Implementation of behavioral economic approaches to improve evidence uptake for mechanically ventilated patients

实施行为经济学方法以提高机械通气患者的证据吸收

• 批准号: 10614507
• 负责人: Meeta Prasad Kerlin
• 金额: $ 67.52万
• 依托单位: UNIVERSITY OF PENNSYLVANIA
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-03-15 至 2025-02-28
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10614507
• 关键词: Accountability; Accounting; Acute Respiratory Distress Syndrome; Adherence; Affect; Air; American; Clinical; Cluster randomized trial; Cognitive; Communities; Data; Delirium; Diagnostic; Dose; Effectiveness; Electronic Health Record; Elements; Emotional; Environment; Evidence based practice; Guidelines; Health system; Heterogeneity; Hospital Mortality; Hybrids; Impairment; Inferior; Intensive Care Units; International; Intervention; Knowledge; Life; Literature; Lung; Mechanical ventilation; Methods; Monitor; Morbidity - disease rate; Organ failure; Outcome; Patient-Focused Outcomes; Patients; Physicians; Pneumonia; Population; Relaxation; Respiratory Failure; Sedation procedure; Sepsis; Survivors; Testing; Tidal Volume; Time; Trauma; Uncertainty; Ventilator; adverse outcome; arm; behavior change; behavior influence; behavioral economics; cluster randomized design; compare effectiveness; contextual factors; design; effectiveness outcome; future implementation; health care settings; implementation fidelity; implementation outcomes; implementation strategy; improved; improved outcome; innovation; lung injury; mortality; novel; patient population; patient subsets; pragmatic trial; pressure; randomized trial; respiratory; sedative; theories; treatment effect; uptake; ventilation

PROJECT SUMMARY By some estimates, up to one million Americans undergo invasive mechanical ventilation (MV) each year. MV can be life-saving, but can also be harmful by leading directly to lung injury by delivering artificially large breaths. A growing body of evidence has demonstrated that a specific strategy of “lung-protective ventilation” (LPV), which entails smaller breaths and reduced airway pressures, can reduce both short-term mortality and long-term morbidity. Among patients with acute respiratory distress syndrome (ARDS), a form of severe respiratory failure associated with common illnesses such as pneumonia, sepsis, and trauma, high-quality evidence has demonstrated that LPV reduces mortality, duration of mechanical ventilation, and long-term morbidity of patients with ARDS. Nonetheless, many patients with ARDS who undergo mechanical ventilation do not receive this life-saving therapy. Two reasons for this poor evidence uptake are lack of knowledge about LPV and uncertainty regarding who has ARDS at the time of MV initiation. However, recent recognition that LPV may improve outcomes even among patients without ARDS suggests that encouraging clinicians to begin with LPV for all patients may be an optimal strategy. Therefore, our main objective is to study simple strategies that may circumvent the barriers of knowledge and diagnostic uncertainty, to improve the utilization of LPV. We will conduct a large pragmatic trial of electronic health record (EHR)-based implementation strategies informed by behavioral economic principles to encourage LPV utilization among all MV patients. We will employ a Hybrid Trial Type 3 design to study implementation and effectiveness outcomes. We will test two hypotheses: (1) that a default order set (pre-populated with LPV settings) or an accountable justification prompt (requiring physicians to provide an explicit rationale when non-LPV settings are ordered) will increase LPV utilization among patients with and without ARDS, will be sustainable, and will improve overall clinical outcomes; and (2) that the addition of an accountable justification prompt requiring respiratory therapists to provide a rationale when non-LPV settings are documented will further improve outcomes. We will use a stepped-wedge, cluster randomized design across 12 ICUs. The specific aims of this trial are to: (1) compare fidelity to LPV with the implementation strategies; (2) evaluate the sustainability of the strategies and their effects; (3) explore whether clinician and environmental contextual factors modify the effect of the strategies; (4) compare the effectiveness of strategies to improve patient outcomes; (5) compare the specific efficacy of these strategies, accounting for imperfect adherence to LPV; and (6) evaluate how patient heterogeneity interacts with the strategies. This study will provide high-quality evidence regarding the ability of simple, readily scalable interventions to improve evidence-based practices among patients with very high morbidity and mortality, will expand the literature on effectiveness of LPV among broader patient populations, and will improve understanding of the utility of different behavioral economic strategies in settings in which treatment effects may be heterogeneous.

