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. 2021 Jun:63:167-174.
doi: 10.1016/j.jcrc.2020.09.013. Epub 2020 Sep 20.

Implementation of lung protective ventilation order to improve adherence to low tidal volume ventilation: A RE-AIM evaluation

Briana Short  1 , Alexis Serra  2 , Abdul Tariq  3 , Vivek Moitra  4 , Daniel Brodie  2 , Sapana Patel  5 , Matthew R Baldwin  2 , Natalie H Yip  2
Affiliations

Implementation of lung protective ventilation order to improve adherence to low tidal volume ventilation: A RE-AIM evaluation

Briana Short et al. J Crit Care. 2021 Jun.

Abstract

Purpose: Lung protective ventilation (LPV), defined as a tidal volume (Vt) ≤8 cc/kg of predicted body weight, reduces ventilator-induced lung injury but is applied inconsistently.

Materials and methods: We conducted a prospective, quasi-experimental, cohort study of adults mechanically ventilated admitted to intensive care units (ICU) in the year before, year after, and second year after implementation of an electronic medical record based LPV order, and a cross-sectional qualitative study of ICU providers regarding their perceptions of the order. We applied the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the implementation.

Results: There were 1405, 1424, and 1342 in the control, adoption, and maintenance cohorts, representing 95% of mechanically ventilated adult ICU patients. The overall prevalence of LPV increased from 65% to 73% (p < 0.001, adjusted-OR for LPV adherence: 1.9, 95% CI 1.5-2.3), but LPV adherence in women was approximately 30% worse than in men (women: 44% to 56% [p < 0.001],men: 79% to 86% [p < 0.001]). ICU providers noted difficulty obtaining an accurate height measurement and mistrust of the Vt calculation as barriers to implementation. LPV adherence increased further in the second year post implementation.

Conclusion: We designed and implemented an LPV order that sustainably improved LPV adherence across diverse ICUs.

Keywords: Clinical decision support tool (CDS); Implementation science; Low tidal volume ventilation (LTVV); Lung protective ventilation (LPV); Mechanical ventilation.

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Conflict of interest statement

Declaration of Competing Interest There are no conflicts of interest or competing interest regarding this manuscript.

Figures

Fig. 1.
Fig. 1.
Study flowsheet.
Figure 2:
Figure 2:. Adherence to lung protective ventilation in delivered and ordered tidal volume.
Difference in adherence to lung protective ventilation (LPV) in control and adoption cohorts. Adherence shown in both the ordered tidal volume (Vt) and delivered Vt. Both ordered and delivered models were adjusted from age, sex, height, SOFA score and ICU location and show a significant improvement in adherence between control and adoption cohorts.
Figure 3:
Figure 3:. Tidal volumes plotted by height in control and adoption cohorts.
Each individual dot represents the initial tidal volume (Vt) in cubic centimeters (cc) for a unique patient plotted against the patient’s height in centimeters. Women are represented in orange, and men are represented in blue. The orange and blue lines indicate 8cc/kg of predicted body weight (PBW) for women and men respectively. Adherence to lung protective ventilation (LPV) is below these lines. Panel 3a depicts ordered Vt in the control cohort, 3b depicts delivered Vt in the control cohort. Panel 3c depicts ordered Vt in the adoption cohort and 3d depicts delivered Vt in the adoption cohort.
Figure 4:
Figure 4:. Adherence to lung protective ventilation (LPV) in men and women.
Percentage of men and women adherence to LPV in control, adoption and maintenance cohorts with standard error for each cohort. 4a: Adherence to LPV in ordered Vt. Adherence to LPV in men in each cohort: 86%, 87% and 85% for control, adoption and maintenance respectively; adherence to LPV in women in each cohort: 42%, 73% and 77% in control, adoption and maintenance respectively. 4b: Adherence in men and women to LPV in delivered tidal volume (Vt). Adherence to LPV in men in each cohort: 79%, 86% and 92% for control, adoption and maintenance respectively; adherence to LPV in women in each cohort: 44%, 56% and 64% in control, adoption and maintenance respectively
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