OBJECTIVE:The aim of this study was to develop and externally validate a machine-learning model that retrospectively identifies patients with acute respiratory distress syndrome (acute respiratory distress syndrome [ARDS]) using electronic health record (EHR) data.DESIGN:In this retrospective cohort study, ARDS was identified via physician-adjudication in three cohorts of patients with hypoxemic respiratory failure (training, internal validation, and external validation). Machine-learning models were trained to classify ARDS using vital signs, respiratory support, laboratory data, medications, chest radiology reports, and clinical notes. The best-performing models were assessed and internally and externally validated using the area under receiver-operating curve (AUROC), area under precision-recall curve, integrated calibration index (ICI), sensitivity, specificity, positive predictive value (PPV), and ARDS timing.PATIENTS:Patients with hypoxemic respiratory failure undergoing mechanical ventilation within two distinct health systemsINTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:There were 1,845 patients in the training cohort, 556 in the internal validation cohort, and 199 in the external validation cohort. ARDS prevalence was 19%, 17%, and 31%, respectively. Regularized logistic regression models analyzing structured data (EHR model) and structured data and radiology reports (EHR-radiology model) had the best performance. During internal and external validation, the EHR-radiology model had AUROC of 0.91 (95% CI, 0.88-0.93) and 0.88 (95% CI, 0.87-0.93), respectively. Externally, the ICI was 0.13 (95% CI, 0.08-0.18). At a specified model threshold, sensitivity and specificity were 80% (95% CI, 75%-98%), PPV was 64% (95% CI, 58%-71%), and the model identified patients with a median of 2.2 hours (interquartile range 0.2-18.6) after meeting Berlin ARDS criteria.CONCLUSIONS:Machine-learning models analyzing EHR data can retrospectively identify patients with ARDS across different institutions.

Introduction Right heart catheterization (RHC) can be used to measure resting cardiac output in acute decompensated heart failure, with measurements based on the Fick Principle (Oxygen consumption = Cardiac Output x ∆Arterio-venous O2 content difference). While direct measurement of resting oxygen consumption (VO2) is the gold standard, this is not routinely performed due to cumbersome equipment and time limitations, leading to reliance on estimation equations or thermodilution-based CO determinations. However, the accuracy of these alternative methods in a contemporary inpatient heart failure population is unknown. Hypothesis We hypothesized that the estimated Fick (eFick) and Td would overestimate cardiac index (CI) as compared with the direct measured VO2 Fick (dFick) in patients admitted for suspected cardiogenic shock undergoing RHC. Methods We prospectively enrolled a convenience sample of inpatients with heart failure undergoing RHC who volunteered to have direct VO2 measurement undertaken from June 2022 through January 2023. eVO2 was determined using the Dehmer method (125*body surface area). VO2 was directly measured by metabolic cart (Carefusion N29 Vmax)using the canopy method. dFick, eFick, and Td measurements were compared using linear regression and Bland-Altman plots. Results Nine patients underwent direct VO2 measurement and RHC. Seven patients were male (77.8%), 8 (88.9%) had reduced ejection fraction (<50%), and ages ranged from 42-76 years. eVO2 overestimated measured resting VO2 in all 9 patients (mean difference 28.1±17.1 mL O2/min). The mean CI were dFick: 1.8±0.6, eFick: 2.1±0.8, Td: 1.9±0.8 L/min/m2. eFick overestimated CI by 14±9%, and Td overestimated CI by 6±16%, as compared to the dFick determination of CI. While eFick had higher precision for CI than Td, Td had higher accuracy. Body mass index correlated with the difference in CI between Td and dFick (r = 0.85, p<0.01), but not for difference in CI between eFick and dFick (r = 0.27, p = 0.49). No correlation with difference in CI was observed between either Td and dFick or eFick and dFick for age, ejection fraction, tricuspid regurgitation severity, mitral regurgitation severity, left ventricular internal diameter at end diastole, pulmonary capillary wedge pressure, or pulmonary artery pulsatility index. Conclusion eFick and Td methods for invasive hemodynamics generally overestimate CI compared with directly measured resting VO2 using a metabolic cart in a contemporary heart failure population. Further study should determine whether use of routine direct VO2 measurement impacts clinical outcomes.

