Impact of Clinical, Unit-Specific Guidelines on Dornase Alfa Use in Critically Ill Pediatric Patients Without Cystic Fibrosis

Abstract

Purpose: The purpose of this study was to evaluate the impact of the implementation of pharmacist-guided, unit-specific dornase alfa utilization guidelines for patients without cystic fibrosis in an academic medical institution. The study reviewed the prescribing patterns in the institution’s pediatric intensive care unit (PICU) and pediatric cardiac intensive care unit (PCICU) before and after the implementation of these guidelines. The primary objective of this study was to determine the effects of the guidelines on the number of dornase alfa doses prescribed in critically ill pediatric patients without cystic fibrosis. We also evaluated the pharmacoeconomic effect of the guidelines and the impact on clinical outcomes in these critically ill patients. Methods: This study was a single-center, retrospective evaluation of the implementation of pharmacist-guided, unit-specific dornase alfa guidelines. The guidelines were piloted on November 1, 2015. Pre-guideline implementation data were collected from February 1, 2015 to October 31, 2015. Post-guideline implementation data were collected from December 1, 2016 to August 31, 2016. We included patients admitted to the PICU and PCICU who had received at least 1 dose of dornase alfa and did not have a medical history or suspicion of cystic fibrosis. Results: During the pre-guideline data collection period, 1067 doses of dornase alfa were administered, and following guideline implementation, 239 doses were administered. The average total admission length of stay for patients admitted to the PICU or PCICU before guideline implementation and after implementation was 16.22 and 13.14 days, respectively ( P = .042). Conclusions: The implementation of pharmacist-guided, unit-specific dornase alfa guidelines within the PICU and PCICU resulted in a 77.6% reduction in the use of dornase alfa among these units. The implementation of these guidelines led to a cost reduction of approximately US $87 707.76 over a 9-month period for the health system. During the study, the length of stay for patients admitted to the PICU and PCICU did not increase, indicating that the reduction in use of dornase alfa did not negatively affect the overall hospital length of stay for patients.

Use of dornase alfa in the paediatric intensive care unit: current literature and a national cross-sectional survey

“…Interestingly, pharmacist-guided implementation of dornase alfa protocols in the PICU has been shown to reduce the use and costs of dornase alfa by approximately 75%, without increasing PICU length of stay. 35 This further underscores the potential benefit of close involvement of pharmacists in the multidisciplinary PICU environment to guide protocols and ensure appropriate prescribing. 36 Following the frequent use of dornase alfa despite limited scientific evidence, potential safety issues, in addition to the associated costs as discussed above, should also be addressed.…”

“…These findings are in line with a recent single centre PICU study from the US reporting major usage of dornase alfa, which was associated with high costs of up to US$150 000 per year. 35 In an era with much need for applying meaningful critical care, randomised controlled testing in superiority or non-inferiority trials comparing dornase alfa with normal saline administration in the treatment of airway mucus obstruction is warranted. Interestingly, pharmacist-guided implementation of dornase alfa protocols in the PICU has been shown to reduce the use and costs of dornase alfa by approximately 75%, without increasing PICU length of stay.…”

A Quality Improvement Approach to Influence Value-based Mucolytic Use in the PICU

“…However, our work is unique in that it used a QI methodology performed in real-time over the study period and not a pre-test post-test comparison. 19 This allowed for a more robust analysis of concomitant ordering practices, specifically hypertonic saline and N-acetylcysteine. Contrary to their findings in which N-acetylcysteine use decreased along with dornase alfa, we observed a significant increase in both alternative mucolytics.…”

“…Our project can serve as a model for other groups considering value-based pharmacoeconomic projects. While recent publications promote a similar dornase alfa reduction workaround, 19 we feel it is essential to highlight the benefits of using a prospective QI-based approach instead of a pre/post design. The ability to track balancing measures (eg, ventilator days) and other unintended consequences, including a significant increase in alternative mucolytics in our case, allows for further contextualization of results and an additional layer of safety when performing this work.…”

Identification of the area of service provided by clinical pharmacist in the pediatric patient care

“…U pacjentów pediatrycznych chorych na padaczkę leczonych kwasem walproinowym dzięki edukacji prowadzonej przez farmaceutów poprawiła się współpraca pacjentów i opiekunów z personelem fachowym w zakresie przestrzegania zaleceń terapeutycznych, co potwierdziło monitorowanie i analiza stężeń leku w surowicy [22]. Interwencje farmaceuty klinicznego pozwalały osiągnąć także korzyści w aspekcie farmakoekonomicznym poprzez zmniejszenie liczby podawanych leków lub wykorzystanie ich tańszych alternatyw oraz zmniejszenie częstotliwości występowania działań niepożądanych i powiązanych z nimi kosztów [16,17,23,24].…”