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Implementation of Nudges to Promote Utilization of Low Tidal Volume Ventilation (INPUT) Study (INPUT)

Primary Purpose

ARDS, Critical Illness, Acute Respiratory Distress Syndrome

Status
Recruiting
Phase
Not Applicable
Locations
United States
Study Type
Interventional
Intervention
RT-targeted accountable justification
Default order set
physician-targeted accountable justification
Standard of Care
Sponsored by
University of Pennsylvania
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional health services research trial for ARDS focused on measuring mechanical ventilation, lung-protective ventilation

Eligibility Criteria

18 Years - 99 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  1. Aged 18 and over; AND
  2. Admission to 1 of the 12 participating ICUs; AND
  3. Undergoing mechanical ventilation

Exclusion Criteria:

  1. The episode of MV lasts less than 12 hours, because we believe that the evidence-based practice may not apply to these patients nor alter their outcomes.
  2. The patient is on minimal settings for the entirety of MV, defined as a spontaneous mode (e.g., pressure support ventilation) with pressure support <10 Centimeters of Water Column (cmH2O), AND positive end-expiratory pressure (PEEP) <8 cmH20, AND fraction of inspired oxygen (FiO2) <50%, because the clinical significance of spontaneous tidal volumes is unknown and low tidal volumes may not be beneficial or desirable.
  3. Goals of care are documented as comfort measures only (as identified through their "code status" field in the EHR) during the first 72 hours during episode of MV, because mechanical ventilation is managed differently during care focused exclusively on comfort and low tidal volume ventilation may not be appropriate, nor would it likely influence clinical outcomes.
  4. There is no height documented in the EHR at the time of initiation of MV, because we will be unable to estimate ideal body weight, a necessary parameter to calculate the primary outcome, and because they will not receive the interventions.
  5. The height documented is less than 4 feet, because the formula for ideal body weight does not hold true below this height.

Sites / Locations

  • Princeton Medical CenterRecruiting
  • Hospital of the University of PennsylvaniaRecruiting
  • Penn Presbyterian Medical CenterRecruiting
  • Pennsylvania HospitalRecruiting
  • Chester County HospitalRecruiting

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm 4

Arm 5

Arm Type

Active Comparator

Active Comparator

Active Comparator

Placebo Comparator

Active Comparator

Arm Label

Default order set

Physician-targeted accountable justification

Default order set + physician-targeted accountable justification

Standard of Care

Physician-targeted accountable justification + RT-targeted accountable justification

Arm Description

This arm will have the default order set implementation strategy

This arm will have the physician-targeted accountable justification implementation strategy

This arm will have the default order set and physician-targeted accountable justification

This arm will have no interventions and standard of care practices will be in place.

This arm will have the default order set and respiratory therapist-targeted accountable justification

Outcomes

Primary Outcome Measures

fidelity to LPV
percentage of time that a patient is exposed to tidal volume <6.5 cc/kg ideal body weight (hours)
sustainability
the percentage of time that a patient is exposed to tidal volume <6.5 cc/kg ideal body weight (IBW) among MV patients (hours)

Secondary Outcome Measures

Total duration of exposure to tidal volume >8 cc/kg and >10 cc/kg IBW
Total duration of exposure to tidal volume >8 cc/kg and >10 cc/kg IBW (hours)
hospital mortality
patient mortality occurring during hospitalization
ICU length of stay
ICU length of stay (hours)
hospital length of stay
hospital length of stay (hours)
hospital discharge disposition
patient disposition at time of hospital discharge
mechanical ventilation duration
mechanical ventilation duration (hours)
initial tidal volume administered
initial tidal volume (cc/kg)
Duration of time exposed to plateau pressure (Pplat)>30 mmHg
Duration of time exposed to plateau pressure (Pplat)>30 mmHg (hours)
total cumulative doses of sedative medications during and after mechanical ventilation
Total cumulative doses of sedative medications during and after mechanical ventilation
Total number of days with acute brain dysfunction during hospitalization
Total number of days with acute brain dysfunction during hospitalization, during and after mechanical ventilation