BACKGROUND: Endotracheal aspirates (ETAs) are widely used for microbiologic studies of the respiratory tract in intubated patients. However, they involve sampling through an established endotracheal tube using suction catheters, both of which can acquire biofilms that may confound results. RESEARCH QUESTION: Does standard clinical ETA in intubated patients accurately reflect the authentic lower airway bacterial microbiome? STUDY DESIGN AND METHODS: Comprehensive quantitative bacterial profiling using 16S rRNA V1-V2 gene sequencing was applied to compare bacterial populations captured by standard clinical ETA vs contemporaneous gold standard samples acquired directly from the lower airways through a freshly placed sterile tracheostomy tube. The study included 13 patients undergoing percutaneous tracheostomy following prolonged (median, 15 days) intubation. Metrics of bacterial composition, diversity, and relative quantification were applied to samples. RESULTS: Pre-tracheostomy ETAs closely resembled the gold standard immediate posttracheostomy airway microbiomes in bacterial composition and community features of diversity and quantification. Endotracheal tube and suction catheter biofilms also resembled cognate ETA and fresh tracheostomy communities. INTERPRETATION: Unbiased molecular profiling shows that standard clinical ETA sampling has good concordance with the authentic lower airway microbiome in intubated patients.

Abstract Background MDROs frequently contaminate hospital environments. We performed a multicenter cluster-randomized, crossover trial of two methods for intensive monitoring of terminal cleaning effectiveness at reducing infection and colonization with MDROs within ICUs. Methods Six medical and surgical ICUs at three medical centers received both intensive monitoring interventions sequentially, in a randomized order. The intervention included surveying a minimum of 10 surfaces each in 5 rooms weekly, after terminal cleaning, with adenosine triphosphate (ATP) monitoring or an ultraviolet fluorescent marker (UV/F). Results were delivered to environmental services (EVS) staff in real-time, with failing surfaces recleaned. The primary study outcome was the monthly rate of infection or colonization with MDROs, including methicillin-resistant Staphylococcus aureus, Clostridioides difficile, vancomycin-resistant Enterococcus, and multidrug-resistant gram-negative bacilli (MDR-GNB), assessed during a 12-month baseline comparison period and sequential 6-month intervention periods, separated by a 2-month washout. Outcomes during each intervention period were compared to the combined baseline period plus the alternative intervention period using mixed-effects Poisson regression, with study hospital as a random effect. Results The primary outcome rate varied by hospital and ICU (Figure 1). The ATP method was associated with a relative reduction in the incidence rate of infection or colonization with MDROs (incidence rate ratio (IRR) 0.887, 95% confidence-interval (CI) 0.811–0.969, P=0.008) (Table 1), infection with MDROs (IRR 0.924, 95% CI 0.855–0.998, P=0.04), and infection or colonization limited to multidrug-resistant MDR-GNB (IRR 0.856, 95% CI 0.825–0.887, P< 0.001). The UV/F intervention was not associated with a statistically significant impact on these outcomes. Room turn-around time was increased by a median of one minute with the ATP intervention and 4.5 minutes with the UV/F intervention compared to baseline. Conclusion Intensive monitoring of ICU terminal room cleaning with an ATP modality is associated with a relative reduction of infection and colonization with MDROs with a negligible impact on TAT. Disclosures Hilary Babcock, MD, MPH, FIDSA, FSHEA (nothing to disclose), David K. Warren, MD, MPH, Homburg & Partner (consultant), Ebbing Lautenbach, MD, MPH, MSCE (nothing to disclose), Jennifer Han, MD, MSCE, GlaxoSmithKline (employee, shareholder).

BACKGROUND: Pulse oximetry is the mainstay of patient oxygen monitoring. Measurement error from pulse oximetry is more common for those with darker skin pigmentation, yet this topic remains understudied, and evidence-based clinical mitigation strategies do not currently exist. Our objectives were to measure the rate of occult hypoxemia, defined as arterial oxygen saturation (SaO2) < 88% when pulse oximeter oxygen saturation was between 92-96%, in a racially diverse critically ill population; to analyze degree, direction, and consistency of measure-ment error; and to develop a mitigation strategy that minimizes occult hypoxemia in advance of technological advancements. METHODS: We performed a multi-center retrospective cohort study of critically ill subjects. RESULTS: Among 105,467 paired observations from 7,693 sub-jects, we found occult hypoxemia was more common among minority subjects. The frequency of occult hypoxemia was 7.9% versus 2.9% between Black and white subjects, respectively, (P < .001). Pulse oximeter measurement errors were inconsistent throughout a patient encounter, with 67% of encounters having a range of intra-subject measurement errors > 4 percentage points. In 75% of encounters, the intra-subject errors were bidirectional. SaO2 < 88% was less common at higher pulse oximeter oxygenation ranges (4.1% and 1.8% of observations among Black and white subjects at a pulse oximeter threshold of 94-98%). Although occult hypoxemia was further reduced at oxygenation saturation range 95-100%, the frequency of hyperoxemia (partial pressure of arterial oxygen > 110 mm Hg) became more common, occurring in 42.3% of Black and 46.0% of white observations. CONCLUSIONS: Measurement error in pulse oxime-try is common for all racial groups, but occult hypoxemia occurred most commonly in Black subjects. The highly variable magnitude and direction of measurement error preclude an indi-vidualized mitigation approach. In advance of technological advancements, we recommend tar-geting a pulse oximetry saturation goal of 94-98% for all patients.

