Optimizing ED to ICU triage decisions for critically ill patients in respiratory distress

PROJECT SUMMARY The goal of the proposed research and career development plan is for the Principal Investigator (PI) to become an independent clinical investigator using multiple research methods to directly improve the quality of care for critically ill patients at the interface between the Emergency Department (ED) and Intensive Care Unit (ICU). To transition into the next phase of her career and build upon her strengths as a critical care physician and her prior training in clinical investigation and quantitative analysis, the PI will learn advanced research skills through individualized and classroom training, including multi-level modeling, qualitative and mixed methods approaches, decision analysis, and clinical decision support tool development. Triage decisions around ICU admission for ED patients have profound implications for patient outcomes and utilization of ED and ICU resources. Variation in this decision exists beyond what is explained by patient-related factors and bed availability. The proposed K23 research seeks to improve access to appropriate ICU care and develop innovative clinical solutions to reduce mortality by understanding the interaction between subjective and objective factors on triage decision-making at the ED-ICU interface. The specific aims of this proposal are (1) Examine the extent of variation in current ICU triage practice in an existing multi-hospital dataset of critically ill ED patients with respiratory distress, using a mixed methods approach and multi-level modeling, (2) Identify factors influencing subjective assessments of illness severity and likelihood to benefit from ICU admission, using semi-structured physician interviews with scenarios developed from dataset analysis, and 3) Develop and test the feasibility of an electronic health record-based clinical decision support tool to reduce potentially harmful variation in ICU admission decisions. These aims have the potential to 1) identify disparities in triage decisions for patients with certain characteristics when resources are limited, 2) provide insight into which factors most affect physician triage practices as well as their perceptions of acuity and likelihood to benefit, and 3) pinpoint target areas for intervention using clinical decision support tools to improve care at the ED-ICU interface.