项目摘要 据一些估计，每年多达一百万美国人接受侵入性机械通气（MV）。 MV 可以挽救生命，但也可能通过直接造成肺部损伤来有害 呼吸。越来越多的证据表明，“肺部保护通风”的特定策略 （LPV）呼吸较小并减轻气道压力，可以降低短期死亡率和 长期发病率。在患有急性呼吸窘迫综合征（ARDS）的患者中，一种严重的形式 与常见疾病有关的呼吸衰竭，例如肺炎，败血症和创伤，高质量 证据表明，LPV降低了死亡率，机械通气持续时间和长期 ARDS患者的发病率。但是，许多接受机械通气的ARDS患者 不要接受这种挽救生命的疗法。这种证据吸收不佳的两个原因是缺乏有关 LPV和关于MV倡议时谁有ARDS的不确定性。但是，最近认识到 LPV即使在没有ARDS的患者中也可能改善结果，这表明鼓励临床医生开始 所有患者的LPV可能是最佳策略。因此，我们的主要目标是研究简单的策略 这可能规避了知识和诊断不确定性的障碍，以改善LPV的利用率。我们 将对已通知的基于电子健康记录（EHR）的实施策略进行大型务实的试验 通过行为经济原则鼓励所有MV患者的LPV利用。我们将采用一个 混合试验3型设计，以研究实施和有效性结果。我们将检验两个假设： （1）默认订单集（由LPV设置预处理）或负责任的提示（要求 医师在订购非LPV设置时提供明确的理由）将增加LPV利用率 在有和没有ARD的患者中，将是可持续的，并将改善整体临床结果； （2） 增加了责任心提示，要求呼吸治疗师提供理由 当记录非LPV设置时，将进一步改善结果。我们将使用一个阶梯式斜角，群集 跨12个ICU的随机设计。该试验的具体目的是：（1）将Fidelity与LPV进行比较 实施策略； （2）评估战略及其影响的可持续性； （3）探索是否 临床和环境背景因素改变了策略的影响； （4）比较有效性 改善患者预后的策略； （5）比较这些策略的具体效率 对LPV的依从性不完美； （6）评估患者异质性如何与策略相互作用。 研究将提供有关简单，易于扩展干预措施改进的能力的高质量证据 发病率和死亡率非常高的患者中的循证实践将扩大有关的文献 LPV在更广泛的患者人群中的有效性，并将提高对效用的理解 在治疗效果可能是异质的环境中的不同行为经济策略。

项目成果

Implementing nudges to promote utilization of low tidal volume ventilation (INPUT): a stepped-wedge, hybrid type III trial of strategies to improve evidence-based mechanical ventilation management.

• DOI: 10.1186/s13012-021-01147-7
• 发表时间: 2021-08-10
• 期刊: Implementation science : IS
• 作者: Kerlin MP;Small D;Fuchs BD;Mikkelsen ME;Wang W;Tran T;Scott S;Belk A;Silvestri JA;Klaiman T;Halpern SD;Beidas RS
• 通讯作者: Beidas RS

Adherence to Lung Protective Ventilation in Patients With Coronavirus Disease 2019.

• DOI: 10.1097/cce.0000000000000512
• 发表时间: 2021-08
• 期刊: Critical care explorations
• 作者: Levy E;Scott S;Tran T;Wang W;Mikkelsen ME;Fuchs BD;Kerlin MP
• 通讯作者: Kerlin MP