BACKGROUND: Recent studies have revealed high rates of burnout among respiratory thera-pists (RTs), which has implications for patient care and outcomes as well as for the health care workforce. We sought to better understand RT well-being during the COVID-19 pandemic. The purpose of this study was to determine rates and identify determinants of well-being, including burnout and professional fulfillment, among RTs in ICUs. METHODS: We conducted a mixed -methods study comprised of a survey administered quarterly from July 2020-May 2021 to criti-cal-care health care professionals and semi-structured interviews from April-May 2021 with 10 ICU RTs within a single health center. We performed multivariable analyses to compare RT well-being to other professional groups and to evaluate changes in well-being over time. We ana-lyzed qualitative interview data using thematic analysis, followed by mapping themes to the Maslow needs hierarchy. RESULTS: One hundred eight RTs responded to at least one quarterly survey. Eighty-two (75%) experienced burnout; 39 (36%) experienced professional fulfillment, and 62 (58%) reported symptoms of depression. Compared to clinicians of other professions in multivariable analyses, RTs were significantly more likely to experience burnout (odds ratio 2.32 [95% CI 1.41-3.81]) and depression (odds ratio 2.73 [95% CI 1.65-4.51]) and less likely to expe-rience fulfillment (odds ratio 0.51 [95% CI 0.31-0.85]). We found that staffing challenges, safety concerns, workplace conflict, and lack of work-life balance led to burnout. Patient care, use of specialized skills, appreciation and a sense of community at work, and purpose fostered profes-sional fulfillment. Themes identified were mapped to Maslow's hierarchy of needs; met needs led to professional fulfillment, and unmet needs led to burnout. CONCLUSIONS: ICU RTs experienced burnout during the pandemic at rates higher than other professions. To address RT needs, institutions should design and implement strategies to reduce burnout across all levels.

INTRODUCTION/HYPOTHESIS: Complications of Mechanical Ventilation (MV) are well-described and related to duration of exposure to the intervention. A protocolized approach to MV liberation is recommended by Critical Care society guidelines and avoidance of delay to MV liberation was recently selected as one of five 2021 Choosing Wisely® for Critical Care recommendations. Baseline data in our tertiary hospital Medical Intensive Care Unit (MICU) showed that the average time of extubation was 1:30PM, with only 16% of patients extubated in the morning before 10AM. These findings prompted a Quality Improvement (QI) initiative aimed at achieving earlier extubation of eligible patients. METHODS: A multidisciplinary QI project team was formed, with representation from attending physicians, respiratory therapists, nurses, and physicians-in-training. A SMART Aim was created in September of 2020, with a goal set for the rate of morning (6AM to 10AM) extubation for eligible patients to increase from 16% to 20% or greater by June of 2021. Countermeasures were developed based on root cause analysis and targeted early morning initiation of Spontaneous Breathing Trials (SBTs), limiting overnight sedation, and staff education on hospital SBT and extubation protocols. A novel telemedicine Respiratory Therapy service, initially formed in response to the COVID-19 pandemic, was leveraged to ensure early SBTs and sedation minimization. PDSA cycles were performed to optimize educational and telemedicine countermeasures. RESULTS: 334 patients were extubated during the study period. The cumulative rate of extubation between 6AM - 10AM increased from 16% in the pre-intervention period to 27% in the post-intervention period and an upward shift in the run chart baseline was observed. Reintubation rate within 48 hours was monitored as a balancing measure and did not increase in the post-intervention period. There was no shift in median ICU length of stay or median MV duration in the postintervention period. CONCLUSIONS: A multidisciplinary QI initiative was able to increase the rate of morning extubations in a tertiary hospital MICU. The initiative demonstrated the value of a novel telemedicine Respiratory Therapy service to ensure adherence to best practices and achieve improvements in quality of care.

