Better Ventilator Settings Using a Computerized Clinical Tool

Abstract

BACKGROUND: The Acute Respiratory Distress Syndome (ARDS) Network low tidal volume (V T )trial paved the ground for mechanically ventilating ARDS patients with a V T of 6 mL/kg ideal body weight (IBW). Although there is no consensus that a low V T is advantageous in non-ARDS patients, it is accepted that high V T should be avoided. Because compliance rates with ventilator recommendations are 30%, there is a need for process improvement. We postulated that a computerized screen prompt that recommended V T based on height would improve compliance with low V T . During ventilator order entry, the computerized decision tool prompts the clinician and encourages ventilation of patients at 8 mL/kg IBW, and 6 mL/kg IBW for patients with ARDS. METHODS: A retrospective review was performed on patients who required volume controlled mechanical ventilation over a 3-y period. Subjects were chosen randomly from the respiratory records of 6 different ICUs at a single tertiary care academic center. Half of the charts selected were before intervention of on-screen prompt, and the other half were after implementation of the computerized decision tool. RESULTS: The initial set V T ranged from 6.26 to 13.45 mL/kg IBW, with a mean of 8.92 mL/kg. After implementation of the on-screen prompt, mean V T decreased by 0.84 mL/kg to 8.07 mL/kg (P ‫؍‬ .001) with a lower range of 4.73-11.56 mL/kg IBW. We also noted a significant decrease in the number of subjects placed on an initial V T > 10 mL/kg IBW from 20% to 4% (P ‫؍‬ .003). CONCLUSIONS: A computerized clinical decision tool with the preferred initial V T settings based on the patients' sex and height is a safe and reliable way to increase low V T strategy compliance across multiple ICUs. Its limitations are similar to those shared by other computergenerated prompts.

A Critical Care Clinician Survey Comparing Attitudes and Perceived Barriers to Low Tidal Volume Ventilation with Actual Practice

“…These potential barriers support the development of specific interventionsaudit and feedback, clinician education, and clinical decision support to improve the recognition of ARDS (e.g., prompting or reminders) and overcome process barriers to the delivery of low-VT ventilation. However, recent studies whose aim was to improve identification of or provide clinical decision support for ARDS, as well as sepsis, have shown mixed results in improving processes or patient outcomes (21)(22)(23)(24)(25)(26)(27), suggesting an urgent need for more investigation in this area.…”

Respiratory Complications in Trauma Patients: A Multidisciplinary Approach to Prevention

“…By instituting automatic triggers for implementation, care teams can better ensure that this occurs without subverting practitioners' autonomy to care for their patients based on their clinical judgment, improving outcomes and increasing the impact of practice improvement protocols. 8 The outcomes of their efforts were highly convincing in support of these measures. The authors noted that admission to the ward from the emergency department was higher in the protocol phase and speculated that this may be due to improved awareness and comfort on behalf of physicians admitting these subjects to a non-ICU setting.…”

Barriers and Challenges to the Successful Implementation of an Intensive Care Unit Mobility Program

“…Protocol compliance has been shown to improve in other ICU-specific interventions, such as use of a low tidal volume lung protective ventilation strategy when on-screen prompts were embedded into order entry. 16 Additional examples of muda, muri, and mura as they apply to ICU mobility projects are shown in Box 1.…”