Abstract
BackgroundLung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome (ARDS) through the administration of low tidal volumes (≤ 6.5 ml/kg predicted body weight [PBW]) with co-titration of positive end-expiratory pressure and fraction of inspired oxygen. Many patients with ARDS, however, are not managed with LPV. The purpose of this study was to understand the implementation barriers and facilitators to the use of LPV and a computerized LPV clinical decision support (CDS) tool in intensive care units (ICUs) in preparation for a pilot hybrid implementation-effectiveness clinical trial.MethodsWe performed an explanatory sequential mixed methods study from June 2018 to March 2019 to evaluate the variation in LPV adherence across 17 ICUs in an integrated healthcare system with > 4000 mechanically ventilated patients annually. We analyzed 47 key informant interviews of ICU physicians, respiratory therapists (RTs), and nurses in 3 of the ICUs using a qualitative content analysis paradigm to investigate site variation as defined by adherence level (low, medium, high) and to identify barriers and facilitators to LPV and LPV CDS tool use.ResultsForty-two percent of patients had an initial set tidal volume of ≤ 6.5 ml/kg PBW during the measurement period (site range 21–80%). LPV CDS tool use was 28% (site range 6–91%). This study’s main findings revealed multi-factorial facilitators and barriers to use that varied by ICU site adherence level. The primary facilitator was that LPV and the LPV CDS tool could be used on all mechanically ventilated patients. Barriers included a persistent gap between clinician attitudes regarding the use of LPV and actual use, the perceived loss of autonomy associated with using a computerized protocol, the nature of physician-RT interaction in ventilation management, and the lack of clear organization measures of success.ConclusionsVariation in adherence to LPV persists in ICUs within a healthcare delivery system that was an early adopter of LPV. Potentially promising strategies to increase adherence to LPV and the LPV CDS tool for ARDS patients include initiating low tidal ventilation on all mechanically ventilated patients, establishing and measuring adherence measures, and focused education addressing the physician-RT interaction. These strategies represent a blueprint for a future hybrid implementation-effectiveness trial.
Highlights
Lung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome (ARDS) through the administration of low tidal volumes (≤ 6.5 ml/kg predicted body weight [Predicted body weight (PBW)]) with co-titration of positive end-expiratory pressure and fraction of inspired oxygen
Research has shown that lung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome and is not consistently applied in intensive care settings
Clinical decision support (CDS) tools are being evaluated as one mechanism to standardize LPV use
Summary
Lung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome (ARDS) through the administration of low tidal volumes (≤ 6.5 ml/kg predicted body weight [PBW]) with co-titration of positive end-expiratory pressure and fraction of inspired oxygen. An international study in 50 countries found that 10% of patients admitted to the intensive care unit (ICU) and 23% of mechanically ventilated patients had ARDS [2]. Lung-protective ventilation (LPV), which combines low tidal volume ventilation (LTVV) with step-wise cotitration of positive end-expiratory pressure (PEEP) and the fraction of inspired oxygen (FiO2), improves outcomes for patients with ARDS in clinical studies [5, 6] and is recommended by the American Thoracic Society (ATS) Clinical Practice Guidelines [7, 8] as well as in other recent reviews [9, 10]. Identified barriers to the use of LPV include physician’s ability to recognize ARDS in a timely fashion [12, 13], lack of written protocols [14, 15], lack of concordance with clinician perceptions of patient needs [11, 12, 14], and perceptions by nurses and RTs that LTVV is more labor-intensive and that present staffing is inadequate to achieve full adherence [11, 14]
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