SESSION TITLE: Critical Care Management of COVID-19SESSION TYPE: Original InvestigationsPRESENTED ON: 10/17/2022 01:30 pm - 02:30 pmPURPOSE: Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in the intensive care unit (ICU), with a mortality rate approaching 40%. Early prone positioning (PP) in ARDS improves oxygenation and mortality; however, observational studies have previously shown low uptake of this life-saving treatment. The COVID-19 pandemic resulted in high volumes of patients with easily recognized ARDS, potentially overcoming an important implementation barrier of PP. This study aimed to test the hypothesis that patients with ARDS with COVID-19 would be more likely to undergo PP compared to patients without COVID-19.METHODS: We conducted a retrospective cohort study of patients admitted to ICUs in 5 University of Pennsylvania Health System hospitals between March 16 and July 14, 2020. Patients with a PaO2:FiO2 (P:F) ratio ≤ 150 on first blood gas after intubation or at 24h were identified using an automated EHR-based algorithm and verified by chart review. PP was identified by chart review. We compared patient characteristics of patients with and without COVID-19 in unadjusted analyses using chi-square and rank sum tests. We estimated the odds of PP using multivariable logistic regression adjusted for patient age, gender, Sequential Organ Failure Assessment (SOFA) score, and body mass index (BMI).RESULTS: The cohort included 197 patients, 158 with COVID-19 and 39 without COVID-19. Median initial P:F ratio in all patients was 99 (IQR 76-130; COVID-19 ARDS median 99, IQR 76-129; non-COVID-19 ARDS median 100, IQR 76-138 p=0.81). Patients with COVID-19 ARDS were older (median age 65 vs 60 years, p=0.01), more predominantly male (57% vs 38%, p=0.04), had longer hospital length of stay (median 23 vs 15 days, p=0.001), and had lower SOFA scores (worst score on first day 10 vs 12, p=0.02) than non-COVID-19 ARDS patients. There were no significant differences between the COVID-19 and non-COVID-19 ARDS groups in BMI (p=0.2) or unadjusted in-hospital mortality (p=0.4). 87 (55%) COVID-19 ARDS patients and 6 (15%) non-COVID-19 ARDS patients underwent PP (chi-square=19.76, p<0.001). After adjustment for patient characteristics, patients with COVID-19 ARDS were significantly more likely to undergo PP than non-COVID-19 ARDS patients (OR 7.7, 95% CI 2.7-22.0, p=0.9).CONCLUSIONS: Patients with COVID-19-associated ARDS were significantly more likely to undergo PP than those with non-COVID-19 ARDS during the early months of the COVID-19 pandemic. This may be due to the fact that PP was one of the few interventions consistently identified to improve outcomes in a time of great uncertainty and high mortality from COVID-19. In non-COVID-19 ARDS, the diagnosis may not be made as frequently, and when it is, PP is often incorrectly thought of as a “last resort” for refractory hypoxemia.CLINICAL IMPLICATIONS: Further efforts should be made to identify ARDS and offer PP to non-COVID-19 ARDS patients.DISCLOSURES: No relevant relationships by Barry FuchsNo relevant relationships by Lilian IglesiasNo relevant relationships by Meeta KerlinNo relevant relationships by Rachel KohnNo relevant relationships by Allyson LiebermanNo relevant relationships by Stefania ScottNo relevant relationships by Gary Weissman SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: Acute respiratory distress syndrome (ARDS) is a major cause of hypoxemic respiratory failure in the intensive care unit (ICU), with a mortality rate approaching 40%. Early prone positioning (PP) in ARDS improves oxygenation and mortality; however, observational studies have previously shown low uptake of this life-saving treatment. The COVID-19 pandemic resulted in high volumes of patients with easily recognized ARDS, potentially overcoming an important implementation barrier of PP. This study aimed to test the hypothesis that patients with ARDS with COVID-19 would be more likely to undergo PP compared to patients without COVID-19. METHODS: We conducted a retrospective cohort study of patients admitted to ICUs in 5 University of Pennsylvania Health System hospitals between March 16 and July 14, 2020. Patients with a PaO2:FiO2 (P:F) ratio ≤ 150 on first blood gas after intubation or at 24h were identified using an automated EHR-based algorithm and verified by chart review. PP was identified by chart review. We compared patient characteristics of patients with and without COVID-19 in unadjusted analyses using chi-square and rank sum tests. We estimated the odds of PP using multivariable logistic regression adjusted for patient age, gender, Sequential Organ Failure Assessment (SOFA) score, and body mass index (BMI). RESULTS: The cohort included 197 patients, 158 with COVID-19 and 39 without COVID-19. Median initial P:F ratio in all patients was 99 (IQR 76-130; COVID-19 ARDS median 99, IQR 76-129; non-COVID-19 ARDS median 100, IQR 76-138 p=0.81). Patients with COVID-19 ARDS were older (median age 65 vs 60 years, p=0.01), more predominantly male (57% vs 38%, p=0.04), had longer hospital length of stay (median 23 vs 15 days, p=0.001), and had lower SOFA scores (worst score on first day 10 vs 12, p=0.02) than non-COVID-19 ARDS patients. There were no significant differences between the COVID-19 and non-COVID-19 ARDS groups in BMI (p=0.2) or unadjusted in-hospital mortality (p=0.4). 87 (55%) COVID-19 ARDS patients and 6 (15%) non-COVID-19 ARDS patients underwent PP (chi-square=19.76, p<0.001). After adjustment for patient characteristics, patients with COVID-19 ARDS were significantly more likely to undergo PP than non-COVID-19 ARDS patients (OR 7.7, 95% CI 2.7-22.0, p=0.9). CONCLUSIONS: Patients with COVID-19-associated ARDS were significantly more likely to undergo PP than those with non-COVID-19 ARDS during the early months of the COVID-19 pandemic. This may be due to the fact that PP was one of the few interventions consistently identified to improve outcomes in a time of great uncertainty and high mortality from COVID-19. In non-COVID-19 ARDS, the diagnosis may not be made as frequently, and when it is, PP is often incorrectly thought of as a “last resort” for refractory hypoxemia. CLINICAL IMPLICATIONS: Further efforts should be made to identify ARDS and offer PP to non-COVID-19 ARDS patients. DISCLOSURES: No relevant relationships by Barry Fuchs No relevant relationships by Lilian Iglesias No relevant relationships by Meeta Kerlin No relevant relationships by Rachel Kohn No relevant relationships by Allyson Lieberman No relevant relationships by Stefania Scott No relevant relationships by Gary Weissman

