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Beyond audit: Embracing QI methodology to drive improvements in lung-protective ventilation.

BACKGROUND
Mechanical ventilation supports patients with respiratory failure during critical illness. Evidence suggests that excessive tidal volumes (regarded as >8 mL/kg predicted body weight [PBW]) cause lung damage through increased lung stretch and alveolar inflammation. Lung-protective ventilation strategies have been shown to decrease morbidity and mortality, and that all patients should receive tidal volumes between 6 and 8 mls/kg PBW. Despite this, studies demonstrate that fewer than half of patients in critical care successfully receive lung-protective ventilation.


AIM
The primary aim was to reduce tidal volumes delivered to all patients receiving mandatory ventilation, with a target of >85% of tidal volumes delivered to be compliant with lung-protective ventilation strategies by the end of November 2019.


METHODS
A multidisciplinary team of nurses and doctors, based in a UK tertiary hospital, utilized the Institute for Healthcare Improvement's (IHI) quality improvement methodology to improve compliance with lung-protective ventilation.


RESULTS
Baseline data demonstrated that only 60.1% of tidal volumes recorded were compliant with lung-protective ventilation. Quality improvement (QI) methodology was utilized to systematically diagnose the aetiology of poor compliance and to produce and implement solutions. Real-time data collection and reporting were utilized to monitor and report improvement. Following 8 months of continuous data collection and repeated PDSA cycles, sustainable compliance with lung-protective ventilation for >85% of tidal volumes was achieved.


CONCLUSIONS
The use of QI methodology to implement low tidal volume ventilation has shown a significant improvement in the delivery of lung-protective ventilation. Using QI methodology is central to this sustained improvement and offers a useful tool to systematically approach complex clinical problems.