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ARDSINPUTNCT04663802

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

A study testing Default order set, Physician-targeted accountable justification and Respiratory therapist (RT)-targeted accountable justification in people with ARDS and Critical Illness, run by University of Pennsylvania at 5 sites in United States.

Completed

Finished. The study has ended and is not enrolling. Results may be posted on the official record.

Official record
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Trial 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. Read more about this study

Who is it for?
Ages 18 to 99 years
What is being tested?
Default order set, Physician-targeted accountable justification and Respiratory therapist (RT)-targeted accountable justification
Could I receive a placebo?
No, everyone receives an active treatment
How many people
7,342 participants
Where
5 sitesUnited States
Study dates
22 Feb 2021to 15 Dec 2023
Phase
Interventional
Are there results?
Yes, posted in the registrySummary in the doctors' view

Key requirements

Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.

  • Ages 18 to 99 years
  • All sexes
  • No healthy volunteers
  • Adult, Older adult

Who may be able to join

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

Who cannot join

  • 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.

Trial locations and contacts

5 sites in 1 country.

5 sites in 1 country

United States5 sites
  • Hospital of the University of Pennsylvania

    Philadelphia, Pennsylvania, 19104

  • Penn Presbyterian Medical Center

    Philadelphia, Pennsylvania, 19104

  • Pennsylvania Hospital

    Philadelphia, Pennsylvania, 19107

  • Princeton Medical Center

    Plainsboro, New Jersey, 08536

  • Chester County Hospital

    West Chester, Pennsylvania, 19380

Other trials in United States

About this study

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.

Read the 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 intensive care units (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 accountable justification strategy targeting respiratory therapists (RT; 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.

Being tested
Default order set, Physician-targeted accountable justification, Respiratory therapist (RT)-targeted accountable justification
Keywords
mechanical ventilation, lung-protective ventilation
Medical subject headings
Critical Illness, Respiratory Distress Syndrome

What participants receive

What participants receive. In a randomised study each person is assigned to one group by chance.

  • Default order setBehavioural

    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 milliliters per kilogram of predicted body weight (cc/kg PBW; as determined by each patient's height and gender). The physician will have the option to opt out of any of the specified LPV settings and select other values.

  • Physician-targeted accountable justificationBehavioural

    When a physician enters a mechanical ventilation order for a tidal volume that is greater than 6 cc/kg PBW, 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.

  • Respiratory therapist (RT)-targeted accountable justificationBehavioural

    If an RT enters a tidal volume in a flowsheet documentation field value greater than 6 cc/kg PBW, an alert will appear requiring them to enter a reason for entering 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 RT will not be able to save the documentation in the EHR until after a response is entered.

Study groups in NCT04663802
Study groupRoleWhat they receive
Usual careNo interventionThis arm will have no interventions and standard of care practices will be in place.
Default order setActive comparatorThis arm will have the default order set implementation strategy
Receives: Behavioral: Default order set
Physician-targeted accountable justificationActive comparatorThis arm will have the physician-targeted accountable justification implementation strategy
Receives: Behavioral: Physician-targeted accountable justification
Default order set + RT-targeted accountable justificationActive comparatorThis arm will have the default order set and respiratory therapist-targeted accountable justification
Receives: Behavioral: Default order set; Behavioral: Respiratory therapist (RT)-targeted accountable justification
Physician-targeted accountable justification + RT-targeted accountable justificationActive comparatorThis arm will have the default order set and respiratory therapist-targeted accountable justification
Receives: Behavioral: Physician-targeted accountable justification; Behavioral: Respiratory therapist (RT)-targeted accountable justification

What is being measured

The primary outcome is the main question the study is designed to answer.

  1. Fidelity to LPV

    percentage of time that a patient is exposed to tidal volume <6.5 cc/kg ideal body weight

    Measured: up to 72 hours, from initiation of mechanical ventilation in a study ICU until discontinuation of mechanical ventilation

Secondary outcomes (12)
  1. Total Duration of Exposure to Tidal Volume >8 cc/kg PBW

    Total duration of exposure to tidal volume greater than 8 cc/kg PBW, in hours. The time frame for follow-up is based on the total duration of IMV during the total follow-up period of 30 days. Note it is intentionally different from the time frame of the primary outcome variable, which focuses on the initial 72 hours, as the period most likely to be influenced by the study interventions.

    Measured: from initiation to discontinuation of mechanical ventilation in the study ICU, up to 720 hours (30 days)

  2. Total Duration of Exposure to Tidal Volume >10 cc/kg PBW

    Total duration of exposure to tidal volume greater than 10 cc/kg PBW, in hours. The time frame for follow-up is based on the total duration of IMV during the total follow-up period of 30 days. Note it is intentionally different from the time frame of the primary outcome variable, which focuses on the initial 72 hours, as the period most likely to be influenced by the study interventions.

    Measured: from initiation to discontinuation of mechanical ventilation in the study ICU, up to 720 hours (30 days)

  3. Initial Tidal Volume Administered

    Binary variable for whether initial tidal volume (first documented value after initiation of mechanical ventilation in a study ICU) is less than or equal to 6.5 milliliters per kilogram of predicted body weight (cc/kg PBW)

    Measured: within 24 hours of initiation of mechanical ventilation in a study ICU

  4. Initial Plateau Pressure (Pplat)>30 Centimeters of Water (cm H2O)

    Binary variable for whether initial plateau pressure (Pplat) > 30 cm H2O (first documented value after initiation of mechanical ventilation in a study ICU)

    Measured: within 24 hours of initiation of mechanical ventilation in a study ICU

  5. Hospital Mortality

    All-cause mortality occurring during hospitalization.

