Evaluating Delivery of Low Tidal Volume Ventilation in Six ICUs Using Electronic Health Record Data.

Sjoding MW, Gong MN, Haas CF, Iwashyna TJ. Evaluating Delivery of Low Tidal Volume Ventilation in Six ICUs Using Electronic Health Record Data. Critical care medicine. 2019 Jan 1; 47(1):56-61.

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Abstract:

OBJECTIVES: Mechanical ventilation with low tidal volumes is recommended for all patients with acute respiratory distress syndrome and may be beneficial to other intubated patients, yet consistent implementation remains difficult to obtain. Using detailed electronic health record data, we examined patterns of tidal volume administration, the effect on clinical outcomes, and alternate metrics for evaluating low tidal volume compliance in clinical practice. DESIGN: Observational cohort study. SETTING: Six ICUs in a single hospital system. PATIENTS: Adult patients who received invasive mechanical ventilation more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tidal volumes were analyzed across 1,905 hospitalizations. Although mean tidal volume was 6.8?mL/kg predicted body weight, 40% of patients were exposed to tidal volumes greater than 8?mL/kg predicted body weight, with 11% for more than 24 hours. At a patient level, exposure to 24 total hours of tidal volumes greater than 8?mL/kg predicted body weight was associated with increased mortality (odds ratio, 1.82; 95% CI, 1.20-2.78), whereas mean tidal volume exposure was not (odds ratio, 0.87/1?mL/kg increase; 95% CI, 0.74-1.02). Initial tidal volume settings strongly predicted exposure to volumes greater than 8?mL/kg for 24 hours; the adjusted rate was 21.5% when initial volumes were greater than 8?mL/kg predicted body weight and 7.1% when initial volumes were less than 8?mL/kg predicted body weight. Across ICUs, correlation of mean tidal volume with alternative measures of low tidal volume delivery ranged from 0.38 to 0.66. CONCLUSIONS: Despite low mean tidal volume in the cohort, a significant percentage of patients were exposed to a prolonged duration of high tidal volumes which was correlated with higher mortality. Detailed ventilator records in the electronic health record provide a unique window for evaluating low tidal volume delivery and targets for improvement.