OBJECTIVES: Prior studies have demonstrated suboptimal adherence to lung protective ventilation among patients with acute respiratory distress syndrome. A common barrier to providing this evidence-based practice is diagnostic uncertainty. We sought to test the hypothesis that patients with acute respiratory distress syndrome due to coronavirus disease 2019, in whom acute respiratory distress syndrome is easily recognized, would be more likely to receive low tidal volume ventilation than concurrently admitted acute respiratory distress syndrome patients without coronavirus disease 2019. DESIGN: Retrospective cohort study. SETTING: Five hospitals of a single health system. PATIENTS: Mechanically ventilated patients with coronavirus disease 2019 or noncoronavirus disease 2019 acute respiratory distress syndrome as identified by an automated, electronic acute respiratory distress syndrome finder in clinical use at study hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among 333 coronavirus disease 2019 patients and 234 noncoronavirus disease 2019 acute respiratory distress syndrome patients, the average initial tidal volume was 6.4 cc/kg predicted body weight and 6.8 cc/kg predicted body weight, respectively. Patients had tidal volumes less than or equal to 6.5 cc/kg predicted body weight for a mean of 70% of the first 72 hours of mechanical ventilation in the coronavirus disease 2019 cohort, compared with 52% in the noncoronavirus disease 2019 cohort (unadjusted p < 0.001). After adjusting for height, gender, admitting hospital, and whether or not the patient was admitted to a medical specialty ICU, coronavirus disease 2019 diagnosis was associated with a 21% higher percentage of time receiving tidal volumes less than or equal to 6.5 cc/kg predicted body weight within the first 72 hours of mechanical ventilation (95% CI, 14–28%; p < 0.001). CONCLUSIONS: Adherence to low tidal volume ventilation during the first 72 hours of mechanical ventilation is higher in patients with coronavirus disease 2019 than with acute respiratory distress syndrome without coronavirus disease 2019. This population may present an opportunity to understand facilitators of implementation of this life-saving evidence-based practice.

