Multi-factorial Barriers and Facilitators to High Adherence to Lung Protective Ventilation Using a Computerized Protocol: A Mixed Methods Study

Abstract

Background Lung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome (ARDS) through 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 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. Methods We performed an explanatory sequential mixed methods study from June 2018 – March 2019 to evaluate variation in LPV adherence across 17 ICUs in an integrated healthcare system with > 4,000 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 identify barriers and facilitators to LPV and LPV CDS tool use. Results Forty-two percent of patients had an initial set tidal volume ≤ 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. Conclusions Variation in adherence to LPV persists in ICUs within a healthcare delivery system that was an early adopter of LPV. Strategies to increase adherence to LPV for ARDS patients should 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.