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Variable effectiveness of stepwise implementation of nudge-type interventions to improve provider compliance with intraoperative low tidal volume ventilation
  1. Vikas N O’Reilly-Shah1,
  2. George S Easton2,
  3. Craig S Jabaley1,
  4. Grant C Lynde1
  1. 1 Department of Anesthesiology, Emory University, Atlanta, Georgia, USA
  2. 2 Department of Information Systems and Operations Management, Emory University, Goizueta Business School, Atlanta, Georgia, USA
  1. Correspondence to Dr Grant C Lynde, Department of Anesthesiology, Emory University, Atlanta, GA 30322, USA; glynde{at}


Background Identifying mechanisms to improve provider compliance with quality metrics is a common goal across medical disciplines. Nudge interventions are minimally invasive strategies that can influence behavioural changes and are increasingly used within healthcare settings. We hypothesised that nudge interventions may improve provider compliance with lung-protective ventilation (LPV) strategies during general anaesthesia.

Methods We developed an audit and feedback dashboard that included information on both provider-level and department-level compliance with LPV strategies in two academic hospitals, two non-academic hospitals and two academic surgery centres affiliated with a single healthcare system. Dashboards were emailed to providers four times over the course of the 9-month study. Additionally, the default setting on anaesthesia machines for tidal volume was decreased from 700 mL to 400 mL. Data on surgical cases performed between 1 September 2016 and 31 May 2017 were examined for compliance with LPV. The impact of the interventions was assessed via pairwise logistic regression analysis corrected for multiple comparisons.

Results A total of 14 793 anaesthesia records were analysed. Absolute compliance rates increased from 59.3% to 87.8%preintervention to postintervention. Introduction of attending physician dashboards resulted in a 41% increase in the odds of compliance (OR 1.41, 95% CI 1.17 to 1.69, p=0.002). Subsequently, the addition of advanced practice provider and resident dashboards lead to an additional 93% increase in the odds of compliance (OR 1.93, 95% CI 1.52 to 2.46, p<0.001). Lastly, modifying ventilator defaults led to a 376% increase in the odds of compliance (OR 3.76, 95% CI 3.1 to 4.57, p<0.001).

Conclusion Audit and feedback tools in conjunction with default changes improve provider compliance.

  • anaesthesia
  • audit and feedback
  • implementation science
  • quality improvement

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  • Contributors VNO-S helped design the data review, was primary author of this manuscript and performed statistical analysis of the data. GSE analysed the data, provided statistical guidance and critically revised the manuscript. CSJ reviewed the data and analysis plan and critically revised the manuscript. GCL designed the quality improvement project and the subsequent study and coauthored the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Approval for secondary data analysis with the intent to generalise and publish findings was granted by the Emory University Institutional Review Board (IRB00095280).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement There are no unpublished data available from this study.