BACKGROUND: Staffing strategies used to meet the needs of respiratory care departments during the COVID-19 pandemic included the deployment of respiratory therapist extenders. The purpose of this study was to evaluate respiratory therapist extenders' comfort level with critical care ventilators while caring for patients with COVID-19. To our knowledge, this is the first study to evaluate the deployment of certified registered nurse anesthetists (CRNAs) in a critical care setting. METHODS: A qualitative survey method was used to assess CRNA experience with critical care ventilators. Prior to deployment in the ICU, CRNAs were trained by clinical lead respiratory therapists. Education included respiratory clinical practices and ventilator management. Sixty-minute sessions were held with demonstration stations set up in ICUs for hands-on experience. RESULTS: Fifty-six CRNAs responded to our survey (63%). A mean +/- SD of 9.48 +/- 12.27 h was spent training prior to deployment in the ICU. CRNAs were at the bedside a mean +/- SD of 73.0 +/- 40.6 h during the pandemic. While CRNA comfort level with critical care ventilators increased significantly (P < .001) from the beginning to the end of their work experience, no statistically significant differences were found between CRNA comfort based on years of experience. Differences in comfort level were not found after training (chi-squared test 23.82, P = .09) or after ICU experience was completed (chi-squared test = 15.99, P = .45). Similarly, mean comfort level did not increase based on the number of hours spent working in the ICU (chi-squared test = 13.67, P = .55). CONCLUSIONS: Comfort level with mechanical ventilation increased for CRNAs working alongside respiratory therapists during the COVID-19 pandemic.

Background: Despite high-quality evidence of a mortality benefit from low tidal volume ventilation (LTVV), many patients with acute respiratory distress syndrome do not receive LTVV. We developed a respiratory therapist (RT)-directed strategy in the electronic health record (EHR) based on behavioral economics. In this pilot study, our objective was to obtain RTs’ perceptions about the strategy and the process of determining tidal volume settings generally. Methods: We performed a two-phase pilot test as part of an NIH-funded, IRB-approved randomized trial in one cardiac care unit (CCU). The strategy employed an accountable justification alert, which required documentation of a reason in a free-text field if an RT recorded a set tidal volume greater than 6.5 cc/kg PBW. We implemented the alert for one month during each phase, making modifications based on iterative feedback. During both phases we conducted semi-structured interviews with RTs. We performed content analysis to identify perceptions of the alert and mechanical ventilation (MV) management. Results: The alert fired 62 times on 12 patients and for 27 RTs, and 31 times on 14 patients for 24 RTs during phases 1 and 2, respectively. In response to the nudges, RTs commonly dismissed the alert without completing it in phase 1. Based on these results, we modified the alert to require a response in order to proceed in the EHR. Prior to phase 2, we increased educational efforts with daily outreach to staff RTs during implementation. Common reasons provided for not using LTVV during phase 2 included that the patient did not have ARDS, that a higher tidal volume was prescribed, and that the patient was asynchronous. RTs generally viewed the nudge as favorable and unobtrusive to workflow, describing it as easy to use and fantastic. They felt the alert was a useful reminder and may help them advocate for patients during disagreements about LTVV use. RTs viewed use of LTVV as beneficial for patients but recognized its inconsistent use among physicians and throughout different ICUs. While RTs generally agreed that physicians made the final decisions regarding MV settings, they also felt they were able to advocate for patients and had autonomy when managing MV. Conclusions: Iterative pilot-testing of a nudge strategy to promote use of low tidal volumes proved useful to improve RT interactions with the nudge. The alert was viewed as useful and acceptable by RTs and has potential to improve evidence-based delivery of low tidal volume ventilation.

Gbadamosi, Sheriff1; Bellamy, Cassandra2; Augustino, Melissa3; Garbovsky, Lyudmila1; Fuchs, Barry3; Candeloro, Christina2 Author Information

In a large health system in the United States, investigators examined whether mortality, receipt of mechanical ventilation, and patient acuity changed over time among adult patients with COVID-19–related critical illness admitted to intensive care units.

Background 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 under-utilized 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. Methods 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 strategies to improve adherence to low tidal volume ventilation. The strategies target clinicians who enter electronic orders and respiratory therapists who manage the mechanical ventilator, two key stakeholder groups. 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. We will create six matched pairs of twelve intensive care units (ICUs) in five hospitals in one large health system to balance patient volume and baseline adherence to low tidal volume ventilation. We will randomly assign ICUs within each matched pair to one of the order panels, and each pair to one of six wedges, which will determine date of adoption of the order panel strategy. All ICUs will adopt the flowsheet documentation strategy 6 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. Discussion 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. Trial registration ClinicalTrials.gov , NCT04663802 . Registered 11 December 2020.