Multi-factorial barriers and facilitators to high adherence to lung-protective ventilation using a computerized protocol: a mixed methods study

• Published in: Implementation science communications Vol. 1; no. 1; pp. 67 - 12
• Main Authors: Knighton, Andrew J, Kean, Jacob, Wolfe, Doug, Allen, Lauren, Jacobs, Jason, Carpenter, Lori, Winberg, Carrie, Berry, Jay G, Peltan, Ithan D, Grissom, Colin K, Srivastava, Raj
• Format: Journal Article
• Language: English
• Published: England BioMed Central 28.07.2020; BMC
• Subjects: Acute respiratory distress syndrome (ARDS); Barriers and facilitators; Clinical decision support; Computerized protocol; Coronaviruses; COVID-19; Critical care; Implementation; Intensive care; Intervention; Interviews; Mechanical ventilation; Mixed methods research; Patients; Physicians; Qualitative research; Respiratory distress syndrome; Ventilators; Computerized protocol; Acute respiratory distress syndrome (ARDS); Mixed methods; Barriers and facilitators; Clinical decision support; Mechanical ventilation; Implementation
• ISSN: 2662-2211; 2662-2211
• DOI: 10.1186/s43058-020-00057-x

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. 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. We 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. Forty-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. Variation 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.