Clinical decision support optimizing NEC prevention implementation in NICU

临床决策支持优化 NEC 预防在 NICU 的实施

• 批准号: 8923171
• 负责人: Sheila Maria Gephart
• 金额: $ 13.71万
• 依托单位: UNIVERSITY OF ARIZONA
• 依托单位国家: 美国
• 财政年份: 2014
• 资助国家: 美国
• 起止时间: 2014-09-30 至 2019-09-29
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8923171
• 关键词: Clinical; decision; support; optimizing; NEC

DESCRIPTION (provided by applicant): In neonatal intensive care using clinical decision support, the focus of this career development proposal is to improve application of evidence-based practices for prevention and early recognition of necrotizing enterocolitis (NEC) among premature infants. NEC is a catastrophic complication threatening the life of fragile premature infants, yet adoption of prevention and early recognition practices (e.g. preferential use of human milk; adoption of standardized feeding protocols; transfusion and antibiotics management) differ widely as do NEC rates. Parents play a key role in NEC prevention (e.g. providing mother's own milk), but heretofore, have been insufficiently engaged as partners. Accounting for 20% of US NICU costs, NEC develops late in the hospital postnatal course and can strike suddenly but until now, no tools to guide early NEC recognition were available. To address this need, a NEC risk decision rule, called GutCheckNEC was derived and validated by our team to accurately discriminate NEC. Integration of prevention practices into clinical workflow using clinical decision support (CDS) has been shown to improve adherence to recommended care across settings. Yet, both the use and evaluation of CDS in NICUs are sparse, and we know of no studies related to CDS support for prevention of NEC. Informed by the Translating Research Into Practice (TRIP) framework for implementation science, in two NICUs using an interrupted time series design, we will integrate NEC-Zero into CDS to fit clinician workflow, optimize usability, and test effects on NEC disease, neonate nutrition and parental satisfaction. The central hypothesis is that adherence to guideline-recommended NEC prevention and early recognition practices (called "NEC-Zero" and evaluated using an adherence score) will improve when delivered using CDS and NEC disease will decline. First, clinician workflow will be described using workflow maps constructed from interviews with local clinicians and the NEC-Zero integrated into CDS in the form of standard order sets, alerts, reminders and trend data (Aim 1). Then, using a simulated NEC scenario and iterative evaluation, NEC-Zero usability will be optimized (Aim 2). Finally, with an interrupted time series analysis from indicators in the 1 year prior to and 1 year after NEC-Zero implementation, we will compare the trend for NEC disease, neonate nutrition, and parent satisfaction outcomes; then describe the relationship between post-NEC-Zero clinician CDS outcomes (adherence scores, use response rates, satisfaction, perception of unintended consequences of CDS) and NEC disease outcomes (Aim 3). Formal training in usable clinical decision support under the mentorship of Daniel Malone, PhD, RPh & co-mentor Robert Greenes, MD, PhD will complement training in theories and methodologies of Implementation Science mentored by Drs. Marita Titler and Melanie Bell. Over time we will be able to apply the automation and testing of CDS for multi-faceted interventions to other clinical challenges in NICUs to achieve the goal for this program of research, which is to reduce morbidity and mortality from neonatal complications and limit costs.

描述（由申请人提供）：在使用临床决策支持的新生儿重症监护中，这项职业发展建议的重点是改善基于证据的实践的应用，以预防和早期认识坏死性小肠结肠炎（NEC）。 NEC是一种灾难性的并发症，威胁着脆弱的早产儿的生命，但是采用预防和早期识别实践（例如，优先使用人牛奶；采用标准化喂养方案；输血和抗生素管理）差异很大。父母在预防NEC（例如提供母亲的牛奶）中发挥了关键作用，但迄今为止，作为合作伙伴的参与不足。 NEC占了我们20％的NICU费用，在医院后期发展，可能会突然罢工，但直到现在，尚无指导早期NEC识别的工具。为了满足这一需求，我们的团队得出并验证了一个名为GutcheckNec的NEC风险决策规则，以准确区分NEC。使用临床决策支持（CD）将预防实践集成到临床工作流程中，已显示可提高跨环境中建议的护理的依从性。然而，NICUS中CD的使用和评估都很少，我们知道与CDS支持预防NEC有关。通过将研究科学的研究转化为实践框架，使用中断的时间序列设计，我们将NEC-Zero将NEC-Zero整合到CD中，以适应临床医生的工作流程，优化可用性以及对NEC疾病，新生儿营养和父母满意度的测试影响。中心假设是，使用CDS和NEC疾病递送时，遵守指南推荐的NEC预防和早期识别实践（称为“ NEC-Zero”，并使用依从性评分进行评估）将有所改善。首先，将使用与当地临床医生的访谈和NEC-Zero构建的工作流图来描述临床医生的工作流程，并以标准顺序集，警报，提醒和趋势数据的形式集成到CD中（AIM 1）。然后，使用模拟的NEC方案和迭代评估，将优化NEC-Zero可用性（AIM 2）。最后，通过在NEC-Zero实施后的1年和1年中的指标进行中断的时间序列分析，我们将比较NEC疾病，新生儿营养和父母满意度的趋势；然后描述NEC-Zero后临床医生CD结果（依从性得分，使用响应率，满意度，对CD的意外后果的看法）与NEC疾病结果（AIM 3）之间的关系。在丹尼尔·马龙（Daniel Malone），博士，RPH＆Co-Encortor Robert Greenes，MD，PhD的指导下进行的可用临床决策支持的正式培训将补充DRS指导的实施科学理论和方法论。 Marita Titler和Melanie Bell。随着时间的流逝，我们将能够将CD的自动化和测试用于多方面的干预措施，以实现NICUS中其他临床挑战，以实现这项研究计划的目标，即从新生儿并发症中降低发病率和死亡率并限制成本。