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

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.研究目标：低潮气量（TVe）通气可改善机械通气患者的预后，多数临床医师表示会采用该通气策略。然而绝大多数患者始终未能接受规范的低潮气量通气。“助推（Nudges）”干预通过微妙的认知机制影响决策制定，在诸多场景中均已被证实有效，但目前针对其对临床决策影响的相关研究仍较为稀缺。本研究旨在探究基于行为科学原理设计的两种干预措施，对重症监护病房（ICU）内低潮气量通气临床实施情况的影响。 研究场景：布里斯托大学医院为三级医疗中心，设有20张床位的内外混合ICU，年收治患者超过1300例。 研究对象：本研究于2010年10月至2014年9月期间，纳入2144例接受控制性机械通气时长超过1小时的连续入组患者；最终分析仅纳入控制性机械通气时长超过20小时的患者。 干预措施： （1）将呼吸机默认参数调整为符合低潮气量通气目标，自通气启动时即生效，除非临床医师主动更改参数设置。 （2）部署大型可视化监护大屏，以mL/kg理想体重（IBW）的格式显示TVe值，当TVe超出安全阈值时触发警报。 主要结局指标：以mL/kg理想体重（IBW）为单位的TVe值。 研究结果：默认参数干预组的TVe水平显著低于对照组。与对照组相比，大屏可视化干预组在TVe超出8mL/kg IBW阈值后，TVe下降速度更快、降幅更大；且该干预效果在后续3年间逐年提升。 研究结论：本研究证实，调整呼吸机默认参数设置及部署潮气量超标警报可视化大屏，可显著影响临床决策制定。该方案为提高低潮气量通气的临床依从性提供了极具前景的策略，同时表明借助行为科学的研究思路，有望推动循证医学证据向临床实践的转化。