Implementation of lung protective ventilation order to improve adherence to low tidal volume ventilation: A RE-AIM evaluation.

Short, Briana; Serra, Alexis; Tariq, Abdul; Moitra, Vivek; Brodie, Daniel; Patel, Sapana; Baldwin, Matthew R; Yip, Natalie H

PURPOSE Lung protective ventilation (LPV), defined as a tidal volume (Vt) ≤8 cc/kg of predicted body weight, reduces ventilator-induced lung injury but is applied inconsistently. MATERIALS AND METHODS We conducted (Acute Respiratory Distress Syndrome N, Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A, 2000 [1]) a prospective, quasi-experimental, cohort study of adults mechanically ventilated admitted to intensive care units (ICU) in the year before, year after, and second year after implementation of an electronic medical record based LPV order, and (Needham et al., 2015 [2]) a cross-sectional qualitative study of ICU providers regarding their perceptions of the order. We applied the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the implementation. RESULTS There were 1405, 1424, and 1342 in the control, adoption, and maintenance cohorts, representing 95% of mechanically ventilated adult ICU patients. The overall prevalence of LPV increased from 65% to 73% (p < 0.001, adjusted-OR for LPV adherence: 1.9, 95% CI 1.5-2.3), but LPV adherence in women was approximately 30% worse than in men (women: 44% to 56% [p < 0.001],men: 79% to 86% [p < 0.001]). ICU providers noted difficulty obtaining an accurate height measurement and mistrust of the Vt calculation as barriers to implementation. LPV adherence increased further in the second year post implementation. CONCLUSION We designed and implemented an LPV order that sustainably improved LPV adherence across diverse ICUs.