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

Bourdeaux, C. P., Thomas, M. J. C., Gould, T. H. , Malhotra, G., Jarvstad, A. ORCID: 0000-0002-3175-8733, Jones, T. & Gilchrist, I. D. (2016). Increasing compliance with low tidal volume ventilation in the ICU with two nudge-based interventions: evaluation through intervention time-series analyses. BMJ Open, 6(5), e010129. doi: 10.1136/bmjopen-2015-010129

Abstract

Objectives: Low 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).

Setting: University Hospitals Bristol, a tertiary, mixed medical and surgical ICU with 20 beds, admitting over 1300 patients per year.

Participants: Data 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 measure: TVe in mL/kg IBW.

Findings: TVe 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.

Conclusions: This 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.

Publication Type:	Article
Publisher Keywords:	decision-making; behavioural science; low tidal volume ventilation; nudge
Subjects:	B Philosophy. Psychology. Religion > BF Psychology R Medicine > RC Internal medicine
Departments:	School of Health & Psychological Sciences > Psychology