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

Implementation Science

Rinad S. Beidas¹  Aerielle Belk²  Stefania Scott²  Wei Wang²  Teresa Tran²  Jasmine A. Silvestri²  Tamar Klaiman³  Dylan Small⁴  Barry D. Fuchs⁵  Mark E. Mikkelsen⁶  Meeta Prasad Kerlin⁷  Scott D. Halpern⁸ 

[1] Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA;Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA;Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, PA, USA;Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA;Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA;Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA;Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA;Pulmonary, Critical Care and Allergy Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Pulmonary, Critical Care and Allergy Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Pulmonary, Critical Care and Allergy Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA;Pulmonary, Critical Care and Allergy Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA;Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA;Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA;

关键词: Hybrid implementation-effectiveness trial;    Behavioral economics;    Nudge;    Mechanical ventilation;    Acute respiratory distress syndrome;    Low tidal volume;   

DOI  :  10.1186/s13012-021-01147-7

来源: Springer

【 摘 要 】

BackgroundBehavioral 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.MethodsThe 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.DiscussionThis 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 registrationClinicalTrials.gov, NCT04663802. Registered 11 December 2020.

【 授权许可】

CC BY