COPD is the fourth leading cause of death in the US, and COPD exacerbations result in approximately 700,000 hospitalizations annually. Patients who do not respond to pharmacotherapy are placed on invasive (IMV) or noninvasive mechanical ventilation (NIV). Although IMV reverses hypercapnia/hypoxia, it causes significant morbidity and mortality. NIV is an alternative ventilatory option for acute respiratory failure that provides positive pressure ventilation via a mask. Multiple randomized controlled trials and analyses of real-world data have shown that patients treated with NIV are less likely to require IMV and have better mortality and length of hospital stay. NIV is recommended in all COPD guidelines as the first-line treatment for patients with severe exacerbation who have failed pharmacologic treatment. Yet, despite compelling evidence of benefit, we have previously demonstrated substantial variation in the implementation of NIV across hospitals, leading to preventable morbidity and mortality. Through a series of mixed-methods studies we and other investigators have found that successful implementation of NIV requires physicians, respiratory therapists (RTs), and nurses to communicate and collaborate effectively to select appropriate patients for treatment, and to carefully manage patients after NIV initiation. These studies suggest that efforts to increase the use of NIV in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Our main goal is to conduct a two-arm pragmatic type III hybrid implementation- effectiveness trial to compare two educational strategies in 20 hospitals with low NIV use in COPD: interprofessional education (IPE) which targets complex team-based care in NIV delivery and on-line education (OLE). The primary outcome of the trial is change in the hospital rate of NIV use among patients with COPD requiring ventilatory support. Our central hypothesis is that IPE will outperform OLE, leading to greater improvement in the uptake of NIV and that RT autonomy and team functionality will act as mediators. We will accomplish our goal by completing three specific aims.
In Aim 1 we will compare the uptake change over time of NIV use among patients with COPD in hospitals enrolled in the two arms.
In Aim 2, we will explore mediators' role (RT autonomy and team functionality) on the relationship between the implementation strategies and implementation effectiveness. Finally, in Aim 3, through interviews with providers, we will assess acceptability and feasibility of the educational training. This proposal is significant because NIV is the only therapy that has been shown to improve short-term survival for patients hospitalized for exacerbation of COPD, yet a large number of hospitals still have not adopted this approach fully. This proposal is feasible because it builds upon our strong interdisciplinary team's experience and it will be conducted within a large network of hospitals that we have previously worked with, and because it will have a very pragmatic design. Our application is innovative because it will be among the first to carefully test the impact of IPE in the inpatient setting. This work promises to change practice by offering approaches to facilitate greater uptake of NIV and may generalize to other interventions directed to seriously-ill patients.
PROJECT NARATIVE Nearly 750,000 patients are hospitalized yearly with COPD in the United States and one in five requires mechanical ventilation for acute respiratory failure. Many of them would benefit from mechanical ventilation delivered through a face mask rather than through a breathing tube, but this practice is currently underutilized. This project will compare two innovative educational strategies to increase the use of this evidence-based practice.
