How can we improve adoption of protective mechanical ventilation in United Kingdom critical care units?

We have read with interest the multicentre audit into the application of protective mechanical lung ventilation across the Severn and Wessex regions. ¹ Through the Critical Care Network (CCN) in Lancashire and South Cumbria, we have undertaken a quality improvement project associated with lung-protective ventilation over the last year. Our initial findings were similar to those reported with only 31% of patients being ventilated in a manner consistent with lung protection (≥7 ml/kg ideal body weight) and only 11% were ventilated at ≤6 ml/kg ideal body weight).

A number of factors have been identified as perceived barriers to reducing tidal volumes; “we move to spontaneous ventilation as soon as possible,” how you report tidal volumes using different (pressure or volume) modes of ventilation, accurate measurement of height to determine predicted body weight, perception that “normal physiological parameters” are good.

It is widely known that 6 ml/kg is a better target volume than higher ones based upon available evidence, yet translating this evidence into clinical practice seems fraught with difficulty. Successes in reducing tidal volumes across Lancashire and South Cumbria have been achieved through; switching to volume regulated pressure control modes alongside prescriptive nurse led ventilator set up guidance, a “blow low campaign” consisting of educational material alongside daily senior nursing monitoring of tidal volumes (with an acceptance that higher volumes would be challenged) and continued local monitoring and reporting of tidal volumes facilitated by the CCN using accepted QI strategies driven by QI leads within each of the critical care unit. Consultant champions appear crucial to sustained improvement within units. Overcoming the human factor barriers to improvement^2–4 appears to be the greatest challenge.

Should the use of QI indicators (in addition to Key Performance indicators or Process Measures) based upon the GPICS document may be the next step to achieving quality improvement in Critical Care?