Full Information

First Posted
June 5, 2020
Last Updated
June 27, 2023
Sponsor
University of Pennsylvania
Collaborators
National Heart, Lung, and Blood Institute (NHLBI)
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1. Study Identification

Unique Protocol Identification Number
NCT04663802
Brief Title
Implementation of Nudges to Promote Utilization of Low Tidal Volume Ventilation (INPUT) Study
Acronym
INPUT
Official Title
Implementation of Nudges to Promote Utilization of Low Tidal Volume Ventilation (INPUT) Study
Study Type
Interventional

2. Study Status

Record Verification Date
June 2023
Overall Recruitment Status
Recruiting
Study Start Date
February 22, 2021 (Actual)
Primary Completion Date
November 15, 2023 (Anticipated)
Study Completion Date
November 15, 2023 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University of Pennsylvania
Collaborators
National Heart, Lung, and Blood Institute (NHLBI)

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
This study is a large pragmatic stepped-wedge trial of electronic health record (EHR)-based implementation strategies informed by behavioral economic principles to increase lung-protective ventilation (LPV) utilization among all mechanically ventilated (MV), adult patients. The study will compare the standard approach to managing MV across 12 study Intensive Care Units (ICUs) within University of Pennsylvania Health System (UPHS) versus interventions prompting physicians and respiratory therapists (RTs) to employ LPV settings promote LPV utilization among all MV patients.
Detailed Description
The study is a 5-arm, stepped-wedge cluster randomized trial of electronic health record (EHR)-based implementation strategies set in 12 community and academic ICUs in 5 hospitals of UPHS all currently using an EHR-based algorithm to identify patients with Acute Respiratory Distress Syndrome (ARDS) and prompt physicians to employ LPV will sequentially add two of three EHR-based implementation strategies to further promote LPV utilization among all MV patients. ICUs will be randomly assigned to first receive either a default order set (Strategy A) or physician-targeted accountable justification strategy (Strategy B). ICUs will be assigned to one of six wedges using computerized random-number generation, thereby determining the date on which they adopt their assigned EHR-based strategy. The first wedge will begin in the fourth month of the trial phase, so that all hospitals will contribute a minimum of 3 months of data prior to having adopted the implementation strategy. Six months after adoption, ICUs will add on an RT-targeted accountable justification strategy (Strategy C). By the end of the 27-month study period, all hospitals will have been utilizing two strategies in combination for at least 3 months. This design enables comparisons of outcomes before and after implementation within ICUs, as well as at a given point in time among ICUs which will have been randomly assigned to different strategies. During the two months after the implementation strategy rolls out in each ICU, researchers will perform semi-structured interviews of all physicians and RTs who staff study ICUs. After intervention period, there will be a 6-month observational period where trial monitoring will cease.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
ARDS, Critical Illness, Acute Respiratory Distress Syndrome, Acute Respiratory Failure
Keywords
mechanical ventilation, lung-protective ventilation

