title: Increasing compliance with low tidal volume ventilation in the ICU with two nudge-based interventions: evaluation through intervention time-series analyses.
abstract: Low tidal volume (TVe) ventilation improves outcomes for ventilated patients, and the majority of clinicians state they implement it. Unfortunately, most patients never receive low TVes. 'Nudges' influence decision-making with subtle cognitive mechanisms and are effective in many contexts. There have been few studies examining their impact on clinical decision-making. We investigated the impact of 2 interventions designed using principles from behavioural science on the deployment of low TVe ventilation in the intensive care unit (ICU).
  
  
  
  University Hospitals Bristol, a tertiary, mixed medical and surgical ICU with 20 beds, admitting over 1300 patients per year.
  
  
  
  Data were collected from 2144 consecutive patients receiving controlled mechanical ventilation for more than 1 hour between October 2010 and September 2014. Patients on controlled mechanical ventilation for more than 20 hours were included in the final analysis.
  
  
  
  (1) Default ventilator settings were adjusted to comply with low TVe targets from the initiation of ventilation unless actively changed by a clinician. (2) A large dashboard was deployed displaying TVes in the format mL/kg ideal body weight (IBW) with alerts when TVes were excessive.
  
  
  
  TVe in mL/kg IBW.
  
  
  
  TVe was significantly lower in the defaults group. In the dashboard intervention, TVe fell more quickly and by a greater amount after a TVe of 8 mL/kg IBW was breached when compared with controls. This effect improved in each subsequent year for 3 years.
  
  
  
  This study has demonstrated that adjustment of default ventilator settings and a dashboard with alerts for excessive TVe can significantly influence clinical decision-making. This offers a promising strategy to improve compliance with low TVe ventilation, and suggests that using insights from behavioural science has potential to improve the translation of evidence into practice.
authors.affiliation: Intensive Care Unit, University Hospitals Bristol, Bristol, UK.
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Bourdeaux
authors.affiliation: Intensive Care Unit, University Hospitals Bristol, Bristol, UK.
authors.forename: Matthew Jc
authors.initials: MJ
authors.lastname: Thomas
authors.affiliation: Intensive Care Unit, University Hospitals Bristol, Bristol, UK.
authors.forename: Timothy H
authors.initials: TH
authors.lastname: Gould
authors.affiliation: School of Experimental Psychology, University of Bristol, Bristol, UK.
authors.forename: Gaurav
authors.initials: G
authors.lastname: Malhotra
authors.affiliation: School of Experimental Psychology, University of Bristol, Bristol, UK.
authors.forename: Andreas
authors.initials: A
authors.lastname: Jarvstad
authors.affiliation: NIHR CLARHC West, Bristol, UK.
authors.forename: Timothy
authors.initials: T
authors.lastname: Jones
authors.affiliation: School of Experimental Psychology, University of Bristol, Bristol, UK.
authors.forename: Iain D
authors.initials: ID
authors.lastname: Gilchrist
mesh_terms: D000328:Adult; D000368:Aged; D056902:Clinical Alarms; D000066491:Clinical Decision-Making; D003661:Decision Support Techniques; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D056865:Ideal Body Weight; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods*; D013990:Tidal Volume; D014584:User-Computer Interface
keywords: behavioural science; decision-making; low tidal volume ventilation; nudge