Organizational factors associated with adherence to low tidal volume ventilation: a secondary analysis of the CHECKLIST-ICU database

Thais Dias Midega; Fernando A Bozza; Flávia Ribeiro Machado; Helio Penna Guimarães; Jorge I Salluh; Antonio Paulo Nassar Jr; Karina Normílio-Silva; Marcus J Schultz; Alexandre Biasi Cavalcanti; Ary Serpa Neto; CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet)

doi:10.1186/s13613-020-00687-3

Organizational factors associated with adherence to low tidal volume ventilation: a secondary analysis of the CHECKLIST-ICU database

Ann Intensive Care. 2020 Jun 1;10(1):68. doi: 10.1186/s13613-020-00687-3.

Authors

Thais Dias Midega¹, Fernando A Bozza^{2

3}, Flávia Ribeiro Machado⁴, Helio Penna Guimarães^{1

5}, Jorge I Salluh^{6

7}, Antonio Paulo Nassar Jr⁸, Karina Normílio-Silva⁹, Marcus J Schultz^{10

11}, Alexandre Biasi Cavalcanti⁹, Ary Serpa Neto^{12

13}; CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet)

Collaborators

CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet):
Pedro Aniceto Nunes Neto, Carlos Alberto Fernandes, Cristiano Ávila Luchesi, Natalia Rodrigues de Sa, Roberta Antunes Faria Rodrigues, Larissa Stefany Radespiel, Vinicius Leonardo Dos Santos Iorio, Danielle Bhering, Viviane Ribeiro Linhares, Glauco Adrieno Westphal, Geonice Sperotto, Soraya Byana Rezende da Silva Rossi, Thaismari Escarmanhani Ferreira, Edgar de Brito Sobrinho, Helder Jose Lima Reis, Mauricio Soares Carneiro, Adriana de Oliveira Lameira Veríssimo, Juliana Fernandez Fernandes, Rodrigo Lopes Ferreira, Sylvania Campos Pinho, Leonardo Dultra, Lise Oliveira Hizumi, Neiva Fernandes de Lima, Alexsandra Raimunda da Silva, Liliane Dos Santos, Sidiner Mesquita Vaz, José Marcio Oliveira, Miria Bonjour Laviola, Wania Vasconcelos de Freitas, Leonardo Passos, Ligia Sarmet Cunha Farah Rabello, Carollina Resende de Siqueira, Luiz Carlos de Oliveira Silva, Francisco Felix Barreto Junior, Eduarda Maria Alves Cruz, Luiz Marcelo Sa Malbouisson, Fabiola Prior Caltabeloti, Estevão Bassi, Patrícia Regiane da Silva, Filipe Cadamuro, Renata Graciliano Dos Santos Cagnon, Yeh-Li Ho, Lucas Chaves Neto, Bruno Azevedo Randi, Michele Maria Goncalves de Godoy, Pollyanna Dutra Sobral, Evônio de Barros Campelo Júnior, Laercio Martins de Stefano, Ana Lucia Gut, Greicy Mara Mengue Feniman de Stefano, Denise Milioli Ferreira, Fernanda Alves Ferreira Gonçalves, Fernanda Rubia Negrao Alves, Wilson Nogueira Filho, Renata Ortiz Marchetti, Sheila Sa, Nadia Tomiko Anabuki, Silvia Regina Rios Vieira, Edino Parolo, Karen Prado, Natalia Gomes Lisboa, Simone Castelo Branco Fortaleza, Maria Liduina Nantua Beserra Porfirio, Marcela Maria Sousa Colares, Rosicley Souza da Silva, Marcia Vasconcelos, Fabio de Souza, Lanese Medeiros de Figueiredo, Niedila Pinheiro Bastos Seabra, Paula Celia Pires de Oliveira, Marcio Andrade Martins, Ricardo Beduschi Muller, Manoela Cristina Recalcatti, Riani Helenditi Fernandes Camurça Martins, Leatrice Emilia Ferreira de França, Frederico Bruzzi de Carvalho, Gustavo Cesar Augusto Moreira, Evelin Drociunas Pacheco Cechinatti, Aline Cristina Passos, Mariana da Costa Ferreira, Antonio Carlos Babo Rodrigues, Vladimir Dos Santos Begni, Alfredo Maximo Grilo Jardim, Amanda