2020
资助国家：
美国
起止时间：
2020-07-01 至 2024-06-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/10689697
关键词：
Accident and Emergency department Acute respiratory failure Address Admission activity Advisory Committees Advocate Beds Caring Characteristics Clinical Consolidated Framework for Implementation Research Critical Care Data Data Set Development Elasticity Empathy Environment Ethnography Future Geography Goals Health Care Costs Healthcare Healthcare Systems Home Hospital Administrators Hospitalization Hospitals Intensive Care Units Intervention Interview Knowledge Learning Length of Stay Life Mechanical ventilation Medical Medical center Methodology Methods Multicenter Trials Outcome Patient Admission Patient Care Patient Triage Patient-Focused Outcomes Patients Pattern Policies Process Quality of Care Randomized, Controlled Trials Regression Analysis Research Resources Risk Risk Adjustment Sampling Services Severity of illness Site Source Structure System Techniques Testing Thinking Training Triage United States Variant Veterans Veterans Health Administration Work acceptability and feasibility care delivery cohort cost design effectiveness/implementation hybrid health care delivery health care settings hospital care human centered design improved improved outcome informant innovation insight intervention refinement mortality novel pilot test prevent process improvement prototype therapy design therapy development ward

项目摘要

Background: Critical care is one of the most resource-intensive and costly components of hospital care. Substantial variability exists across VA hospitals in the use of critical care for patients with acute respiratory failure (ARF), suggesting a knowledge gap about when and how to best use the intensive care unit (ICU). Furthermore, overuse of the ICU for patients who do not need critical care contributes to rising healthcare costs and may cause harm. Significance: First, this proposal will help clarify whether ICU bed supply influences ICU bed utilization. This has important implications for healthcare delivery across the VHA, as it would indicate that decreasing ICU bed supply may help prevent unnecessary ICU use without sacrificing quality of care, thereby improving the overall value of critical care. Second, it will identify modifiable organizational factors and care processes that enable the provision of high-quality and efficient care outside the ICU. Third, it will lead to the development of a hospital- level intervention that will tailor care and guide triage strategies for Veterans with ARF. Innovation: For this study, Dr. Vranas has created a novel dataset that combines highly-granular data from over 100 geographically diverse hospitals within the VHA. This proposal is also innovative in its application of Human- Centered Design Thinking to develop scalable interventions to improve the value of critical care at VA. Specific Aims: 1) Evaluate the association of ICU bed supply with ICU admission, and the association of ICU admission with outcomes; 2) Use a positive-deviance approach to identify organizational factors and care processes associated with high-value care of patients with ARF; 3) Use Human-Centered Design Thinking to develop and pilot test an intervention that will guide ICU utilization and improve the value of ICU care. Methods: Aims 1 and 2 will use an explanatory sequential mixed methods approach to evaluate organizational factors and care processes associated with high value ICU care. In Aim 1a, Dr. Vranas will perform patient-level multivariable regression analyses to test the hypothesis that increased ICU bed supply is associated with increased odds of ICU admission. To test the hypothesis that ICU admission is not independently associated with improved outcomes (Aim 1b), Dr. Vranas will use propensity score techniques to evaluate the association of ICU utilization with outcomes including mortality and discharge to home. In Aim 2, Dr. Vranas will use a positive deviance approach to identify hospitals with high/low ICU utilization, and above/below average risk-adjusted 30- day mortality for patients with ARF. Using purposive sampling, she will conduct medical ethnography and semi- structured interviews of key stakeholders at approximately 12 select hospitals. She will use Rapid Qualitative Inquiry methods to characterize processes associated with outcomes observed in Aim 1. She will also utilize the Consolidated Framework for Implementation Research to identify common domains that are modifiable and generalizable across healthcare settings. In Aim 3, Dr. Vranas will assemble a stakeholder taskforce and use Human-Centered Design Thinking to inform the development of an intervention designed to guide triage decisions for patients with ARF. She will pilot this intervention at the Portland VA hospital to evaluate its acceptability/feasibility, and to generate preliminary data for a future multicenter trial. Next Steps: This work will lead to the submission of multiple IIR proposals, including a hybrid effectiveness- implementation clustered randomized controlled trial of the refined intervention across multiple VA sites.