7. Study Design

Primary Purpose
Health Services Research
Study Phase
Not Applicable
Interventional Study Model
Crossover Assignment
Masking
Outcomes Assessor
Allocation
Randomized
Enrollment
15100 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Default order set
Arm Type
Active Comparator
Arm Description
This arm will have the default order set implementation strategy
Arm Title
Physician-targeted accountable justification
Arm Type
Active Comparator
Arm Description
This arm will have the physician-targeted accountable justification implementation strategy
Arm Title
Default order set + physician-targeted accountable justification
Arm Type
Active Comparator
Arm Description
This arm will have the default order set and physician-targeted accountable justification
Arm Title
Standard of Care
Arm Type
Placebo Comparator
Arm Description
This arm will have no interventions and standard of care practices will be in place.
Arm Title
Physician-targeted accountable justification + RT-targeted accountable justification
Arm Type
Active Comparator
Arm Description
This arm will have the default order set and respiratory therapist-targeted accountable justification
Intervention Type
Behavioral
Intervention Name(s)
RT-targeted accountable justification
Intervention Description
This strategy will require that the RT enter an explicit rationale in the EHR if he/she enters a tidal volume value greater than 6 cc/kg into the flowsheet, similar to the physician-targeted accountable justification strategy.
Intervention Type
Behavioral
Intervention Name(s)
Default order set
Intervention Description
With the default order set strategy, some mechanical ventilation order settings will be pre-populated to be consistent with LPV, including the mode and tidal volume, automatically calculated as 6 cc/kg of the patient's ideal body weight (as determined by each patient's height and gender, which are entered into the EHR on admission). The physician will have the option to opt out of any of the specified LPV settings and select other values.
Intervention Type
Behavioral
Intervention Name(s)
physician-targeted accountable justification
Intervention Description
When a physician enters a mechanical ventilation order for a tidal volume that is greater than 6 cc/kg ideal body weight, an alert will appear requiring the physician to enter a reason for choosing a setting inconsistent with LPV. Clinicians will be instructed to provide a reason for deviation from LPV settings and that their response will be maintained in the medical record. The physician will not be able to sign the mechanical ventilation order set until after a response is entered.
Intervention Type
Other
Intervention Name(s)
Standard of Care
Intervention Description
ICUs and clinicians will deliver standard of care to patients with no intervention
Primary Outcome Measure Information:
Title
fidelity to LPV
Description
percentage of time that a patient is exposed to tidal volume <6.5 cc/kg ideal body weight (hours)
Time Frame
first 72 hours of mechanical ventilation, during study intervention period
Title
sustainability
Description
the percentage of time that a patient is exposed to tidal volume <6.5 cc/kg ideal body weight (IBW) among MV patients (hours)
Time Frame
first 72 hours of mechanical ventilation, during study observation period
Secondary Outcome Measure Information:
Title
Total duration of exposure to tidal volume >8 cc/kg and >10 cc/kg IBW
Description
Total duration of exposure to tidal volume >8 cc/kg and >10 cc/kg IBW (hours)
Time Frame
from initiation to discontinuation of mechanical ventilation, average of 72 hours
Title
hospital mortality
Description
patient mortality occurring during hospitalization
Time Frame
from hospital admission to hospital discharge, average of 120 hours
Title
ICU length of stay
Description
ICU length of stay (hours)
Time Frame
from time of first eligibility to ICU discharge, average of 120 hours
Title
hospital length of stay
Description
hospital length of stay (hours)
Time Frame
from time of first eligibility to hospital discharge, average of 264 hours
Title
hospital discharge disposition
Description
patient disposition at time of hospital discharge
Time Frame
through time of hospital discharge, average of 264 hours
Title
mechanical ventilation duration
Description
mechanical ventilation duration (hours)
Time Frame
from initiation to discontinuation of mechanical ventilation, average of 72 hours
Title
initial tidal volume administered
Description
initial tidal volume (cc/kg)
Time Frame
at time of mechanical ventilation initiation, average of 72 hours
Title
Duration of time exposed to plateau pressure (Pplat)>30 mmHg
Description
Duration of time exposed to plateau pressure (Pplat)>30 mmHg (hours)
Time Frame
from initiation to discontinuation of mechanical ventilation, average of 72 hours
Title
total cumulative doses of sedative medications during and after mechanical ventilation
Description
Total cumulative doses of sedative medications during and after mechanical ventilation
Time Frame
from initiation of mechanical ventilation to hospital discharge, average of 264 hours
Title
Total number of days with acute brain dysfunction during hospitalization
Description
Total number of days with acute brain dysfunction during hospitalization, during and after mechanical ventilation
Time Frame
from initiation of mechanical ventilation to hospital discharge, average of 264 hours