Carvalho Maciel, Marlus Muri Thompson, Erica Palacio Berçacola Pinheiro, Claudio Henrique Pinto Gonçalves, Ricardo Schilling Rosenfeld, Valéria Abrahao Rosenfeld, Leticia Japiassú, Maria Inês Pinto de Oliveira Bissoli, Rosemary da Costa Tavares, Marta Rocha Gonçalves, Laercia Ferreira Martins, Maria Helena Oliveira, Adriana Kelly Almeida Ferreira, Emídio Jorge Santos Lima, Tárcio de Almeida Oliveira, Milena Teixeira Campos, Nilce Almino de Freitas, Stephanie Wilkes da Silva, Vera Lucia Bento Ferreira, Alexander de Oliveira Sodré, Cid Leite Villela, Eduardo Duque Estrada Medeiros, Nairo Jose de Souza Junior, Jhocrenilcy de Souza Maya Nunes, Rones de Souza Monteiro, André Scazufka Ribeiro, Carlos Cesar Nogueira Giovanini, Elisete Tavares Carvalho, Lenise Castelo Branco Camurça Fernandes, Domitilha Maria Coelho Rocha, Cristiane Maria Gadelha de Freitas, Marcia Adélia de Magalhaes Menezes, Rosa Imaculada Stancato, Guilherme Brenande Alves Faria, Giovanna Asturi, Ricardo Reinaldo Bergo, Frederico Toledo Campo Dall'Orto, Gislayne Rogante Ribeiro, Cidamaiá Aparecida Arantes, Michelle Aparecida Dos Santos Toneto, Cassiano Teixeira, Juçara Gasparetto Maccari, Sergio Tadeu Górios, Julliana Pires de Morais, Daniela Marangoni Zambelli, Roberta Machado de Souza, Eduardo Cenísio Teixeira de Paiva, Alessandra Gonçalves Ribeiro, Marcus Vinicius Pereira, Leoni Nascimento, Rosangela da Silva, Roberto de Almeida, Karin Aline Zilli Couto, Izabella Moroni Toffolo, Jorge Eduardo da Rocha Paranhos, Antonio Ricardo Paixão Fraga, Alberto Augusto de Oliveira Junior, Roberto Lannes, Andrea da Silva Gomes Ludovico, Luiz Fernando Costa Carvalho, Leticia de Araújo Campos, Patricia Soboslai, Israel Silva Maia, Tatiana Rassele, Christiany Zanzi, Valeria Nunes Martins Michel, Sinésio Pontes Gonçalves, Ricardo Rath de Oliveira Gargioni, Rosangela Zen Duarte, Mariza D'Agostino Dias, Andrea Delfini Diziola, Daniela Veruska da Silva, Melissa Sayuri Hagihara, André Luís Veiga de Oliveira, Diego Leonnardo Reis, Janaina Feijó, Marco Antonio da Costa Oliveira, Luiza Veiga Coelho de Souza, Liane de Oliveira Cavalcante, Jacilda Rodrigues, Moises Cruz de Pinho, Marcos Antonio Gadelha Maia, Vladia Fabiola Jorge Lima, Emilianny Maria Nogueira, Antonielle Carneiro Gomes, Katia Regina de Oliveira, Jose Antonio Bandeira, Carla Cordeiro Botelho Mesquita, Guilherme Arcaro, Camila Wolff, Délcio Caran Bertucci Filho, Gustavo Navarro Betonico, Rafaela Pereira Maroto, Leonardo Fantinato Menegon, Patrício Junior Henrique da Silveira, Germana Estrela Gadelha de Queiroga Oliveira, Wallber Moreno da Silva Lima, Lilian Batista Nunes, Sotero Gonçalves Martins Neto, Liwcy Keller de Oliveira Lopes Lima, Maria Augusta de Mendonça Lima, Lidiane Miranda Milagres, Vivian Gribel D'Ávila, Paulo Marcelo Schiavetto, Paulo Alves Dos Santos, Francislaine de Matos Raimundo, Carmen Leonilia Tavares de Melo, Aline Albuquerque de Carvalho, Cynthia Franca de Santana, Adriana Lessa Ventura Fonseca, Martha Aparecida da Silva, Mara Lilian Soares Nasrala, Eloisa Kohl Pinheiro, Mara Regina Pereira Santos, Guilherme Abdalla da Silva, Rener Moreira, Marcia Loureiro Sebold, Marcone Lisboa Simões da Rocha, Marco Antonio Ribeiro Leão, Jaqueline de Assis, Felipe