Increasing compliance with low tidal volume ventilation in the ICU with two nudge-based interventions: evaluation through intervention time-series analyses

Abstract

ObjectivesLow tidal volume (TVe) ventilation improves outcomes for ventilated patients, and the majority of clinicians state they implement it. Unfortunately, most patients never receive low TVes. ‘Nudges’ influence decision-making with subtle cognitive mechanisms and are effective in many contexts. There have been few studies examining their impact on clinical decision-making. We investigated the impact of 2 interventions designed using principles from behavioural science on the deployment of low TVe ventilation in the intensive care unit (ICU).SettingUniversity Hospitals Bristol, a tertiary, mixed medical and surgical ICU with 20 beds, admitting over 1300 patients per year.ParticipantsData were collected from 2144 consecutive patients receiving controlled mechanical ventilation for more than 1 hour between October 2010 and September 2014. Patients on controlled mechanical ventilation for more than 20 hours were included in the final analysis.Interventions(1) Default ventilator settings were adjusted to comply with low TVe targets from the initiation of ventilation unless actively changed by a clinician. (2) A large dashboard was deployed displaying TVes in the format mL/kg ideal body weight (IBW) with alerts when TVes were excessive.Primary outcome measureTVe in mL/kg IBW.FindingsTVe was significantly lower in the defaults group. In the dashboard intervention, TVe fell more quickly and by a greater amount after a TVe of 8 mL/kg IBW was breached when compared with controls. This effect improved in each subsequent year for 3 years.ConclusionsThis study has demonstrated that adjustment of default ventilator settings and a dashboard with alerts for excessive TVe can significantly influence clinical decision-making. This offers a promising strategy to improve compliance with low TVe ventilation, and suggests that using insights from behavioural science has potential to improve the translation of evidence into practice.

Variable effectiveness of stepwise implementation of nudge-type interventions to improve provider compliance with intraoperative low tidal volume ventilation

“…The methodology for calculating VT8 compliance is described below. This nudge-type intervention is similar to A&F dashboard reports previously used to improve ventilation compliance 14. Our emails were sent to attendings and non-attendings (attending dashboards and non-attending dashboards).…”

“…Nudge interventions are perceived as less intrusive and are generally achieved at lower cost 13. Two examples of nudge intervention are audit and feedback (A&F) dashboards and modification of default settings on medical devices 14. Dashboards can be as simple as a quarterly email highlighting provider compliance.…”

Translating evidence into practice in acute respiratory distress syndrome: teamwork, clinical decision support, and behavioral economic interventions

“…In a 2016 study, investigators evaluated two behavioral economic strategies to improve compliance with LTV (24). In the first, ventilators were configured so tidal volumes would default to 6 ml/kg IBW at the start of invasive mechanical ventilation, unless manually overridden by a clinician.…”

Towards a decision support tool for intensive care discharge: machine learning algorithm development using electronic health care data from MIMIC-III and Bristol, UK.

“…In our previous work on the psychology of clinical decision making we have demonstrated the effectiveness of simple 'nudge' based interventions in changing clinical practice [19][20][21]. Building on this foundation we were motivated to develop a classifier to automatically flag patients that appear physiologically fit for discharge.…”