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
99 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Aged 18 and over; AND Admission to 1 of the 12 participating ICUs; AND Undergoing mechanical ventilation Exclusion Criteria: The episode of MV lasts less than 12 hours, because we believe that the evidence-based practice may not apply to these patients nor alter their outcomes. The patient is on minimal settings for the entirety of MV, defined as a spontaneous mode (e.g., pressure support ventilation) with pressure support <10 Centimeters of Water Column (cmH2O), AND positive end-expiratory pressure (PEEP) <8 cmH20, AND fraction of inspired oxygen (FiO2) <50%, because the clinical significance of spontaneous tidal volumes is unknown and low tidal volumes may not be beneficial or desirable. Goals of care are documented as comfort measures only (as identified through their "code status" field in the EHR) during the first 72 hours during episode of MV, because mechanical ventilation is managed differently during care focused exclusively on comfort and low tidal volume ventilation may not be appropriate, nor would it likely influence clinical outcomes. There is no height documented in the EHR at the time of initiation of MV, because we will be unable to estimate ideal body weight, a necessary parameter to calculate the primary outcome, and because they will not receive the interventions. The height documented is less than 4 feet, because the formula for ideal body weight does not hold true below this height.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Aerielle Belk
Phone
856-354-5683
Email
aerielle.belk@pennmedicine.upenn.edu
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Meeta Kerlin, MD, MSCE
Organizational Affiliation
University of Pennsylvania
Official's Role
Principal Investigator
Facility Information:
Facility Name
Princeton Medical Center
City
Plainsboro
State/Province
New Jersey
ZIP/Postal Code
08536
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Aerielle Belk
Phone
856-354-5683
Email
aerielle.belk@pennmedicine.upenn.edu
Facility Name
Hospital of the University of Pennsylvania
City
Philadelphia
State/Province
Pennsylvania
ZIP/Postal Code
19104
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Aerielle Belk
Phone
856-354-5683
Email
aerielle.belk@pennmedicine.upenn.edu
Facility Name
Penn Presbyterian Medical Center
City
Philadelphia
State/Province
Pennsylvania
ZIP/Postal Code
19104
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Aerielle Belk
Phone
856-354-5683
Email
aerielle.belk@pennmedicine.upenn.edu
Facility Name
Pennsylvania Hospital
City
Philadelphia
State/Province
Pennsylvania
ZIP/Postal Code
19107
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Aerielle Belk
Phone
856-354-5683
Email
aerielle.belk@pennmedicine.upenn.edu
Facility Name
Chester County Hospital
City
West Chester
State/Province
Pennsylvania
ZIP/Postal Code
19380
Country
United States
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Aerielle Belk
Phone
856-354-5683
Email
aerielle.belk@pennmedicine.upenn.edu

12. IPD Sharing Statement

Plan to Share IPD
Yes
IPD Sharing Plan Description
Individual participant data that underlie published results will be made available to other researchers, after deidentification.
IPD Sharing Time Frame
Data will be available beginning 9 months after publication and up to 36 months following publication. After 36 months the data will be available in our University's data warehouse but without support, except for deposited metadata.
IPD Sharing Access Criteria
Proposals for data use will be reviewed by Principal Investigator and independent review boards (such as Institutional Review Board and Data Safety and Monitoring Board). Approved data requestors will need to sign data use agreements to access and use data
IPD Sharing URL
https://www.pair.upenn.edu
Citations:
PubMed Identifier
34376233
Citation
Kerlin MP, Small D, Fuchs BD, Mikkelsen ME, Wang W, Tran T, Scott S, Belk A, Silvestri JA, Klaiman T, Halpern SD, Beidas RS. 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. Implement Sci. 2021 Aug 10;16(1):78. doi: 10.1186/s13012-021-01147-7.
Results Reference
derived

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Implementation of Nudges to Promote Utilization of Low Tidal Volume Ventilation (INPUT) Study

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