Dal Pizzol, Cristiane Damiani Tomasi, Jose Nivon da Silva, Luciana Vladia Carvalhedo Fragoso, Denise Araújo Silva Nepomuceno Barros, Mauricio Mattos Coutinho, Robson Sobreira Pereira, Veronica Oliveira Dos Santos, Sergio Kiffer Macedo, Diego de Souza Bouzaga Furlani, Eduardo Silva Aglio Junior, Aécio Flavio Teixeira de Góis, Kathia Teixeira, Paula Zhao Xiao Ping, Paulo Ricardo Nazario Viecili, Simone Daniela Melo de Almeida, Geovani Moreno Santos Junior, Djalma Novaes Araújo Segundo, Marielle Xavier Santana, Jose Oliveira Calvete, Luciana Renner, Vinicius Vandré Trindade Francisco, Danytieli Silva de Carvalho, Adriana Neri da Silva Batista Campos, Sergio Leôncio Fernandes Curvelo Jr, Nayara Ribas de Oliveira, Suelem de Paula Freitas Deborssan, Maria Raquel Dos Anjos Silva Guimaraes, Luiz Claudio Gomes Bastos, Luciene Moraes Gomes, Erico de Lima Vale, Dionísia Arianne Vieira da Silva, Renato Vieira Gomes, Marco Antonio Mattos, Pedro Miguel Matos Nogueira, Viviane Cristina Caetano Nascimento, Cintia Magalhaes Carvalho Grion, Alexsandro Oliveira Dias, Glaucia de Souza Omori Maier, Paula Frizera Vassallo, Maria Helena Buarque Souza de Lima, Wyllyam Loss Dos Reis, Walace Lirio Loureiro, Andressa Tomazini Borghardt, Ciro Leite Mendes, Paulo Cesar Gottardo, Jose Melquiades Ramalho Neto, Eliane Pereira da Silva, Maria Gorette Lourenço da Silva Aragao, Elisângela Maria de Lima, Rafael Lisboa de Souza, Ken Sekine Takashiba, Dimitri Gusmão-Flores, Taciana Lago Araújo, Rosana Santos Mota, Almir Germano, Flavia Antunes, Sandra Regina Bin Silva, Marcio Osório Guerreiro, Marina Peres Bainy, Patrícia de Azevedo Duarte Hardt, Hugo Correa de Andrade Urbano, Camila Amurim de Souza, Claudia Mangini, Fernando Jose da Silva Ramos, Luany Pereira de Araújo, André Miguel Japiassú, Denise Machado Medeiros, Michele Fernanda Borges da Silva, Fabiano Hirata, Roberto Marco, Elzo Peixoto, Marcio Luiz Fortuna Esmeraldo, Leide Aparecida Damásio Pereira, Raquel Carvalho Leal, Paulo Roberto Aranha Torres, Maricy Morbin Torres, Mara Rubia de Moura, Claudio Dornas de Oliveira, Andressa Siuves Gonçalves Moreira, Brisa Emanuelle Silva Ferreira, Carolina Leticia Dos Santos Cruz, Patrícia Moreira Soares, Paulo Cesar Correia, Lorena Lina Silva Almeida, Marcelo Ferreira Sousa, Andrey Antonio Santiago Vial, Marcia Maria Ferreira Souza, Diogo Quintana, Ana Cecilia Barbosa Guimaraes, Maria Dolores Menezes Diniz, Paulo Henrique Panelli Ferreira, Rosa Maria Rios Santana Cordeiro, Murilo Oliveira da Cunha Mendes, Sergio Oliveira de Lima, Silvia Aparecida Bezerra, Aurélia Baquiao Dos Reis da Silva, Cristiano Correa Batista, Thaís Neumann, Rafael Olivé Leite, Thiago Costa Lisboa, Martha Hädrich, Edison Moraes Rodrigues Filho, Jorge Luiz da Rocha Paranhos, Carlos Henrique Nascimento Dos Santos, Hélia Cristina de Souza, Robson Viera de Souza, Jose Luís Toribio Cuadra, Jonas Spanholi, Marcos de Carvalho Borges, Wilson Jose Lovato, Tania Mara Gomes, Luís Artur Mauro Witzel Machado, Thiago Martins Santos, Marco Antonio de Carvalho Filho, Karina Aparecida Garcia Bernardes, Jose Roberto Pereira Santos, Aline Esteves Mautoni Queiroga Liparizi, Patrícia Venturim Lana, Claudio Piras, Luiz Virgílio Nespoli, Aparecida Silva Taliule

