Implementation of a Clinical Decision Support Tool for Improving Adherence to Lung Protective Ventilation Strategies

Abstract

RATIONALE: Pre-pandemic, ARDS accounted for approximately 10% of all ICU admissions and 25% of ICU patients requiring mechanical ventilation (MV). Surges in severe Covid-19 cases have increased the number of ICU patients requiring MV for ARDS. It has been estimated that only 60% of ARDS cases are identified at any time during the clinical course, and only 34% of ARDS cases are identified when initial criteria are met. Additionally, it is estimated that only 60% of ARDS patients are managed with evidence based MV settings, including low tidal volume ventilation (LTV) of <6 cc/kg ideal body weight, plateau pressure <30 cm H2O, and low driving pressure <15 cm H2O. Adherence to lung protective ventilation strategies have been linked to decreased mortality in ARDS. We implemented a clinical decision support tool (CDST) to aid clinicians in the early recognition of ARDS and aid in implementation of lung protective ventilation strategies. METHODS: From March 2020 to March 2021 we used medical informatics (SickbayTM) to identify ICU patients requiring MV that met criteria for ARDS based on the Berlin Criteria. We monitored documentation of ARDS, MV tidal volume as cc/kg ideal body weight, plateau pressure, driving pressure, MV settings, arterial blood gas values (ABG), and PaO2 / FiO2. From March 2021 to October 2021, we implemented a CDST outlining above variables to aide ICU clinicians in 1) recognition of ARDS and 2) utilization of MV and ABG data to make evidence based MV changes. Lung protective strategies were automatically recorded every two hours via informatics software. The results were analyzed using a chi-squared test. RESULTS: There were 207 patients reviewed preimplementation of the CDST and 88 patients reviewed during implementation of the CDST. Implementation of the CDST resulted in improved detection and documentation of ARDS (63.8% vs 100%, p=.0001), improved adherence to LTV (53.9% vs 64.9%, p = .0005), and improved adherence to low plateau pressure (67.7% vs 71.8%, p=.20). There was a decrease in adherence to low driving pressure (36.6% vs 23.9%, p=.0003).CONCLUSIONS: Implementation of CDST is a low-cost, efficacious measure to aide clinicians in the detection and documentation of ARDS. Using CDST was associated with improved adherence to LTV and low plateau pressure MV strategies. We hypothesize that difficulty with adherence to low driving pressure is related to the respiratory mechanics of Covid-19 ARDS differing from other forms of ARDS. A validation cohort is needed to further support our findings.