(1477) Adherence to Low Tidal Volume Ventilation in an Urban ICU: A Quality Improvement Project

Introduction: The compelling mortality reduction of Low Tidal Volume Ventilation (LTVV) in ARDS and maintaining tidal volumes < 8ml/kg IBW (ideal body weight) in all patients is supported by the evidence and accepted practice. However, LTVV remains widely underutilized. We present a quality improvement project in an urban community hospital aimed at improving compliance of LTVV.

Methods: 254 total patients in three cohorts of 4-month durations were established from 4th quarter 2022 to 1st quarter 2024. Intervention phases lasting 2-months were set for 2 PDSA cycles between cohorts. First intervention added LTVV charts for height and sex on every ventilator and education of respiratory therapists on LTVV. Second intervention added target tidal volume to MICU note templates, resident didactics, and an ICU daily Mechanical Ventilation checklist LTVV adherence was assessed via Chart review documenting set tidal volume 6 hours post-intubation and recording height to determine target tidal volume. Admission diagnoses were documented to also evaluate adherence to a target of ≤6ml/kg IBW for patients with acute hypoxemic respiratory failure (AHRF).

Results: Adherence to a target of ≤8ml/kg IBW improved across our 3 cohorts: Cohort 1: 72.29%, n=83, Cohort 2: 79.31% n=87, Cohort 3 82.14% n=84). This represents a near 10% increase in adherence to this target, however this is not statistically significant (X2 =2.50, p=0.29). We noted disparities in sex with only 48.65% of females having tidal volume < 8ml/kg IBW improving to 69.05% and 62.05% in Cohorts 2 and 3. For patients with AHRF, adherence to a stricter target of ≤6ml/Kg IBW improved from 19.05% to 22.22% to 57.14% from Cohorts 1-3.

Conclusions: Tidal volume impacts important clinical outcomes, yet adherence to evidence-based ventilator management is a challenge nationwide and the COVID-19 pandemic is likely attributable to a deterioration in practice. Emerging from the pandemic, we sought to promote compliance and achieved improvements in our target tidal volume—especially for those with diagnoses that led to AHRF . Given the challenges of monitoring and changing practice utilizing chart review, we are in the process of developing our work by building reporting dashboards to allow real time tracking of ventilator management in the ICUs across our Health System.