Affiliations

¹ Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil.
² Research Institute, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil.
³ Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil.
⁴ Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, São Paulo, Brazil.
⁵ Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil.
⁶ Graduate Program in Translational Medicine and Department of Critical Care, Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil.
⁷ Post Graduate Program in Internal Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
⁸ Intensive Care Unit and Postgraduate Program, A.C. Camargo Cancer Center, São Paulo, Brazil.
⁹ Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.
¹⁰ Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.
¹¹ Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
¹² Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil. [email protected].
¹³ Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands. [email protected].

Abstract

Background: Survival benefit from low tidal volume (V_T) ventilation (LTVV) has been demonstrated for patients with acute respiratory distress syndrome (ARDS), and patients not having ARDS could also benefit from this strategy. Organizational factors may play a role on adherence to LTVV. The present study aimed to identify organizational factors with an independent association with adherence to LTVV.

Methods: Secondary analysis of the database of a multicenter two-phase study (prospective cohort followed by a cluster-randomized trial) performed in 118 Brazilian intensive care units. Patients under mechanical ventilation at day 2 were included. LTVV was defined as a V_T ≤ 8 ml/kg PBW on the second day of ventilation. Data on the type and number of beds of the hospital, teaching status, nursing, respiratory therapists and physician staffing, use of structured checklist, and presence of protocols were tested. A multivariable mixed-effect model was used to assess the association between organizational factors and adherence to LTVV.

Results: The study included 5719 patients; 3340 (58%) patients received LTVV. A greater number of hospital beds (absolute difference 7.43% [95% confidence interval 0.61-14.24%]; p = 0.038), use of structured checklist during multidisciplinary rounds (5.10% [0.55-9.81%]; p = 0.030), and presence of at least one nurse per 10 patients during all shifts (17.24% [0.85-33.60%]; p = 0.045) were the only three factors that had an independent association with adherence to LTVV.

Conclusions: Number of hospital beds, use of a structured checklist during multidisciplinary rounds, and nurse staffing are organizational factors associated with adherence to LTVV. These findings shed light on organizational factors that may improve ventilation in critically ill patients.

Keywords: Intensive care unit; Invasive ventilation, lung protection; Organizational factors; Tidal volume, low tidal volume ventilation.