Nudging implementation of low tidal volume ventilation: a stepped wedge, cluster randomized trial

Area of Science:

• Critical Care Medicine
• Health Informatics
• Implementation Science

Background:

• Electronic health records (EHR) can incorporate "nudges" to promote evidence-based practices.
• Low tidal volume ventilation is a recommended best practice in intensive care units (ICUs).
• Implementation barriers, such as lack of knowledge, can hinder adoption of best practices.

Purpose of the Study:

• To evaluate the effectiveness of EHR-based nudges in increasing low tidal volume ventilation.
• To assess the impact of default settings and justification requirements on clinician behavior.
• To explore clinician perspectives on implementing low tidal volume ventilation strategies.

Main Methods:

• A stepped-wedge, cluster randomized, hybrid type 3 effectiveness-implementation trial was conducted in 12 ICUs.
• Three EHR nudges were tested: default low tidal volume order, accountable justification for high tidal volume orders, and accountable justification flowsheet for high tidal volume documentation.
• The primary outcome was fidelity to low tidal volume ventilation over the first 72 hours of mechanical ventilation.

Main Results:

• The primary analysis included 4412 patients; overall fidelity to low tidal volume ventilation was 45.7%.
• EHR nudges did not significantly increase low tidal volume ventilation utilization across all ICUs.
• Qualitative interviews suggested variability in nudge effectiveness influenced by clinician experience, interprofessional collaboration, and the COVID-19 pandemic.

Conclusions:

• EHR-based nudges, including default orders and justification requirements, did not broadly increase low tidal volume ventilation.
• The effectiveness of these nudges varied significantly between intensive care units.
• Further research is needed to understand factors influencing successful implementation of clinical best practices via EHR.