INPUT: A Stepped-Wedge, hybrid Type III Trial of Strategies to Improve Evidence-Based Mechanical Ventilation Management

TERESA TRAN, MPH
Palliative and Advanced Illness Research Center

Behavioral 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 underutilized 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.

Mechanically ventilated patients aged 18 and older admitted to twelve intensive care units (ICUs) in five hospitals of the University of Pennsylvania Health System and clinicians who staff the study ICUs and interact with the implementation strategies.

The 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 electronic health record (EHR)-based strategies to improve adherence to low tidal volume ventilation. The strategies target two key stakeholder groups: clinicians who enter electronic orders and respiratory therapists who manage and document mechanical ventilation settings. 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. ICUs will be randomly assigned to receive one of the order strategies, with two ICUs each adopting one of the strategies every three months, and then ICUs will adopt the flowsheet documentation strategy six 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. Study safety monitoring is conducted through EHR-based reports and chart review completed by the study team.

This 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.