Multi-factorial barriers and facilitators to high adherence to lung-protective ventilation using a computerized protocol: a mixed methods study.
Multi-factorial barriers and facilitators to high adherence to lung-protective ventilation using a computerized protocol: a mixed methods study.
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DOI：
10.1186/s43058-020-00057-x
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发表时间：
2020-01-01
影响因子：
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通讯作者：
Srivastava, Raj
中科院分区：
文献类型：
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作者：
Knighton, Andrew J;Kean, Jacob;Srivastava, Raj
背景技术背景：肺保护性通气（LPV）通过给予低潮气量（≤6.5ml/kg预计体重[PBW]）并联合呼气末正压和吸入氧分数滴定，改善了急性呼吸窘迫综合征（ARDS）患者的结局。然而，许多患有ARDS的患者不接受LPV治疗。本研究的目的是了解在重症监护病房（ICU）中使用LPV和计算机化LPV临床决策支持（CDS）工具的实施障碍和促进因素，为试点混合实施有效性临床试验做准备。我们从2018年6月至2019年3月进行了一项解释性序贯混合方法研究，以评估17个ICU中LPV依从性的变化，医疗保健系统每年有超过4000名机械通气患者。我们分析了47个关键的知情人访谈的ICU医生，呼吸治疗师（RT），和护士在3个ICU使用定性内容分析范式，以调查网站的变化，定义为遵守水平（低、中、高），并确定LPV和LPV CDS工具使用的障碍和促进因素。在测量期间，42%的患者的初始设定潮气量≤6.5ml/kg PBW（研究中心范围21-80%）。LPV CDS工具使用率为28%（研究中心范围6-91%）。这项研究的主要发现揭示了多因素的促进因素和使用障碍，这些因素因ICU站点依从性水平而异。主要促进因素是LPV和LPV CDS工具可用于所有机械通气患者。障碍包括一个持续的差距，临床医生的态度，对LPV的使用和实际使用，与使用计算机化协议的自主权的感知损失，在通气管理的医生RT互动的性质，以及缺乏明确的组织措施successful.CONCLUSIONS：在坚持LPV的变化持续在ICU内的医疗服务系统，是LPV的早期采用者。增加ARDS患者对LPV和LPV CDS工具依从性的潜在有希望的策略包括对所有机械通气患者启动低潮通气，建立和测量依从性措施，以及针对医生-RT相互作用的集中教育。这些策略代表了未来混合实施有效性试验的蓝图。
BACKGROUND: Lung-protective ventilation (LPV) improves outcomes for patients with acute respiratory distress syndrome (ARDS) through the administration of low tidal volumes (≤6.5ml/kg predicted body weight [PBW]) with co-titration of positive end-expiratory pressure and fraction of inspired oxygen. Many patients with ARDS, however, are not managed with LPV. The purpose of this study was to understand the implementation barriers and facilitators to the use of LPV and a computerized LPV clinical decision support (CDS) tool in intensive care units (ICUs) in preparation for a pilot hybrid implementation-effectiveness clinical trial.METHODS: We performed an explanatory sequential mixed methods study from June 2018 to March 2019 to evaluate the variation in LPV adherence across 17 ICUs in an integrated healthcare system with >4000 mechanically ventilated patients annually. We analyzed 47 key informant interviews of ICU physicians, respiratory therapists (RTs), and nurses in 3 of the ICUs using a qualitative content analysis paradigm to investigate site variation as defined by adherence level (low, medium, high) and to identify barriers and facilitators to LPV and LPV CDS tool use.RESULTS: Forty-two percent of patients had an initial set tidal volume of ≤6.5ml/kg PBW during the measurement period (site range 21-80%). LPV CDS tool use was 28% (site range 6-91%). This study's main findings revealed multi-factorial facilitators and barriers to use that varied by ICU site adherence level. The primary facilitator was that LPV and the LPV CDS tool could be used on all mechanically ventilated patients. Barriers included a persistent gap between clinician attitudes regarding the use of LPV and actual use, the perceived loss of autonomy associated with using a computerized protocol, the nature of physician-RT interaction in ventilation management, and the lack of clear organization measures of success.CONCLUSIONS: Variation in adherence to LPV persists in ICUs within a healthcare delivery system that was an early adopter of LPV. Potentially promising strategies to increase adherence to LPV and the LPV CDS tool for ARDS patients include initiating low tidal ventilation on all mechanically ventilated patients, establishing and measuring adherence measures, and focused education addressing the physician-RT interaction. These strategies represent a blueprint for a future hybrid implementation-effectiveness trial.