背景：重症监护是医院护理中资源最密集、成本最高的组成部分之一。退伍军人管理局各医院在对急性呼吸道患者进行重症监护方面存在很大差异失败（ARF），表明在何时以及如何最好地使用重症监护病房（ICU）方面存在知识差距。此外，过度使用 ICU 来治疗不需要重症监护的患者会导致医疗费用上升并可能造成伤害。意义：首先，该提案将有助于澄清ICU床位供应是否影响ICU床位利用率。这对整个 VHA 的医疗服务提供具有重要影响，因为这表明 ICU 床位的减少供应可能有助于在不牺牲护理质量的情况下防止不必要的 ICU 使用，从而改善整体情况重症监护的价值。其次，它将确定可修改的组织因素和护理流程，使在 ICU 之外提供高质量和高效的护理。第三，它会带动医院的发展—— 级干预，将为患有 ARF 的退伍军人定制护理并指导分诊策略。创新：在这项研究中，Vranas 博士创建了一个新颖的数据集，该数据集结合了来自多个国家的高粒度数据。 VHA 内有 100 家分布在不同地区的医院。该提案在人性化的应用上也具有创新性。以中心设计思维开发可扩展的干预措施，以提高 VA 重症监护的价值。具体目标： 1) 评估 ICU 床位供应与 ICU 入院的关联性，以及 ICU 的关联性录取及结果； 2）使用积极偏差方法来识别组织因素和关怀与 ARF 患者高价值护理相关的流程； 3）运用以人为本的设计思维开发并试点测试一种干预措施，以指导 ICU 使用并提高 ICU 护理的价值。方法：目标 1 和 2 将使用解释性顺序混合方法来评估组织与高价值 ICU 护理相关的因素和护理流程。在目标 1a 中，Vranas 博士将执行患者级别的多变量回归分析检验 ICU 床位供应增加与以下因素相关的假设：入住 ICU 的几率增加。检验 ICU 入住不独立相关的假设随着结果的改善（目标 1b），Vranas 博士将使用倾向评分技术来评估关联 ICU 使用率以及死亡率和出院回家等结果。在目标 2 中，Vranas 博士将使用积极的偏差方法来识别 ICU 使用率高/低以及高于/低于平均风险调整后的医院 30- ARF 患者的日死亡率。她将利用有目的的抽样，进行医学民族志和半对大约 12 家选定医院的主要利益相关者进行结构化访谈。她将使用快速定性探究方法来描述与目标 1 中观察到的结果相关的过程。她还将利用实施研究综合框架，以确定可修改和可修改的共同领域可以在整个医疗保健环境中推广。在目标 3 中，Vranas 博士将组建一个利益相关者工作组并使用以人为本的设计思维，为指导分诊的干预措施的发展提供信息 ARF 患者的决定。她将在波特兰退伍军人管理局医院试点这项干预措施，以评估其效果可接受性/可行性，并为未来的多中心试验生成初步数据。后续步骤：这项工作将导致提交多项 IIR 提案，包括混合有效性- 在多个 VA 站点实施精细干预的集群随机对照试验。

项目成果

期刊论文数量（11）

专著数量（0）

科研奖励数量（0）

会议论文数量（0）

专利数量（0）

"You're Socially Distant and Trying Not to Be Emotionally Distant." Physicians' Perspectives of Communication and Therapeutic Relationships in the ICU During the COVID-19 Pandemic: A Qualitative Study.

DOI：
10.1097/cce.0000000000000854
发表时间：
2023-02
期刊：
Critical care explorations
影响因子：
0
作者：
通讯作者：

Complexity and Challenges of the Clinical Diagnosis and Management of Long COVID.

DOI：
10.1001/jamanetworkopen.2022.40332
发表时间：
2022-11-01
期刊：
JAMA NETWORK OPEN
影响因子：
13.8
作者：
O'Hare, Ann M.;Vig, Elizabeth K.;Iwashyna, Theodore J.;Fox, Alexandra;Taylor, Janelle S.;Viglianti, Elizabeth M.;Butler, Catherine R.;Vranas, Kelly C.;Helfand, Mark;Tuepker, Anais;Nugent, Shannon M.;Winchell, Kara A.;Laundry, Ryan J.;Bowling, C. Barrett;Hynes, Denise M.;Maciejewski, Matthew L.;Bohnert, Amy S. B.;Locke, Emily R.;Boyko, Edward J.;Ioannou, George N.
通讯作者：
Ioannou, George N.

Looking to the Past, Learning From the Present, and Preparing for the Future: Toward Understanding Critical Care Strain During a Global Pandemic.

DOI：
10.1016/j.chest.2020.10.035
发表时间：
2021-03
期刊：
Chest
影响因子：
9.6
作者：
Vranas KC;Kerlin MP
通讯作者：
Kerlin MP

Association of Patient-Centered Elements of Care and Palliative Care Among Patients With Advanced Lung Cancer.

晚期肺癌患者中以患者为中心的护理要素与姑息治疗的关联。

DOI：
10.1177/10499091221130944
发表时间：
2023
期刊：
The American journal of hospice & palliative care
影响因子：
0
作者：
Schweiger,Liana;Vranas,KellyC;Furuno,JonP;Hansen,Lissi;Slatore,ChristopherG;Sullivan,DonaldR
通讯作者：
Sullivan,DonaldR

Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State.

DOI：
10.1001/jamanetworkopen.2022.7639
发表时间：
2022-04-01
期刊：
JAMA NETWORK OPEN
影响因子：
13.8
作者：
Butler, Catherine R.;Webster, Laura B.;Diekema, Douglas S.;Gray, Megan M.;Sakata, Vicki L.;Tonelli, Mark R.;Vranas, Kelly C.
通讯作者：
Vranas, Kelly C.