Implementing nudges to promote utilization of low tidal volume ventilation (INPUT): a stepped-wedge, hybrid type III trial of strategies to improve evidence-based mechanical ventilation management

Abstract

Background Behavioral economic insights have yielded strategies to overcome implementation barriers. For example, default strategies and accountable justification strategies have improved adherence to best practices in clinical settings. Embedding such strategies in the electronic health record (EHR) holds promise for simple and scalable approaches to facilitating implementation. A proven-effective but under-utilized treatment for patients who undergo mechanical ventilation involves prescribing low tidal volumes, which protects the lungs from injury. We will evaluate EHR-based implementation strategies grounded in behavioral economic theory to improve evidence-based management of mechanical ventilation. Methods The Implementing Nudges to Promote Utilization of low Tidal volume ventilation (INPUT) study is a pragmatic, stepped-wedge, hybrid type III effectiveness implementation trial of three strategies to improve adherence to low tidal volume ventilation. The strategies target clinicians who enter electronic orders and respiratory therapists who manage the mechanical ventilator, two key stakeholder groups. INPUT has five study arms: usual care, a default strategy within the mechanical ventilation order, an accountable justification strategy within the mechanical ventilation order, and each of the order strategies combined with an accountable justification strategy within flowsheet documentation. We will create six matched pairs of twelve intensive care units (ICUs) in five hospitals in one large health system to balance patient volume and baseline adherence to low tidal volume ventilation. We will randomly assign ICUs within each matched pair to one of the order panels, and each pair to one of six wedges, which will determine date of adoption of the order panel strategy. All ICUs will adopt the flowsheet documentation strategy 6 months afterwards. The primary outcome will be fidelity to low tidal volume ventilation. The secondary effectiveness outcomes will include in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay, and occurrence of potential adverse events. Discussion This stepped-wedge, hybrid type III trial will provide evidence regarding the role of EHR-based behavioral economic strategies to improve adherence to evidence-based practices among patients who undergo mechanical ventilation in ICUs, thereby advancing the field of implementation science, as well as testing the effectiveness of low tidal volume ventilation among broad patient populations. Trial registration ClinicalTrials.gov, NCT04663802. Registered 11 December 2020.

Optimizing damage control resuscitation through early patient identification and real‐time performance improvement

“…78 For example, modeling after the INPUT trial, additional strategies might be explored for improving adherence using the electronic health record. 79 First, a default order for calcium can be programed following the scanning and administration of F I G U R E 2 Nudge ladder demonstrating progressively more assertive prompts to guide desired behavior. These prompts can be adapted to encourage best practice in damage control resuscitation (DCR).…”

A Qualitative Description of Clinician Free-Text Rationales Entered within Accountable Justification Interventions

“…Several large trials are currently evaluating the use of accountable justification interventions, including improving safety of opioid prescribing, 6 reducing overtesting and overtreatment of older adults, 7 8 and, beyond primary care, for improved mechanical ventilation management. 9 …”

“…Several large trials are currently evaluating the use of accountable justification interventions, including improving safety of opioid prescribing, 6 reducing overtesting and overtreatment of older adults, 7,8 and, beyond primary care, for improved mechanical ventilation management. 9 Joglekar and colleagues have described a review of reasons for alert override when the justification was optional and not visible to others. 10 However, we are not aware of other studies that have reviewed visible free-text accountable justifications entered during clinical encounters in outpatient primary care to qualitatively describe what content clinicians enter.…”

Gamification in Critical Care Education and Practice

“…The disconnect between knowledge and implementation has been termed the knowledge, or evidence, to practice gap and is one focus for implementation science ( 1 ). Accordingly, a host of approaches have been applied to help guide, or most recently, “nudge” clinician behavior; such efforts address domains from antimicrobial stewardship to ventilator settings for patients with the acute respiratory distress syndrome ( 2 , 3 ). Each of the approaches has met with only partial success that may reflect unique environments or specific sets of clinicians.…”