Multi-factorial Barriers and Facilitators to High Adherence to Lung Protective Ventilation Using a Computerized Protocol: A Mixed Methods Study

Abstract Background Lung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome (ARDS) through 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 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. Methods We performed an explanatory sequential mixed methods study from June 2018 – March 2019 to evaluate variation in LPV adherence across 17 ICUs in an integrated healthcare system with > 4,000 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 identify barriers and facilitators to LPV and LPV CDS tool use. Results Forty-two percent of patients had an initial set tidal volume ≤ 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. Conclusions Variation in adherence to LPV persists in ICUs within a healthcare delivery system that was an early adopter of LPV. Strategies to increase adherence to LPV for ARDS patients should 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.

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Disparities in Lung Protective Ventilation in the United States

10.21203/rs.3.rs-1217783/v1 ◽

2022 ◽

Author(s):

Michelle Malnoske ◽

Caroline Quill ◽

Amelia Barwise ◽

Anthony Pietropaoli

Keyword(s):

Tidal Volume ◽

Critically Ill ◽

The United States ◽

Protective Ventilation ◽

Lung Protective Ventilation ◽

Insurance Status ◽

Mechanically Ventilated ◽

Mechanically Ventilated Patients ◽

To Receive ◽

Ventilated Patients

Abstract Background: Lung-protective ventilation is often used in critically ill patients with acute respiratory failure, including those without acute respiratory distress syndrome. While disparities exist in the delivery of critical care based on gender, race, and insurance status, it is unknown whether there are disparities in the use of lung-protective ventilation. The objective of our study was to determine whether gender-, racial / ethnic-, or insurance status-based disparities exist in the use of lung-protective ventilation for critically ill mechanically ventilated patients in the United States (U.S.).Methods: This was a secondary data analysis of the U.S. Critical Illness and Injury Trials Group Critical Illness Outcomes Study, a prospective multi-center cohort study conducted from 2010 - 2012. The dependent variable of interest was the proportion of patients receiving tidal volume > 8 mL/kg predicted body weight (PBW). The independent variables of interest were gender, insurance status, and race / ethnicity. Results: Our primary analysis included 1,595 mechanically ventilated patients from 59 intensive care units (ICUs) in the U.S. Women were more likely to receive tidal volumes > 8 ml/kg PBW than men (odds ratio [OR] = 3.25, 95% confidence interval [CI] = 2.58 – 4.09), though this relationship was substantially weakened after adjusting for gender differences in height (OR = 1.26 95% CI = 0.94 – 1.71). The underinsured were significantly more likely to receive tidal volume > 8 ml/kg PBW than the insured in multivariable analysis (odds ratio = 1.54, 95% confidence interval = 1.16 – 2.04). The prescription of > 8 ml/kg PBW tidal volume did not differ by racial or ethnic categories. Conclusions: In this prospective nationwide cohort of critically ill mechanically ventilated patients, women and the underinsured were less likely than their comparators to receive lung protective ventilation, with no apparent differences based on race / ethnicity alone. Differences in height between men and women do not fully explain this disparity. Future research should evaluate whether implicit bias affects tidal volume choice and other management decisions in critical care.

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