Academic Journal
Nudging implementation of low tidal volume ventilation: a stepped wedge, cluster randomized trial.
| Τίτλος: | Nudging implementation of low tidal volume ventilation: a stepped wedge, cluster randomized trial. |
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| Συγγραφείς: | Kerlin MP; Pulmonary, Critical Care and Allergy Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Perelman Center for Advanced Medicine, 627 South Pavilion, Philadelphia, PA, 19104, USA. prasadm@pennmedicine.upenn.edu.; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. prasadm@pennmedicine.upenn.edu.; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. prasadm@pennmedicine.upenn.edu., Harhay MO; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.; Department of Biostatistics, Epidemiology, and Bioinformatics, University of Pennsylvania, Philadelphia, PA, USA., Li F; Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA., Small DS; Department of Statistics, The Wharton School at the University of Pennsylvania, Philadelphia, PA, USA., Lu Y; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA., Wang W; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA., Fuchs BD; Pulmonary, Critical Care and Allergy Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Perelman Center for Advanced Medicine, 627 South Pavilion, Philadelphia, PA, 19104, USA., Mikkelsen ME; Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Anschutz Medical Campus, Denver, CO, USA., Tran T; Continuous Improvement and Innovation, Seattle Children's Hospital, Seattle, WA, USA., Belk A; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA., Silvestri JA; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.; Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA., Klaiman T; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.; Center for Health Incentives and Behavioral Economics (CHIBE), University of Pennsylvania, Philadelphia, PA, USA., Scott S; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA., Levy E; Pulmonary, Critical Care and Allergy Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Perelman Center for Advanced Medicine, 627 South Pavilion, Philadelphia, PA, 19104, USA., Sjoding MW; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA., Kohn R; Pulmonary, Critical Care and Allergy Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Perelman Center for Advanced Medicine, 627 South Pavilion, Philadelphia, PA, 19104, USA.; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA., Roberts KJ; Department of Cardiovascular and Pulmonary Sciences, College of Health Professions, Thomas Jefferson University, Philadelphia, PA, USA., Beidas RS; Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA., Halpern SD; Pulmonary, Critical Care and Allergy Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Perelman Center for Advanced Medicine, 627 South Pavilion, Philadelphia, PA, 19104, USA.; Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.; Department of Biostatistics, Epidemiology, and Bioinformatics, University of Pennsylvania, Philadelphia, PA, USA.; Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA. |
| Πηγή: | Implementation science : IS [Implement Sci] 2026 May 07; Vol. 21 (1). Date of Electronic Publication: 2026 May 07. |
| Τύπος έκδοσης: | Journal Article; Randomized Controlled Trial; Multicenter Study |
| Γλώσσα: | English |
| Στοιχεία περιοδικού: | Publisher: BioMed Central Country of Publication: England NLM ID: 101258411 Publication Model: Electronic Cited Medium: Internet ISSN: 1748-5908 (Electronic) Linking ISSN: 17485908 NLM ISO Abbreviation: Implement Sci Subsets: MEDLINE |
| Imprint Name(s): | Original Publication: [London] : BioMed Central, 2006- |
| Ιατρικοί όροι (MeSH): | Respiration, Artificial*/methods , Tidal Volume*, Humans ; Intensive Care Units ; Electronic Health Records ; Respiratory Therapists ; Female ; Male |
| Περίληψη: | Background: "Nudges" embedded in the electronic health record (EHR) facilitate desired decisions while preserving autonomy and may provide a scalable strategy to overcome the common implementation barrier of lack of knowledge about a best practice. We sought to test whether EHR-based nudges targeting two intensive care unit (ICU) clinician groups would safely increase evidence-based use of low tidal volume ventilation. Methods: We performed a stepped-wedge, cluster randomized, hybrid type 3 effectiveness-implementation trial in 12 ICUs from February 2021 to May 2023 to test three nudges targeting clinicians responsible for order entry and respiratory therapists responsible for operationalizing orders and documentation. A default ventilation order auto-populated a low tidal volume setting; an accountable justification order required a free-text justification to order high tidal volume; and an accountable justification flowsheet required a free-text justification to document delivery of high tidal volume. ICUs were randomly assigned to launch one of the two order nudges on a pre-specified date, followed by the flowsheet nudge six months thereafter. The primary outcome was fidelity to low tidal volume ventilation, defined as percentage of time during the first 72 h of ventilation with low tidal volumes. For additional contextual inquiry, we conducted qualitative interviews with ICU clinicians regarding their perspectives on low tidal volume ventilation and study nudges. Results: The primary analysis included 4412 patients. Unadjusted median fidelity to low tidal volume ventilation was 45.7%. Using multivariable mixed effects regression, marginal estimates of fidelity to low tidal volume ventilation ranged from 47.1% to 57.8% across study groups, with no significant differences after Holm adjustment for multiple comparisons. ICUs experienced variable changes with nudges in fidelity to low tidal volume ventilation. Clinician interviews revealed potential explanations for this variability, including the possibility of differential effects by experience level of clinicians and culture of interprofessional collaboration, and influence of the COVID-19 pandemic on familiarity with and use of low tidal volume ventilation. Conclusions: EHR-based default and accountable justification nudges did not increase utilization of low tidal volume ventilation in a broad population of mechanically ventilated patients; however, nudge effectiveness varied by ICU. Trial Registration: Clinicaltrials.gov, NCT04663802. Registered 10 December 2020, https://clinicaltrials.gov/study/NCT04663802. (© 2026. The Author(s).) |
| Competing Interests: | Declarations. Ethics approval and consent to participate: The institutional review boards of the University of Pennsylvania (Protocol #833400) and Chester County Hospital (Protocol ID CCH19-05 PENN #833400) approved this trial with a waiver of informed consent. Consent for publication: Not applicable. Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ . and declare: MPK, MOH, DSS, YL, WW, BDF, MEM, TT, AMB, JAS, TK, KDR, RSB, SDH were given support from the National Heart, Lung and Blood Institute of the National Institutes for Health for the submitted work; KJR has received grants, honoraria and support for meeting travel from the American Association for Respiratory Care, Society for Critical Care Medicine, and California Society for Respiratory Care; MOH and FL have received research funding from Patient-Centered Outcomes Research Institute; MOH has received fees for statistical consulting from Elsevier, the American Thoracic Society, Unlearn.AI, and Guidepoint LLC, has participated on a Data Safety and Monitoring Board for the University of California San Francisco and the University of Pittsburgh, and has received honoraria for pilot grant reviews by the National Institute of Aging; no other relationships or activities that could appear to have influenced the submitted work. |
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| Grant Information: | R01 HL141608 United States HL NHLBI NIH HHS; R01HL141608 NIH/NHLBI |
| Molecular Sequence: | ClinicalTrials.gov NCT04663802 |
| Entry Date(s): | Date Created: 20260507 Date Completed: 20260702 Latest Revision: 20260813 |
| Update Code: | 20260813 |
| PubMed Central ID: | PMC13321408 |
| DOI: | 10.1186/s13012-026-01500-8 |
| PMID: | 42098760 |
| Βάση Δεδομένων: | MEDLINE |
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