    Measured: All-cause mortality as a study outcome was assessed through hospital discharge, up to 720 hours (30 days); all adverse events (including mortality) were assessed though 24 hours after initiation of mechanical ventilation.

  6. ICU-free Days

    days alive and not admitted to an ICU; composite of ICU length of stay and death

    Measured: from time of first eligibility to 30 days

  7. Hospital Free Days

    days alive and not admitted to a hospital;composite of hospital length of stay and death

    Measured: from time of first eligibility to 30 days

  8. Ventilator Free Days

    days alive and not on mechanical ventilation; composite of ventilator free days and death

    Measured: from time of first eligiblity to 30 days

  9. Hospital Discharge Disposition

    Location to which the patient was discharged after the end of the hospital admission

    Measured: At the time of discharge from the hospital, up to 720 hours (30 days) after initiation of mechanical ventilation in a study ICU

  10. Early Deep Sedation

    The percentage of time during the first 72 hours of mechanical ventilation that patients were alive, in the ICU, and with Richmond Agitation-Sedation Scale (RASS) of -3 to -5 . The RASS measures a patient's depth of sedation and ranges from -5 (comatose) to +4 (combative), with a normal level of 0 (defined as "alert and calm"). Negative values indicate a patient is sedated and positive values indicate some degree of agitation.

    Measured: up to 72 hours, from the initiation to the discontinuation of mechanical ventilation in the ICU

  11. Average Sedation Intensity Within the First 72 Hours

    Average Richmond Agitation-Sedation Scale (RASS) value, weighted by duration of time at that value. The RASS measures a patient's depth of sedation and ranges from -5 (comatose) to +4 (combative), with a normal level of 0 (defined as "alert and calm"). Negative values indicate a patient is sedated and positive values indicate some degree of agitation.

    Measured: Up to 72 hours, from initiation to discontinuation of mechanical ventilation in a study ICU

  12. Deep Sedation for the Entirety of the First 72 Hours of Mechanical Ventilation

    Binary variable for whether a patient had Richmond Agitation-Sedation Scale (RASS) score of -3 to -5 for the entirety of the first 72 hours of mechanical ventilation. The RASS measures a patient's depth of sedation and ranges from -5 (comatose) to +4 (combative), with a normal level of 0 (defined as "alert and calm"). Negative values indicate a patient is sedated and positive values indicate some degree of agitation.

    Measured: up to 72 hours, from initiation until discontinuation of mechanical ventilation in a study ICU

Timeline

From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.

  1. First posted11 Dec 2020
  2. Study start22 Feb 2021
  3. Primary completion15 Jun 2023
  4. Study completion15 Dec 2023

Resources

More details

For doctors and researchers: how the study is designed, who runs it, and its registry IDs.

Study design
Study type
Interventional
Phase
Phase N/A
Primary purpose
Health services research
Allocation
Randomised
Intervention model
Crossover
Masking
Single blind
Who is masked
Outcomes assessor
Enrolment
7,342 participants (actual)
IDs, dates and publications
ClinicalTrials.gov ID
NCT04663802
Sponsor's protocol ID
833400
Other IDs
1R01HL141608-01A1
Acronym
INPUT
Status last verified
Sep 2024
First submitted
5 Jun 2020
Last updated
8 Oct 2024
Data monitoring committee
Yes
FDA-regulated drug
No
FDA-regulated device
No
Individual data sharing
Yes: Individual participant data that underlie published results will be made available to other researchers, after deidentification.

Publications

  • Kerlin MP, Harhay MO, Li F, Small DS, Lu Y, Wang W, Fuchs BD, Mikkelsen ME, Tran T, Belk A, Silvestri JA, Klaiman T, Scott S, Levy E, Sjoding MW, Kohn R, Roberts KJ, Beidas RS, Halpern SD. Nudging implementation of low tidal volume ventilation: a stepped wedge, cluster randomized trial. Implement Sci. 2026 May 7;21(1):40. doi: 10.1186/s13012-026-01500-8.

    PubMed 42098760
  • 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.

    PubMed 34376233

Questions about this trial

What is this clinical trial studying?

A study testing Default order set, Physician-targeted accountable justification and Respiratory therapist (RT)-targeted accountable justification in people with ARDS and Critical Illness, run by University of Pennsylvania at 5 sites in United States.

The full registered description is in the About this study section and the official record.

Who may be eligible to take part?

The sponsor lists 3 inclusion and 5 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.

Is this clinical trial currently recruiting?

The record says: finished, as of the sponsor's last update on 8 Oct 2024. Status can change between updates, so confirm with the study contact before making plans.

Where is the study taking place?

The record lists 5 sites in United States. Whether a site is taking part right now should be confirmed with that site. See every site.

What are the possible benefits and risks?

They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.

Are results available for this study?

Yes. Results are posted in the registry (first posted 8 Oct 2024). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.

How can a doctor refer a patient or contact the research team?

The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.

What does the primary outcome measure?

Fidelity to LPV (time frame: up to 72 hours, from initiation of mechanical ventilation in a study ICU until discontinuation of mechanical ventilation). It is what the study was designed to measure, not a finding.

Where can I read the original study information?

On the ClinicalTrials.gov record for NCT04663802, which also lists 2 linked publications.

Does a listing mean the treatment is approved or proven to work?

No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.

How often is this information updated?

AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 8 Oct 2024.

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