Barriers to low tidal volume ventilation in acute respiratory distress syndrome: Survey development, validation, and results

Objective: To evaluate perceived attitudes, knowledge, and behaviors regarding the use of low tidal volume ventilation in acute respiratory distress syndrome among physicians, nurses, and respiratory therapists in intensive care units. Design: Cross-sectional, self-administered survey. Setting: Large Acute Respiratory Distress Syndrome Network teaching hospital in Baltimore, MD. Participants: Attending, fellow, and resident physicians; staff nurses; and respiratory therapists in three intensive care units. Interventions: A survey was designed to assess barriers related to clinicians' perceived attitudes, knowledge, and behaviors related to low tidal volume ventilation in acute respiratory distress syndrome and intensive care unit organization-related barriers. Survey development was guided by a published framework of barriers to clinician adherence to practice guidelines; individual items were derived through literature review and refined through pilot testing. Content validity, face validity, and ease of use were verified by local clinicians. Psychometric properties were assessed and regression analyses were conducted to examine differences in perceptions and knowledge level by provider discipline and training level. Measurements and Main Results: There were 291 completed surveys with a response rate of 84%. Validity and acceptable psychometric properties were demonstrated. Barriers related to clinician attitudes, behaviors, and intensive care unit organization were significantly higher among nurses and respiratory therapists vs. physicians. Knowledge-related barriers also were significantly higher among nurses vs. physicians and respiratory therapists. Barriers were lower and knowledge test scores higher among fellows and attending physicians vs. residents. Similarly, barriers were lower and knowledge test scores higher among nurses with > 10 yrs of experience vs. < 10 yrs of experience. Conclusions: Important organizational and clinician barriers, including knowledge deficits, regarding low tidal volume ventilation were reported, particularly among nurses and resident physicians. Addressing these barriers may be important for increasing implementation of low tidal volume ventilation.